NIOSH Cedar Fire Report
CDF Cedar Fire Report
Novato FPD Investigation Analysis
Draft Standard Operating Procedures
Inaja Fire Tragedy
FIRE PROTECTION DISTRICT
Cedar Fire Incident
Engine 6162 Crew Entrapment,
Fatality, and Burn Injuries
October 29, 2003
Cedar Fire Lessons Learned
Policy and Tactics
The Novato Fire District had created several wildland firefighting standard
operating procedures (SOPs), including the use of Personal Protective
Equipment (PPE) and use of the Incident Command System (ICS); however,
no specific SOPs existed relating to structure protection, firing or turning
The District had developed a Standard Evolution Manual, Tactical and
Task level standards, based on state and nationally recognized training
curriculum relating to structure protection operations.
No internal process had been utilized to compare established state and
national training curriculum with the experience of the members of the
District in order to develop internal standard operating procedures in
the areas of structure protection, firing or turning down assignments.
The crew of E6162 followed a standard structure protection evolution
in accordance with the Districts Standard Evolution Manual and state and
nationally recognized training curriculum in the operations that were
conducted at 920 Orchard Lane by:
Removing light grass fuels, using drip torches and fusees, to create
a defensible space below the structure
Identifying an Escape Route and Safety Zone using the principles
LCES (Lookouts, Communications, Escape Routes and Safety Zones)
Observed flame lengths in the brush were 25’ to 30’.
Safety Zone standards denote a radius (from the center of the Safety
Zone) of four (4) times the flame length for entire circumference
of the Safety Zone. In this case the distance from Engine 6162 to
the unburned brush below (west) was over 140’. This distance
was much further than the 100’ to 120’ required for a
Safety Zone. The distance to the unburned fuels to the south was approximately
Assigning a Lookout (Engineer Rucker)
Maintaining communications between the crew and confirming and maintaining
communications with the Task Force Leader both face to face and via
radio on established incident frequencies
Wearing protective clothing and equipment in accordance with District
policy and industry standards
Identifying specific triggers when the crew would use the escape
route to access the safety zone and when to seek refuge in the shelter.
The collective experience and training of the crew prevented further
injury or fatalities
Developing a plan collectively, discussing the plan, thinking clearly,
calmly and acting decisively when the situation deteriorated.
It is critical that there be mutually agreed philosophy and supporting
policy or standard operating procedures between federal, state and local
agencies regarding wildland firefighting operations with a focus on firefighter
safety and survival. Philosophy derived from experience should be used
to develop policy or standard
operating procedures which should in turn drive training and the formation
of training curriculum. Training curriculum should not drive organizational
philosophy or policy.
It is also crucial that department members are supported by validated
policies or standard operating procedures that are based on firefighter
safety and provide all members with mitigation options that are irrefutable
up to and including refusal of assignments.
In no case should policy impede firefighter safety nor should the basic
premise of firefighter safety be forgotten or neglected.
When reviewing whether Engine 6162 should have taken the assignment
at 920 Orchard Lane the following observations can be made:
There is no way to conclusively prove that any crew, regardless of
experience or training, could have anticipated the outcome of this
event due to the casual, contributing and circumstantial factors that
combined to create burnover.
Post incident evaluation indicates most experienced fire officers
would have made the decision to protect the structure at 920 Orchard
In addition to the Crew of Engine 6162, the TFL, other Engine Companies
in the TF, the Division and Aircraft in the area described the fire
as “backing” or “flanking” in the direction
of the homes on Orchard Lane until just before the burn over occurred.
These same resources were also protecting structures in the same
area, with the same fuel type and conditions.
In a structure protection operation parking an engine between the
oncoming fire and the structure may result in the engine and crew
Novato Fire Protection District being trapped when the flame front
passes as occurred at 920 Orchard Lane.
The significance of this decision depends on the ability to
accurately predict the intensity of the approaching fire and the
capability to assure the survival of the engine without damage
and the crew without injury.
If adequate clearance exists or the fuel, weather, topography
and fire behavior combine to allow a safe operation this tactic
may be acceptable.
A search for safer alternative should still be conducted to take
advantage of the protection of a structure or other feature that
will deflect heat from the on coming flame front and allowing
for a safer operation.
Implementing a standard of basing all actions on worst case possibilities
would simply prevent firefighting personnel from taking any action to
suppress a wildland fire or protect a structure.
- A balance between worst case possibilities and operations that provide
for the survivability of the engine without damage and crew without
injury must be developed and memorialized in policies or standard operating
procedures and reinforced in training.
The philosophy that, “Every Firefighter Deserves a Round
Trip Experience” must become the motto of the fire service
and the basis for policy, standard operating procedures, and training.
In the wildland environment this means that no structure protection
operation is worth risking firefighter injuries, near misses situations
or fatalities nor are they worth sustaining damage to an engine.
Even minor damage to an engine such as, melted lenses or bubbled
paint should be considered a near miss and a close call for the crew.
No plan to protect a structure should be based on the anticipated need
to seek refuge in the engine, structure or in a fire shelter when the
flame front passes. On the other hand even the best managed events can
change for the worse.
- In these cases last resort survival options should be developed and
included in department policies, standard operating procedures and implemented
in training in addition to LCES.
The following guidelines should become the basis for both policy and
training curriculum development:
Activities that present a significant risk to the safety of personnel
shall be limited to situations where there is a potential to save
Activities that are routinely employed to protect property shall
be recognized as inherent risks to the safety of personnel, and actions
shall be taken to reduce/avoid these risks or change tactics.
- No risk to the safety of personnel shall be acceptable where there
is no possibility to save lives or property.
We will risk our lives a lot, in a calculated manner, to save SAVABLE
We will risk our lives a little, in a calculated manner, to save
We will not risk our lives at all for lives, property or the environment
that are already Lost/Can Not Be Saved.
continue reading—Novato FPD Report, Lessons Learned, Human Factors