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Esperanza Fire


Accident Review Board Action Plan


CDF Green Sheet


Accident Investigation
Factual Report

Cover & Table of Contents
Executive Summary
Narrative
Maps
Photographs
Timeline
Investigation Process Summary
Human Findings
Causal Factors and Contributing Factors
Appendix 1 — Fire Behavior Analysis Summary
Appendix 2 — Fire Operations Analysis Summary
Appendix 3 — LCES Analysis Summary
Appendix 4 — Standards for Fire Operations Analysis Summary
Appendix 5 — Compliance Analysis Summary
Appendix 6 — Fire Weather Analysis Summary
Appendix 7 — Human Factors Analysis Checklist Summary
Appendix 8 — Personal Protective Equipment Analysis Summary
Appendix 9 — Equipment Engine 57 Analysis Summary
Appendix 10 — Video Documentation Listing
Appendix 11 — Glossary and Acronyms

US Forest Service logo

Esperanza Fire
Accident Investigation
Factual Report

Riverside County, California
October 26, 2006

California Department of Forestry and Fire Protection logo

Engine 57 memorial


Esperanza Investigation Team

Investigation Team Leaders:

______________________________________________________________
Randy Moore, Regional Forester Date
USDA Forest Service, Eastern Region, Milwaukee, WI
______________________________________________________________
Brad Harris, Unit Chief Date
California Department of Forestry and Fire Protection

Core Team Members

Michael Anderson, USFS Eastern & Southern Regional Offices, Safety Officer
Jeff Brand, CAL FIRE NEU, Chief Investigator
Jon Brothers, CAL FIRE FKU, Documentation
Dave Cleaves, USFS Rocky Mountain Research Station, Deputy Team Leader
Joe Duran, USFS Pacific Southwest Region, Union Representative
Al Matecko, USFS Pacific Northwest Regional Office, Information & Liaison Officer
Rick Moore, CAL FIRE FKU, Lead Investigator
Pete Munoa, CAL FIRE LNU - CDFFF-Documentation/Union Representative
Anthony Rose, USFS Cleveland National Forest, Law Enforcement Officer
Sheryl Shafer, USFS Washington Office, Documentation
Drew Smith, Los Angeles County Fire Department, Fire Behavior Analyst
George Solverson, USFS Boise National Forest, Chief Investigator
Paul Van Gerwen, CAL FIRE SLU –CDFFF, Union Investigator
Rita Wear, USFS Angeles National Forest, Law Enforcement Officer
Don Will, USFS Tahoe National Forest, Fire Operations Specialist
Marge Yarbrough, CAL FIRE SFM, Law Enforcement Officer

Technical Specialists

Mike Arias, USFS Equipment Specialist, Engine
Steve Beach, CAL FIRE RRU, Plans Section Chief
Alison Lara, CAL FIRE AEU, Procurement
Jay Donnelly, CAL FIRE SAC, Critical Incident Stress Management
Paul Flatt, National Weather Service, Meteorologist
Gordon Gholson, CSR-Chief -Mobile Equipment
Todd Hopkins, CAL FIRE RRU, Resource Unit Leader
Elsa Hucks, CAL FIRE SAC, GIS Analyst
Jim Little, USFS Equipment Specialist, Engine
Sandra Lopez, USFS Albuquerque Service Center-Human Capital Mgmt, Writer/Editor
Jon Mills, CAL FIRE RRU, Finance Chief
Tony Petrilli, Missoula Technology Development Center, Equipment Specialist PPE
John Smith, Missoula Technology Development Center, Equipment Specialist PPE
Bob Taylor, CAL FIRE BEU, Investigator


Table of Contents

Executive Summary……………………………………………………………….2
Narrative……………………………………………………………………………3
Maps………………………………………………………………………………..9
Photographs.……………………………………………………………………..21
Timeline …………………………………………………………………………..27
Investigation Process Summary….…………………………………………….34
Human Findings………..………………………………………………………...37
Causal Factors and Contributing Factors……………………………………..43
Appendices
Appendix 1 – Fire Behavior Analysis Summary………………..…………45
Appendix 2 – Fire Operations Analysis Summary………………….…….53
Appendix 3 – LCES Analysis Summary…………….……………………..57
Appendix 4 – Standards for Fire Operations Analysis Summary……….59
Appendix 5 – Compliance Analysis Summary……….…………………...62
Appendix 6 – Fire Weather Analysis Summary………………….……….65
Appendix 7 – Human Factors Analysis Checklist Summary.…………...78
Appendix 8 – Personal Protective Equipment Analysis Summary……..89
Appendix 9 – Equipment Engine 57 Analysis Summary……….………..91
Appendix 10 – Video Documentation Listing………………………....…100
Appendix 11 – Glossary and Acronyms……………..……………..…….101

The U.S. Department of Agriculture (USDA) and California Department of Forestry and Fire Protection (CAL FIRE) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual’s income is derived from any public assistance program. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at (202) 720-2600 (voice and TDD). To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.


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