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NIOSH Cedar Fire Report



Investigation & Medical Findings

Recommendations / Discussions


Glossary of Terms

Maps and Photographs

CDF Cedar Fire Report

Table of Contents

Review Team Process

Overview of Accident

Summary of Events

Sequence of Events


Causal Factors

Contributory Factors


Site Conditions

Graphics – List of Illustrations Table

Description of Supporting Data and Supplementary Information

Novato FPD Investigation Analysis

Table of Contents


CDF Green Sheet


Lessons Learned

Draft Standard Operating Procedures

Inaja Fire Tragedy




Investigation Analysis
of the
Cedar Fire Incident

Engine 6162 Crew Entrapment,
Fatality, and Burn Injuries
October 29, 2003

Cedar Fire Lessons Learned
Human Factors

Pre Incident

  • The Novato Fire District provided physicals for its members

    • Members under 40 receive physicals every two years
    • Members over 40 receive physicals annually
    • Physicals are typically provided by the member’s primary physician

  • Due to legal requirements the District is only provided with general information regarding member health and fitness i.e.:

    • Fit for Duty
    • Fit with Restrictions
    • Unfit for Duty

  • All District fire stations are equipped with a full complement of exercise equipment

    • Treadmills
    • Elliptical Trainers
    • Weights
    • Members are generally provided time to work out each shift between 07:00 hrs and 09:30 hrs

  • The District has been in the practice of conducting third party fitness evaluations for all members annually.

    • Fitness evaluations had not been conducted in Fiscal Year 2002-2003 due to issues with the third party evaluator

  • Firefighters are expected to make appropriate decisions in stressful and occasionally life threatening situations

    • The District does not have program to develop critical thinking skills in stressful situations nor does it have a program to determine if members possess or lack this critical ability.

  • Prior to responding to the Cedar Incident, the crew had just returned from a four day break.

    • They had received adequate rest and had not worked any overtime shifts
    • The shift, prior to dispatch, was relatively uneventful.

  • The total combined fire service experience of the Crew of Engine 6162 was 55.5 years.

  • Captain McDonald had =19 years of firefighting experience, plus an additional 7 years experience as a paramedic. His experience included 17 years with Novato Fire and one year with Marin County Fire Department.

  • Engineer Kreps had 16 years of firefighting experience and 15 years experience as a licensed paramedic. His experience included seven years with Novato Fire and one season with the CDF.

  • Engineer Rucker had 12.5 years of firefighting experience and 15 years as a paramedic. His experience included 11 years with Novato fire and two seasons with CDF.

  • Firefighter Paramedic Smith had 8 years of firefighting experience and 2 years experience as paramedic. His experience included one year with Novato Fire and three seasons with CDF.


  • At the time of the incident the crew of Engine 6162 had all been cleared for regular duty, by their physicians, without restrictions.

    • Engineer Rucker had been issued a recent prescription for an inhaler, typically associated with Asthma.
    • The District was not aware of this prior to the incident
    • NIOSH preliminary investigations indicate there is no evidence that Asthma was a factor in the incident.

  • It is unlikely that fitness was a factor in this case since it was a short distance that the crew had to travel to the safety of the structure.

  • There are several potential explanations for the delayed reaction and subsequent response of Engineer Rucker when the order was given to move to the house.

    • Intake of extremely hot air or fire gases resulting in breathing or respiratory issues
    • Tripping over hose lines or equipment located in the general area
    • An unidentified medical condition
    • A combination of the above

  • There is no definitive proof that any of these factors contributed to the situation.

  • It should be noted that all four crew members were in the same general area at the time of the burnover and were exposed to the same general environmental conditions.

  • Engineer Kreps, standing closest to Engineer Rucker, was forced to cover his mouth with his gloved hand and take shallow breaths due to the intense heat.

  • All crew members felt that they had received adequate rest prior to the incident.

  • The collective experience of the crew and their ability to remain calm, think clearly, and respond according to an established plan was paramount in the survival of three members.

Post Incident

  • In September of 2003 the District implemented the IAFF/IAFC Joint Labor Management, Wellness-Fitness Initiative.

    • All members now receive annual physicals by a designated District physician.
    • Peer fitness testing will be conducted internally and shared with the designated District physician

  • District members are now required to pass a the Pack Test in order to participate in “Out of County Assignments”

    • A annual mandatory physical agility testing is being considered for all safety members

  • As it relates to asthma and firefighters, the 2003 edition of NFPA 1582, Comprehensive Occupational Medical Program for Fire Departments states:

    • Asthma compromises a member’s ability to safely perform essential job tasks
    • Acute hyper-reactivity on the fire ground environment can induce immediate or progressive clinical asthma (bronchospasm and wheeze) that can lead to sudden incapacitation from status asthmaticus and/or cardiac ischemia
    • Certain types of asthma now prevent individuals from being hired because it can inhibit the performance of essential job functions

  • The military and the aviation industry have developed methods to analyze their members ability to think clearly and act decisively in stressful situations

    • This factor has been identified as a causal factor in other firefighter fatalities
    • The fire service needs to implement similar methods in an effort to prevent injuries and fatalities in emergency situations
    • Testing for the predictors of dangerous traits should also occur at the entry level and for those already working on the line
    • Methods to improve members performance in stressful situations, through training, must be developed

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