A causal factor, developed from the findings, is defined as an act, omission, condition, or circumstance that either starts or sustains an accident sequence. A given act, omission, condition, or circumstance is a causal factor if correcting, eliminating, or avoiding it would prevent the accident or mitigate damage or injury.

1. Management oversight was inadequate.

From July 20-22, 2003, line officers and forest fire staff did not provide adequate management oversight and direction to the Cramer Fire incident commanders (ICs). Consequently, no effective communication, discussion, or validation of the ICs' strategies and tactics were accomplished. Even when concerns about management of the fire were raised, forest fire staff and line officers failed to recognize that additional fire management resources were necessary (findings: 9, 13b, 13h, 16f, 18, and 44).

The forest aviation officer (FAO) raised concerns about the management of the fire to the operations staff officer, who passed on the concern to the district ranger (finding: 44f).
Once informed of the concern, the district ranger did not follow up assertively to assess the suppression situation to determine whether or not problems existed (finding: 44f).
There was a failure to fully respond to the IC's request for additional operational and logistical support and to evaluate and react to the information the forest fire staff received from the IC (findings: 13h, 16f, and 18g).
The forest fire staff and the district ranger were occupied with other priorities, both fire and nonfire (findings: 44a, 44b, 44c, 44d, and 44e).

2. The IC did not adequately perform his duties to execute safe and effective suppression operations.

He maintained confidence in his ability to contain the fire on July 22, even though fire behavior had exceeded suppression capabilities and containment efforts the previous day (findings: 13c, 13h, 13j, and 38b).
He failed to modify his plan the morning of July 22 as he faced extreme fire behavior potential and steep, rocky terrain, with a shortage of resources (findings: 13, 22, 25, 26, 27, and 28).
He failed to post adequate lookouts (finding: 29).
He failed to identify effective safety zones (finding: 30).
He was disengaged from the fire, managing the fire from the helibase for most of the day on July 22, affecting the cohesion and integration of his suppression forces (findings: 16h, 16i, 29, 38c, and 38e).
He was not in control of his forces on the fireline, deferring operations to his strike team leader. He did not supervise and adequately contact, monitor, or coordinate with the H-2 operation (findings: 13i, 13k, 18i, 18j, 29, and 38c).
Despite signs that some of his tactics were unsuccessful on July 22, he was slow to adjust and respond in the afternoon (findings: 13i, 13j, 16i, 18j, 35a, 37, 38d, and 38e).
He placed the rappellers, hand crews, and a member of the Moyer helitack crew at risk during the afternoon of July 22 (findings: 13k, 16h, 16i, 17, 29, 35, and 38d).
He did not act on his decision to abandon his plan for the upper helispot (H-2). The rappellers continued to execute the original plan, which delayed their departure from the site (findings: 13i, 13k, and 31).

3. The IC'S attention was diverted to issues other than the Cramer Fire.

The IC Type III was performing collateral duties, diluting his attention to Cramer Fire management on July 22 (findings: 38c and 38e).

4. There was a failure to comply with policy.

Selected personnel involved with the fire did not comply with policies and procedures in the fire management plan and with agency fire management directives ( appendix e) that provided direction to:

Prepare a complexity analysis (IC Type III) (findings: 1a, 8, and 9).
Prepare a wildland fire situation analysis (district ranger) (findings: 1a, 8, and 9).
Use safety officers on Salmon-Challis National Forest (SCNF) incident teams (IC Type III, forest fire staff) (findings: 16f and 38a).
Make adjustments in midslope tactics based on fire suppression hazards (IC Type III) (findings: 1b, 13c, 13d, 13e, 13i, 25, and 26).
Understand and know how to implement the Ten Standard Firefighting Orders ( appendix e; findings: 13a, 13g, 16, 17, 18j, 21, 29, 30, 35a, 35c, 38c, and 38e).
Recognize and mitigate the 18 Watch Out Situations ( appendix e; findings: 13d, 13i, 16, 17, 21b, 21c, 22, 25, 26a, 26d, 29, and 35)*

* It is not known, nor will it ever be known for certain from the investigation, the degree to which the rappellers failed to comply with policy - especially the Ten Standard Firefighting Orders and the 18 Watch Out Situations.

5. There was a failure to recognize and adjust suppression strategy and tactics when initial fire suppression efforts failed.

After initial attack efforts did not contain the fire, fire managers failed to perform required additional analyses upon which to base a successful suppression strategy. They also failed to continually reevaluate the situation and modify the plan as fire conditions changed and as requested resources were not available.

A complexity analysis and a wildland fire situation analysis were not prepared for the Cramer Fire (findings: 1a, 8, 9, and 18b).
A key management position on the fire - a safety officer - was not filled (findings: 16f and 38a).
Operational plans were an extension of the initial-attack response with no trigger points to reevaluate strategy. There were also no clearly articulated suppression objectives and no effective contingency plans (findings: 1a, 8, 9, 12, and 13).
Suppression strategies were not adjusted based on the nature and availability of the resources (findings: 13d, 13e, 13h, and 13j).

6. There was a failure to accurately assess the fire situation, hazards, and risks on the Cramer Fire.

Cramer Fire personnel failed to recognize and/or address the severity of the fire conditions, which impeded their ability to make timely decisions and take appropriate actions on July 22.

Fire personnel were unaware of the severe fire behavior potential of the ceanothus brush field, as indicated by its designation as a safety zone for the rappellers, and they failed to recognize the potential of the fire in the lower Cache Bar drainage on July 22 (findings: 26d, 30, 35e, and 35f).
Of the four preidentified safety zones, the black near H-1 was the only appropriate safety zone (findings: 30, 35b, 35e, and 35f).
There was inadequate change in oversight, strategy, or tactics on the Cramer Fire in response to the extreme fire danger and changing fire conditions (findings: 12, 13, 25, 28, and 44).
There were inadequate briefings and alerts to acknowledge extreme fire danger and fire behavior potential in the Cramer Fire area (findings: 16g, 25, 26, and 27).
Adequate safety mitigation measures were absent in the tactical plan. The integrity of H-2 was dependent on keeping fire below H-2 and out of the Cache Bar drainage. This was not established as an incident objective (findings: 13, 16f, 16g, 29, and 38a).
No action was taken on the fire below the west ridge in the Cache Bar drainage (findings: 35a and 35c).
Though they were asked if they needed to go to a safety zone shortly before the burnover, the rappellers did not seek a safety zone, because they were told a helicopter was coming. They were not directed to safety zones as warning signs increased (findings: 31, 32, and 35c).
Fire behavior in the Cramer Creek drainage and the eventual burnover of H-1 focused the attention of fire personnel and distracted their focus away from H-2 (findings: 13j, 16i, 29, 35a, 35c, 38d, and 43).
H-2 was perceived as a safe place even though visibility was limited and conditions changed (findings: 13g, 17, and 35).

7. There was inadequate integration of the H-2 operation into the Cramer Fire operation.

The rappellers, after being dropped at H-2, were largely disconnected from ongoing operations and were busy accomplishing a single task. Communications with them were inadequate.

The rappellers did not have adequate supervision to provide for their safety, and there was confusion as to who their supervisor was (findings: 38 and 42).
There was no agreed upon course of action to mitigate the changing and dangerous situation for the H-2 operation until it was too late (findings: 13b, 13g, 13h, 13i, 29, 31, 32, 33, and 35).
The rappellers' obscured view of the fire below them, the focus on their task of clearing a helispot, and lack of awareness about changing fire activity resulted in insufficient information upon which to make appropriate decisions and caused them to act as if they were in a secure position (findings: 13e, 13i, 13j, 13k, 17, 27g, 31, 32, 35a, and 35c).

8. There was a delay in formulating and executing a plan to retrieve the rappellers from H-2.

The IC's decision to retrieve personnel from H-2 was not effectively communicated or implemented until the personnel on H-2 requested helicopter retrieval (findings: 13i and 31).
A helicopter retrieving a firefighter east of H-1 could have removed personnel from H-2 during the same flight (findings: 16h and 38d).
Because helicopters were unavailable, they could not retrieve the rappellers at a critical point in time (findings: 18j, 29c, 31, 32, and 33).
A helicopter was not launched the first and second time it was requested, but the rappellers were told that a helicopter was on its way (facts: 189, 190, and 195).
Lead plane 41 assumed that the rappellers had been retrieved from H- 2 (finding: 18i).

9. The rappellers were caught in a burnover.

The rappellers were overrun by fire outside of the two previously identified "safety" zones for H-2 and died without deploying their fire shelters. Conditions at the fatality site were not survivable in a fire shelter. One of the designated "safety" zones for H-2 may have been survivable in fire shelters (findings: 30, 33, 34, and 35f).

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Cramer Fire Dedication

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