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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Freedom of Information Act appeal,
re: Cramer Fire FOIA 06-3051-R
February 10, 2006
Kent Maxwell
Colorado Firecamp, Inc.
9008 County Road 240
Salida, CO 81201
Chief Dale Bosworth
USDA Forest Service
1400 Independence Avenue, SW Mail Stop: 1143
Washington, DC 20250-1143
Dear Chief Bosworth:
On behalf of Colorado Firecamp, I am appealing the:
A) fee waiver denial,
B) redaction of Cramer Fire transcripts and logs,
C) adverse determination of fee assessed for Cramer Fire
audio recordings,
D) adverse determination of redactions proposed for the Cramer
Fire audio recordings,
resulting from our Freedom of Information Act request dated Dec. 19,
2005 in which I requested:
1. audio recordings,
2. transcripts,
3. Central Idaho Dispatch logbook entries,
4. Cove Creek Helibase logbook entries,
5. Indianola Helitack Base logbook entries, and
6. any subsequent timelines or summaries
of the radio transmissions (including Forest Net, air-to-air, and air-to-ground)
concerning the Cramer Fire near North Fork, Idaho on the Salmon-Challis
National Forest from July 20, 2003 at 1630 hours when the fire was first
reported by the Long Tom Lookout, through July 23, 2003 at 1800 hours
when the Cramer Fire accident investigation team arrived in Salmon, Idaho.
Pursuant to 5 U.S.C. § 552(a)(4)(F), “the circumstances surrounding
the withholding raise questions whether agency personnel acted arbitrarily
or capriciously with respect to the withholding.”
A) FEE WAIVER DENIAL
In a letter dated Jan. 18, 2006 denying our request for a fee waiver,
Mr. Charles R. King, Director of the Office of Safety & Occupational
Health, wrote, “You contend that the ‘larger public interest
will be served’ by release of the audio tapes in this case. However,
the only public interest cognizable under FOIA is that the information
sheds light on the agency performance of its statutory duties.”
Mr. King was quoting from the following sentence in our FOIA request:
“The larger public interest will be served by learning lessons from
the events that led to the deaths of USFS firefighters Jeff Allen and
Shane Heath.”
It is ironic and pathetic that Mr. King, whose principle duties are to
ensure agency compliance with section 19 of the Occupational Safety and
Health Act of 1970, 29 U.S.C. § 668, as amended, would claim that
these records fail to “shed light on agency performance of statutory
duties.” Among others, the Forest Service statutory duty to “furnish
employees employment and a place of employment free from recognized hazards
that were causing or likely to cause death or serious physical harm”
led to the Cramer Fire willful, serious, and repeat citations issued by
the Occupational Safety and Health Administration.
Additionally, as part of his fee waiver denial, Mr. King stated, “We
have determined that the ‘words’ from the audio tape are contained
in the 165 pages of written transcripts that we plan to release to you
and that the ‘voice inflections’ on the audio records will
not ‘shed light on the decisions and actions of United States Forest
Service (USFS) employees and contractors with regard to firefighter safety,
situational awareness, direct supervision, and management oversight while
suppressing a wildland fire on public lands’ as stated in your request
letter.”
In fact, the 165 pages of transcripts and logs have shed light on precisely
that. We are now convinced that the Cramer Fire Accident Investigation
Factual Report and Management Evaluation Report are seriously flawed.
Both reports state:
“At 0943, two Indianola helitack personnel rappelled from H-193
into a site above the fire to build H-2. The rappel spotter in H-193 estimated
it would take one hour to clear H-2. During the morning and afternoon,
Cove Creek helibase contacted the rappellers on H-2 several times, inquiring
about their progress. The rappellers responded each time that they needed
another 15 minutes to 1 hour before the helispot was completed.”
Yet, in the released Forest Net transcripts, on July 22, 2003 at 12:36,
someone (whose name and/or position title is redacted) says: “If
you've got time, could you look around that Helispot there and see if
we could improve it in any way, uh, for a possible medium?” and,
seconds later, “I prefer???...just do as much as you can ???”
Jeff Allen and Shane Heath did not decide on their own to change their
original hour-long assignment of merely cutting “a snag and six
trees” to actually spending 5 hours and 22 minutes to fall more
than 70 trees. Someone, acting in an official capacity and in the Agency's
performance of statutory firefighting duties, asked them to do the work
they did.
Finally, as part of his fee waiver denial, Mr. King stated, “In
addition, we have determined that the information, you are requesting
in items 2-6, has be [sic] released to the public multiple times.”
If such were in fact true, one might expect that the Cramer Fire radio
transcripts and logs requested in items 2-6 would already appear in the
Forest Service electronic reading room, as provided for in 5 U.S.C. §
552(a)(2) including (a)(2)(D)-(E), as records that “have become
or are likely to become the subject of subsequent requests for substantially
the same records.”
I request that you grant our fee waiver appeal in consideration of the
above and the following 6 factors, which are identical to our original
fee waiver request, that apparently did not receive consideration:
(1) The audio recordings, transcripts, dispatch logs and timelines/summaries
concern “the operations or activities of the government” as
records of official communication between individuals engaged in wildfire
suppression duties while employed or contracted by the United States Government;
(2) The disclosure is “likely to contribute” to an understanding
of government operations or activities. The disclosure will shed light
on decision-making and risk management related to USFS command and control
of incident operations during initial attack, extended attack and transition
wildland fires.
(3) Disclosure of these materials will contribute to an understanding
of the subject by the general public likely to result from disclosure.
Colorado Firecamp has demonstrated an ability to disseminate information
to the general public, particularly with regard to firefighter safety
and entrapment fatality investigations. Previous FOIA requests to the
Occupational Safety and Health Administration (OSHA) and Bureau of Land
Management (BLM) resulted in disclosure of investigation reports related
to the Cramer Fire and the 1995 Point Fire. By means of a simple request
to the California Department of Forestry and Fire Protection (CDF), Colorado
Firecamp prompted the release of the full, un-redacted investigation report
of the 2004 Tuolumne Fire. Colorado Firecamp has assembled the most complete
and accessible internet collection of investigation reports related to
the entrapment fatality on the 2003 Cedar Fire. Please see:
http://www.coloradofirecamp.com/Cramer/index.htm
http://www.coloradofirecamp.com/point-fire/index.htm
http://www.coloradofirecamp.com/tuolumne_fire/index.htm
http://www.coloradofirecamp.com/cedar_fire/index.htm
During 2005, Colorado Firecamp adapted a case study of the Point Fire
tragedy and mailed the instructor guide, student handout and video to
294 fire departments in Colorado. In addition, the print documents with
video ordering information received national distribution by posting on
the Wildland Fire Lessons Learned Center website. http://www.myfirecommunity.net/documents/Point_Fire_Case_Study.pdf
Colorado Firecamp will incorporate the requested disclosure in a case
study of the Cramer Fire, to be made freely available to the wildfire
community. Review of entrapment incidents is required for the Wildland
Fire Safety Training Annual Refresher (WFSTAR). Colorado Firecamp has
planned a training exercise, “Wildfire Safety Drill: Mobilizing
Lessons Learned” scheduled for the weekend of April 28-30, 2006.
This will be an annual 2-day exercise dedicated to improving firefighter
safety at initial attack and transition fires. The Wildfire Safety Drill
will serve as a showcase for the best practices of the annual fireline
safety refresher class.
In support of our theme of “mobilizing lessons learned,”
the Drill will include evening presentations about fatality entrapments.
We have a commitment from Fire Chief Jeff Meston for a presentation by
the Novato Fire Protection District about the Cedar Fire tragedy. Our
other keynote presentation will feature the Cramer Fire, to include portions
of the requested disclosure.
In early 2006, we anticipate approval of a $147,000 grant request to
the Department of Homeland Security to improve wildland firefighter safety.
The centerpiece of our "Fire Origins" project will be the creation
of a digital archive of 50 wildland entrapment fatality reports to be
hosted by the Wildland Fire Lessons Learned Center in Tucson, Arizona.
Additionally, we will revise the National Wildfire Coordinating Group
(NWCG) PMS-490 curriculum, “Lessons Learned: Fatality Fire Case
Studies.” We will create a more in-depth case study of the Cramer
Fire for inclusion in the PMS-490 revised curriculum. Portion of the requested
audio recordings and transcripts would be included to stimulate discussion
and understanding of the 5-step risk management process.
http://www.coloradofirecamp.com/fire-origins/index.htm
(4) The disclosure is likely to contribute “significantly”
to public understanding of government operations or activities. Specifically,
public understanding will increase with regard to the use and effectiveness
of radio communications within the context of command and control of USFS
fire suppression operations. These operations include: on the evening
of July 20th when a type 3 IC had been assigned but failed to assume command
of the Cramer Fire; on the morning of July 21st when available helicopter
resources were not utilized by the type 4 IC; on the afternoon of July
21st when the forest aviation officer became concerned about command and
control under a second type 3 IC; on the morning of July 22nd while construction
of Helispot 2 was proceeding; on the afternoon of July 22nd as the various
the other crews continued working the fire's east flank near Helispot
1, a lookout was inserted and extracted by helicopter, and the IC dealt
with the need to reassign aerial resources to other fires; the critical
half hour prior to the burnover of H-2; and the rescue/recovery efforts
following as the first type 3 IC assumed command of the incident.
The disclosure also relates to a 1999 report prepared by the RAND Corporation's
National Defense Research Institute, “Command Concepts:
A Theory Derived from the Practice of Command and Control.” http://www.rand.org/pubs/monograph_reports/MR775/index.html
In recent years, the fire service has learned from military operations
and research, just as the military has studied the fire service. The Command
Concepts theory “centers on the idea of a command concept, a commander's
vision of a military operation that informs the making of command decisions
during that operation. The theory suggests that the essential communications
up and down the chain of command can (and should) be limited to disseminating,
verifying, or modifying command concepts. The theory also suggests, as
an extreme case, that an ideal command concept is one that is so prescient,
sound, and fully conveyed to subordinates that it would allow the commander
to leave the battlefield before the battle commences, with no adverse
effect upon the out-come.” (Builder, et al.)
The events of the Cramer Fire, as illuminated by the requested disclosure,
will shed light on government activities as they relate to the command
concept: 1) about the enemy (wildfire) and his plans (expected fire behavior,)
2) about our (USFS) force dispositions and plans, and 3) about contingencies.
(5) No commercial interest exists for Colorado Firecamp with respect
to the materials requested for disclosure. As a 501(c)(3) non-profit,
Colorado Firecamp is clearly not seeking financial gain from this disclosure.
(6) Because the primary interest in disclosure is to improve firefighter
safety and we have no commercial interest in the requested information,
clearly, the public interest is of greater magnitude than any commercial
interest.
In addition to the above 6 factors, 7 CFR, Subtitle A, Subpart A(3) including
A(3)(ii)-(iii), provides that the Forest Service may waive or reduce fees
“Where the recipient is engaged in a nonprofit activity designed
for the public safety, health, or welfare” or “Where it is
determined that payment of the full fee by a … nonprofit group would
not be in the interest of the program involved.” Both of those appear
to apply in our request.
B) REDACTION OF CRAMER FIRE TRANSCRIPTS AND LOGS
In the letter dated Jan. 20, 2006 accompanying the release of 165 pages
of Cramer Fire transcripts and logs, Mr. King stated: “Exemption
6 of the FOIA permits the Government to withhold all information about
individuals in ‘personnel and medical files and similar files,’
where the disclosure of such information ‘would constitute a clearly
unwarranted invasion of personal privacy.’ Exemption 6 also involves
a balancing of the public’s interest in disclosure against the individual’s
privacy interest. We have determined that the names and position titles
of persons, on the enclosed transcripts, that were involved an [sic] accident
investigation must be withheld pursuant to Exemption 6 of the FOIA, 5
U.S.C. 552(b)(6).”
First, the public release of the Cramer Fire Accident Investigation Report
by the Forest Service includes all position titles. The withholding of
position titles from the 165 pages of transcripts and logs lacks a sound
legal basis and appears to be arbitrary and capricious. It is also our
understanding that Cramer Fire incident commander Alan Hackett waived
any supposed privacy claim to release of his name or position title in
his pre-trial diversion agreement.
Secondly, we question the redactions of four lines of text on page 3
and two lines of text on page 6 of the transcript of Cramer Fire Radio
Recordings, July 22, 2003, Forest Net 1200-1500. These redactions do not
seem to be covered by the FOIA exemptions cited in Mr. King's partial
response dated Jan. 20, 2006. It appears that portions of these specific
transmissions have already been released in Facts 194 and 201 of the Cramer
Fire Accident Investigation Factual Report. We also question the redaction
of two lines of text from the third page of the Cove Creek Helibase log.
Thirdly, both the Factual Report and OSHA investigation cited the use
of first and last names in Cramer Fire radio communications. Fact 187
states in part: “Lead plane 41 was confused about the location of
Allen and Heath because personnel on the fire were using first names and
last names on the radio.” Documents released by OSHA indicate that
the specific names causing confusion were Alan Hackett / Jeff Allen and
Heath Hand / Shane Heath. The significant effect in the resulting tragedy
tips the balance in favor of the public interest in disclosure of these
names in the transcripts and logs.
C) ADVERSE DETERMINATION OF FEE ASSESSED FOR
CRAMER FIRE AUDIO RECORDINGS
The Forest Service has attempted to assess an arbitrary and capricious
fee lacking a sound legal basis, apparently in an attempt to use an inflated
cost to withhold requested records.
In the letter dated Jan. 18, 2006 Mr. King wrote: “However, the
original audio recordings will require electronic ‘redaction’
to remove personal information. From past experience we know that it could
cost approximately $1,000 for the electronic redaction process.”
In the letter dated Jan. 20, 2006 Mr. King further wrote: “In your
email message to Sherry Turner dated January 19, 2006, you asked for clarification
regarding whether the redaction of the audio tapes was considered review
or duplication. Pursuant to Title 7 Code of Federal Regulations (CFR),
Subtitle A, Part 1, Subpart A, Appendix A, § 4(c) the fee for other
forms of duplicated records, in this case audio tapes, is the actual direct
cost of producing the record.”
In an e-mail message dated Feb. 6, 2006 George A. Vargas provided a cost
estimate of $1,732.46 for 50 hours of work for a GS 11 Step 5 employee
to provide review services. The dollar figure of $1,732.46 appears to
have been calculated using the formula applicable for manual search services,
of employee salary rate plus 16%, as found in 7 CFR Subtitle A, Part 1,
Subpart A, Appendix A, § 4(d)-(d)(1).
Mr. Vargas stated, “redacting an audio tape is time-consuming mainly
because one has to be extremely careful not to violate any FOIA applicable
exemptions.” That seems to be consistent with 7 CFR, Subtitle A,
Subpart A § 1.11(b), which states: “Review services include
processing any records for disclosure e.g., doing all that is necessary
to redact exempt portions and otherwise prepare records for release.”
The legislative intent also appears to be that redaction is a cost of
review. 5 U.S.C. § 552(a)(4)(A)(iv) which states in part: “Review
costs shall include only the direct costs incurred during the initial
examination of a document for the purposes of determining whether the
documents must be disclosed under this section and for the purposes of
withholding any portions exempt from disclosure under this section.”
According to 7 CFR Subtitle A, Part 1, Subpart A, Appendix A, §
5(b): “Educational and non-commercial scientific institution requesters--Fees
for this category of requesters shall be limited to the cost of providing
duplication service alone, minus the charge for the first 100 reproduced
pages. No charge shall be made for search or review services.”
Colorado Firecamp is a 501(c)(3) non-profit, wildland firefighter school
and has requested classification as an educational institution conducting
scholarly research.
By our understanding, the fee for providing Cramer Fire audio recordings
to Colorado Firecamp should be limited to the cost of duplication alone.
Our preferred media format for the release of the audio recordings is
on CD-R 80 minute compact discs, which retail for about $1 each, although
you can get a better deal by buying in multi-packs. We estimate (based
upon information provided by my teenage step-daughter) that it should
take a GS 4 Step 1 employee about an hour to burn 5 discs. The total cost
of duplication should amount to about $25, if the scope is limited to
6 hours of audio recording. We have previously agreed to pay up to $250
for this FOIA request.
As of yet, we have not received information regarding the existence of
audio recordings of Cramer Fire air-to-air, air-to-ground, or other radio
transmissions responsive to our request. The scope of our request may
exceed 6 hours.
In the letter dated Jan. 18, 2006 Mr. King stated that if I had any questions,
I could contact the Ms. Turner by e-mail, fax, telephone, or mail. Ms.
Turner put me in contact with Mr. Vargas to resolve questions about the
fee determination as we considered reasonable limiting the scope of our
request for audio recordings.
In an e-mail dated Feb. 8, 2006, Mr. Vargas wrote: “Mr. Maxwell,
With the utmost of respect, I would like to request that from now on any
communication on subject above, e.g., appealing the fee waiver denial,
be done via formal correspondence, answering the questions Sherry provided
to you in her last e-mail and mailing it to: USDA Forest Service, FOIA
1400 Independence Avenue, SW Washington, DC 20250-1143 We will analyze
your appeal in the same professional way we analyze others. VR George
A. Vargas”
There appears to be no sound legal basis for Mr. Vargas limiting my opportunity
to exhaust administrative remedies, i.e. communicate by e-mail with FOIA
staff, to resolve the issues such as the fee determination. In addition
to the above, this arbitrary and capricious act constitutes an adverse
determination.
D) ADVERSE DETERMINATION OF THE EXTENT OF REDACTIONS
PROPOSED FOR THE CRAMER FIRE AUDIO RECORDINGS
In an e-mail dated Jan. 31, 2006, Ms. Turner wrote: “However, you
should be aware that since the voices are identifiable, not only the names
would be withheld but also whatever the person (whose name was withheld)
said would be withheld. In other words you already have (in the form of
the transcripts) more information than you will receive in the redacted
audio tapes.”
The administrative record clearly does not support this decision in this
case. Such withholding fails to consider the nature of the requested document
and to consider its relationship to the public interest.
CONCLUSION
I simply ask that the Forest Service comply with statutory and regulatory
provisions in this matter.
Kent
_______________________________
Kent Maxwell, coordinator
Colorado Firecamp, Inc.
"keeping quality in qualification"
(719) 539-9329 (work)
(719) 539-2730 (fax)
9008 County Road 240
Salida, CO 81201
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