Lessons Learned
“Safety
Zone” newsletter, July, 2004
Lessons Learned —
author, date unknown
One-Year Anniversary Letter
by Kelly Close, FBAN
Declaration on Cramer
Redactions, by James Furnish, April, 2005
FSEEE v. USFS, FOIA
Civil Lawsuit Order,
December, 2005
FOIA
Request to USFS, December, 2005
FOIA Appeal to USFS,
February, 2006
Management Evaluation Report
Investigation Team Information
Synopsis of the
Cramer Fire Accident Investigation
Causal Factors
Contributing Factors
Addendum
Factual Report
Executive Summary
Narrative
Background
(facts 1 - 57)
Preaccident
(facts 58 - 201)
Accident
(fact 202)
Postaccident
(facts 203 - 237)
Findings
Appendix A
Resources on the Fire
Appendix B
Cramer Fire Timeline
Appendix C
Fire Behavior and Weather
Prior Conditions
Initial Phase
Transition
Phase
Acceleration
Phase
Entrapment
Phase
Appendix D
Equipment Found at H-2 and the Fatalities Site
Appendix E
Fire Policy, Directives, and Guides
OIG Investigation
OIG FOIA Response,
February, 2005
2nd FOIA Request to OIG,
April, 2006
2nd OIG FOIA Response,
August, 2006, (1.4 mb, Adobe .pdf file)
OSHA Investigation
OSHA Cramer Fire Briefing Paper
• Summary and ToC
• Sections I-IV
• Sections V-VII
• Section VIII
• Acronyms/Glossary
OSHA South Canyon Fire
Briefing Paper
Letter to District
Ranger, June 19, 2003
OSHA Investigation Guidelines
OSHA News Release
• OSHA Citation 1
• OSHA Citation
2
• OSHA
Citation 3
USFS Response
OSHA FOIA Letter
Adobe PDF and Microsoft Word versions of documents related to
the Cramer Fire can be downloaded from the U.S.
Forest Service website.
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Management
Evaluation Report
Cramer Fire Fatalities
North Fork Ranger District
Salmon-Challis National Forest
Region 4
Salmon, Idaho - July 22, 2003
Contributing Factors
A contributing factor, developed from the findings, is defined as a factor
that sets the stage for an accident or incident or increases the severity
of injuries or extent of property damage.
1. The effectiveness of the SCNF fire management organization was impaired.
Ineffective implementation of reallocated authority and responsibility
for Type II fires, in combination with vacancies in key fire management
positions, impaired communication and hampered decisionmaking, reducing
organizational effectiveness. This contributed to a lack of management
oversight, a failure to comply with policy, and a failure to provide guidance
to the Cramer Fire IC Type III (findings: 2,
3, 4, 6,
8, 9, 12,
13a, 13b,
16f, 18e,
18g, 38e,
39, 44).
2. There was a shortage and misallocation of resources.
- The forest presuppression, suppression, and administrative workload
exceeded the resources available, creating a shortage of management
and suppression resources. More resources could have been sought by
requesting additional severity funding and temporary details by off-forest
personnel, but they were not (findings: 2b,
2c, 2d,
6, and 44d).
- Given the ongoing fire activity and known hazards in the Salmon River
Breaks, better trained and experienced Type I crews, which were available,
were not ordered for the Cramer Fire (findings: 1b,
18g, 22,
25, 26,
and 44f).
- Type II fires on the forest received higher priority, more attention,
and greater management oversight from the forest fire staff and North
Fork/Middle Fork district ranger than the Type IV/Type III Cramer Fire.
This contributed to unsafe and ineffective suppression efforts on the
Cramer Fire (findings: 2d, 9,
13a, 13b,
13h, 13j,
16f, 18c,
18e, 18g,
and 44).
3. Initial attack was ineffective.
Initial attack suppression efforts on the Cramer Fire were inadequate
on July 20 and 21, causing the fire to grow in size and complexity under
extreme burning conditions. Initial attack was delayed, district fire
suppression resources were unavailable, crews were diverted or lost and
unable to work the fire, and a helicopter was not used when it was available
(findings: 2d, 13a,
13c, 18c,
18e, 18f,
19, and 27a-d).
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