Colorado Firecamp - Cramer Fire, OSHA Briefing Paper

Notice 1, Item 1 - 29 CFR 1960.8(a): The agency did not furnish employees employment and a place of employment free from recognized hazards that were causing or likely to cause death or serious physical harm, in that employees were exposed to the hazards of burns, smoke inhalation, and death from fire-related causes:

Cramer Fire: On or about July 21 and 22, 2003, as the fire increased in size and complexity, shifted to extended attack, and the suppression strategies and tactics were not successful, an appropriate complexity analysis was not conducted and reviewed. The agency did not ensure that hazardous fires increasing in complexity are quickly identified and a safe transition occurs to the appropriate level incident response.
Cramer Fire: On or about July 21 and 22, 2003, when fire behavior thresholds at which large fires typically occur were exceeded, fire program managers did not provide additional supervisory and suppression support.
Salmon-Challis National Forest: The remote automated weather stations (RAWS) near the fire had not received maintenance and calibration before the start of the fire season. The temperature and relative humidity sensor was reporting incorrect information from the Skull Gulch RAWS, closest to the Cramer Fire.

Notice 1 Item 2 - 29 CFR 1960.25(c): All areas and operations of each workplace did not receive sufficient unannounced safety and health inspections at least annually, and more frequently where there is an increased risk of accident, injury or illness due to the nature or the work performed:

Cramer Fire: On or about July 21 and 22, 2003, inspections of the fire operations were not conducted for safety and health hazards on the fire to determine compliance with LCES (Lookouts, Communications, Escape Routes, and Safety Zones), the Ten Standard Firefighting Orders, and Eighteen Situations that Shout Watch Out.

Notice 1 Item 3 - 29 CFR 1960.57: The Agency did not provide training to safety and health inspectors with respect to identifying and evaluating hazards and suggesting general abatement procedures:

Training provided to District Rangers who conduct supplemental safety and health inspection on the type 3, 4, and 5 wildland fires was not sufficient to enable them to adequately identify, evaluate and suggest general abatement procedures related to complex wildland fire safety.

Willful Notice

Notice 2, Item 1 - 29 CFR 1960.8(a): The agency did not furnish employees employment and a place of employment free from recognized hazards that were causing or likely to cause death or serious physical harm, in that employees were exposed to the hazards of burns, smoke inhalation, and death from fire-related causes:

Cramer Fire: On July 22, 2003, all of the Ten Standard Firefighting Orders from the Interagency Standards for Fire and Fire Aviation Operations 2003 were violated. Management in the Salmon-Challis National Forest and leadership at the Cramer Fire did not ensure that the Ten Standard Firefighting Orders were followed. The Orders were violated as follows:

Fire Order 1 – Keep informed on fire weather conditions and forecasts. A spot weather forecast was not requested or received for July 22. Updated information from the National Weather Service indicating stronger winds than specified in the zone forecast was not known and, therefore, could not be relayed to personnel on the fire.

Fire Order 2 – Know what your fire is doing at all times. The Incident Commander and the rappellers failed to become aware of the status of the fire burning below the Helispot-2 (H-2).

Fire Order 3 – Base all actions on current and expected behavior of the fire. Although management, leadership, and personnel on the fireline were aware that seasonal conditions were extreme, strategies and tactics were not adjusted to account for expected fire behavior during the afternoon of July 22. As fire activity increased and conditions worsened, tactics were not adjusted and the rappellers were left in harm’s way.

Fire Order 4 – Identify escape routes/safety zones and make them known. The escape routes and safety zones for the rappellers at H-2 were not appropriate due to the presence of unburned fuels and smoke from the advancing fire. Also, a helitack was placed on a hillside near Helispot-1 (H-1) without the identification of escape routes and safety zones.

Fire Order 5 – Post Lookouts when there is possible danger. Lookouts were not posted to provide a view of critical fire activity. The rappellers at H-2 did not have a lookout while working in an isolated area uphill from the fire activity with the weather getting hotter, drier, and winds increasing.

Fire Order 6 – Be alert. Keep calm. Think Clearly. Act decisively. The Incident Commander appeared to be overwhelmed by the number of logistical and operational duties to be performed, and did not have the situational awareness to be alert to increasingly hazardous conditions. Key leadership and personnel at the fire did not act decisively to direct the rappellers to safety zones or remove then from their hazardous work location at H-2. The rappellers remained working at the helispot even after a decision had been made to not use it.

Fire Order 7 – Maintain prompt communications with your forces, your supervisor, and adjoining forces. Lines of communication were inadequate between fire leadership and the rappellers at H-2. The rappellers received no direct supervisory communication and had not been informed of the increasing fire activity in the Cache Bar drainage below them, nor had they been informed of the decision to abandon the plan to fly crews into the spot they were clearing.

Fire Order 8 – Give clear instructions and insure they are understood. An employee was placed by helicopter on a hillside uphill from active fire without clear instructions; this was not originally planned, the employee was not wearing a flight helmet and did not receive directions. Also the pilot for the lead plane was not instructed to be the lookout for the rappellers while directing retardant drops and handling other air attack duties.

Fire Order 9 – Maintain control of your forces at all times. There was no supervisory control over the rappellers at H-2 to ensure their safety, even though the Incident Commander was acting as their supervisor. Also, the IC failed to communicate his decision to abandon his plan for the upper helispot; thus the rappellers continued to execute the original plan, thereby delaying their departure from the hazardous work location.

Fire Order 10 – Fight fire aggressively, having provided for safety first. The tactics implemented lacked critical safety procedures, including adequate escape routes and safety zones, posting lookouts, and basing actions on the extreme fire conditions present at the time. Also, the safety of the rappellers working in isolation at H-2 was compromised due to the focus on fire operations and activity elsewhere. Furthermore, firefighters continued to be offloaded at H-1 while it was threatened by fire.

Cramer Fire: On July 22, 2003, Forest Service managers and supervisory personnel at the Cramer Fire did not take immediate actions to mitigate the “18 Situations That Shout Watch Out” listed in the Interagency Standards for Fire and Fire Aviation Operations 2003. Those which were not mitigated included the following:

Watch Out #1 - Fire not scouted and sized up. On July 22, as conditions became increasingly hazardous due to increased activity and complexity, the Incident Commander failed to have the fire scouted and sized up.

Watch Out #3 - Safety zones and escape routes not identified. Safety zones and escape routes had not been re-evaluated and re-established as conditions changed. Escape routes through unburned fuels, such as along a ridge potentially exposed to intense heat from fire in the drainage, had been compromised and were not adequate.

Watch Out #4 - Unfamiliar with weather and local factors influencing fire behavior. A spot weather forecast had not been obtained for the day. Leadership and firefighters were not aware that stronger winds were expected during the afternoon.

Watch Out #5 - Uninformed on strategy, tactics, and hazards. The Incident Commander failed to inform the rappellers working on H-2 of the growth of the hazardous fire burning in the drainage below them.

Watch Out #6 - Instructions and assignments not clear. Instructions regarding the placement of lookouts on the fire were not clear. An employee was placed by helicopter on a grassy clearing across the drainage and uphill from active fire without being given instructions or safety information.

Watch Out #7 - No communication link with crew members, supervisors. A communication link was not maintained between the rappellers and the Incident Commander acting as their direct supervisor.

Watch Out #8 - Constructing fireline without safe anchor point. Crews were working throughout the day on July 22 to construct fireline without establishing a safe anchor point.

Watch Out #9 - Building fire line downhill with fire below. Rappellers were constructing a helispot (H-2) in order to transport crews to an area above the active fire in rugged terrain and extreme conditions.

Watch Out #11 - Unburned fuel between you and fire. Rappellers were working to construct a helispot uphill from active fire with large amounts of unburned fuels, such as grasses, Ceanothus brush, and pine present between them and the active fire burning near the bottom of the Cache Bar drainage.

Watch Out #12 - Cannot see main fire, not in contact with anyone who can. Rappellers working to construct H-2 could not see the main fire, including areas below them on both sides of the ridge, and were not in contact with anyone who could see the hazardous fire developing below them in the Cache bar drainage.

Watch Out #13 - On a hillside where rolling material can ignite fuel below. The rappellers were working on a ridge between Cramer Creek and Cache Bar drainages. “Roll-outs” occurred throughout the Cramer Fire due to steep terrain, which allowed the fire to establish itself in the bottom of the Cache Bar drainage then rapidly spread up the drainage to the employee work location and safety zone.

Watch Out #14 – Weather is getting hotter and drier. The rappellers worked from mid-morning into the afternoon with temperatures increasing to near 100 degrees F and relative humidity decreasing to between 10 to 15 percent. The trend for the three days of the fire was recognized as increasingly hotter and drier conditions.

Watch Out #15 – Wind increases and/or changes direction. No changes in tactics or mitigation measures occurred for rappellers working to construct H-2 as afternoon winds and fire activity increased.

Watch Out #17 – Terrain and fuels make escape to safety zones difficult. Steep and rocky terrain made foot travel slow and hazardous. Fire was burning in the drainage below the helispot with unburned fuels between the work location and safety zone. The possible safety zone across the drainage did not meet the Interagency Standards’ definition of a safety zone “of sufficient size and suitable location that is expected to protect fire personnel from known hazards without using a fire shelter.”

Willful Justification -
The Willful classification is based upon the following:
(Refer to Findings and Casual Factors, Section VI for references and more detailed discussion)

Sufficient information exists to support a serious general duty clause violation of core firefighting safety principles, including employee exposure to well known and recognized hazards, direct employer knowledge, and feasible means to abate or control the hazards. There was a complete failure of key personnel and management to follow the Ten Standard Fire Orders and mitigate many of the Watch Out Situations evident in the hours and even days leading up to these fatalities. It is the wholesale failure of such core safety principles that points most directly to the "conscious disregard" and/or "plain indifference" to the dangers of a fire under widely recognized extremely hazardous conditions.

A) Hazards:

The hazards associated with this fire were clearly evident and well known by fire personnel and leadership, as well as Forest and District managers, but the hazards were completely disregarded for the rappellers at H-2.

Obvious hazards included, but were not limited to the following:

Extreme dry burning conditions (See section VI Findings, "Fire Conditions");

Historic extreme fire behavior in the area;

Steep topography;

Regular increasing afternoon winds and fire activity;

Lack of success with suppression for several days, with significant fire growth each day;

Hazardous situations described below in the "Common Denominators," "Tactical Watch Outs," and "Look Up, Down, Around."

Experienced personnel, the IC, and other key leaders on the fire, as well as District and Forest-level fire managers and line officers, all were aware from training and experience about the hazards of wildland firefighting. In addition, the key personnel involved with these fatalities were local firefighters from the Forest and were aware that conditions at the time were at the high end of extreme fire conditions. These individuals were also aware of the extreme fire behavior in this area of the SCNF from past fires.

The Forest Service recognizes that most fatal accidents occur on smaller fires or isolated portions of larger fires. In several reports among firefighting agencies, the "Common denominators of fire behavior on tragedy fires" are identical to the conditions surrounding this tragedy. The Common Denominators are conveyed in basic fireline training and are printed in a variety of frequently used and readily available publications, such as the Incident Response Pocket Guide carried by fireline personnel (PMS #461, Revised January 2002). Fire program managers, line officers, the Incident Commander, and fire leadership were aware of the hazardous nature of small and transitioning fires, yet did not take steps to ensure the safety of the rappellers during the same conditions.

Common Denominators of Tragedy Fires include the following:

On Relatively small fires or deceptively quiet areas of large fires.

This fire was considered a Type III incident. The IC felt he: could control by the fire by the end of the day with resources requested (Hackett, p. 18). The rappellers were working in an isolated area uphill from the fire. Most of the firefighting activities were occurring near H-1, which is where the ICs attention was focused (Hackett, pp. 54, 93; [————], p. 8).

The Incident Commander was aware of the Fire Orders, Watch Out Situations, Tactical Watch Outs, and Common Denominators which should have indicate the rappellers' location at H-2 to be hazardous. The IC did not perceive the situation as being hazardous enough follow safe procedures, post lookouts, and to use other methods to mitigate the hazards (Hackett, pp. 56,107).

In relatively (deceptively) light fuels such as grass, herbs and light brush.

It had been acknowledged that a "low intensity fire" was burning/backing down below the employees in the Cache Bar drainage ([————], pp. 38-39, 41; Hackett, pp. 14, 59, 66-67; [————], p.3-4; [————], pp, 11-13, 16, 22-24, 39; [————], p. 19). Fire and fuels were underestimated, including the potential for rapid spread in the volatile-burning waxy-leafed Ceanothus brush, prevalent between the employees and the fire in the drainage below them.

When there is an unexpected shift in wind direction or in wind speed.

The Salmon River gorge is widely known to have increased afternoon diurnal winds, predominantly up the canyon from the west, but also affected by adjacent drainages and topography (USFS Accident Report, Appendix A).
The spot weather forecast would have also called for higher winds, but was not obtained. The importance of obtaining weather forecasts is a core firefighting strategic and safety principle, and is addressed in the Standard Fire Orders and Watch Out Situations, and is present in the IC's Great Basin Incident Organizer. Yet the Incident Commander failed to obtain a spot forecast at any time on Tuesday July 22, 2003.
The weather on the prior days also included increased winds which lead to increased fire activity in the late afternoon and evening.

When fire responds to topographic conditions and runs uphill.
"Fires run uphill surprisingly fast in chimneys, gullies, and on steep slopes."

The Salmon River breaks is very steep country, up to 70 degree to even 90 (mostly rock) degree slopes in an area known for extreme fire behavior. The Incident Commander was also the Assistant Fire Management Officer for this area and had the knowledge and experience to recognize the hazards of working above a fire in such steep terrain. However, the rappellers remained working above the main fire in these conditions for more than five hours without any attempt to mitigate or minimize the hazardous circumstances."

Most fires are innocent in appearance before unexpected shifts in wind direction and/or speed results in 'flare-ups' or 'extreme fire behavior.' In some cases, tragedies occur in the mop up stage."

In addition to the above Common Denominators, the IRPG contains the following safety guidelines and reminders in the first pages of the guide:

Look Up, Down and Around (p 2), including the statement to "Pay special attention to indicators" listed below that were present at the Cramer Fire:

Indicators
- Low RH « 25%)
- High temps (> 85F)
- Steep slopes (>50%)
- Chute - Chimneys

- Surface winds above 10 mph

Cramer Fire
- Low teens at 1400, forecast <10%
- Approaching 100 F
- >70 to 90%
- H-2 near top of a steep and narrow drainage
- Brisk Afternoon Winds, gusts up to 30 mph

Tactical Watch Outs (p5) (each requires implementing hazard controls)
The following were present at the Cramer Fire:
- Unburned fuel remains between you and the fire;
- Delivered by aircraft to the top of the fire;
- Terrain and/or fuels make escape to safety zones difficult;
- Small fire transitioning to a larger fire or an isolated area of a large fire;
- Suppression resources are fatigued or inadequate;
- Assignment depends on aircraft support.

Even though the extreme burning conditions potential was known, there continued to be indifference to the applicability of the rules and the Cramer Fire on the July 22nd was thought of as, 'Just another fire, just another day.' And the key leadership at the fire was careless or not diligent in discovering or eliminating a violation.

B) Safety Standards:

Plain indifference to the core safety standards which were well known. It is evident from the complete lack of adherence to almost all of the core safety principles, as well as interviews of personnel and management on this fire, that those responsible for directing and overseeing activities on the Cramer Fire on July 21 and 22, 2003, either consciously disregarded or were plainly indifferent to important basic safety rules.

The most basic safety rules for federal wildland firefighters, the Ten Standard Fire Orders, were written in the 1957 and have been in place with only minor adjustments for over 45 years. If these core principles of firefighting safety had been followed, lives would not have been lost.

The obvious presence of numerous well known hazardous conditions surrounding the Cramer fire was not enough for the IC and leadership to follow core safety rules. Even with the presence of all of the hazards discussed, the IC did not perceive the situation to be hazardous enough to warrant compliance with safety principles. The significant extent to which the ALL of the Ten Standard Firefighting Orders were violated and many of the hazardous Watch Out Situations were present but not mitigated indicates the continuing acceptance of indifference to safe firefighting practices in the Forest Service. It is only when a tragedy occurs that this widespread practice is realized.

LCES is provided a simplified means for firefighters to remember the core safety principles addressed in the Fire Orders (described above in the Causal Findings Section). LCES is widely taught to and known by all firefighters, and is included in the IC's Great Basin Incident Organizer and first pages of the Incident Response Pocket Guide. These fatalities would not have occurred had there been simple consideration of just four basic safety rules, Lookouts, Communications, Escape Routes and Safety Zones.

To emphasize the importance of following the core safety principles,. an enormous amount of documents and items list the Fire Orders, Watch Out Situation, and/or LCES. The Orders and Watch Outs have been printed on miscellaneous items such as water bottles provided to firefighters. The Orders and Watch Outs are routinely listed on the outside or inside covers of most fire safety related publications readily available and frequently used, including: the Great Basin Incident Organizer (GBIO), which the Type III Incident Commander had available but was did not utilize (Hackett, p. 50); the outside back cover of the Incident Response Pocket Guide (IRPG) which is provided to all supervisors and personnel on fires; and the "Redbook" now known as the Interagency Standards for Fire and Fire Aviation Operations. There is not a fire fighter who is not acutely aware of the firefighting safety orders.

According to several off-the-record statements, it is accepted by many firefighters that at least one or more of the Standard Fire Orders must be violated in order to successfully suppress most if not all fires.

When asked about the practice of assigning firefighters to work without supervision, such as cutting a helispot, the I.C. stated that we "do it all the time" (Hackett, p.95).

A discussion had been held between the IC and helicopter foreman about placing a lookout on the opposite ridge across Cramer Creek, which would have had a view of H-2, but not into the Cache Bar drainage (Fogel II, page 71 and 72). Other informal discussions were apparently held the morning of the fatality about a lookout for H-2 ([————], pp. 7, 23, 24, 39-42). The rappellers were working at the same hazardous location for more than five hours, which was more than enough time to realize the hazardous situation, yet a lookout was never provided for H-2 with employees because the IC and leadership did not perceive the situation as being hazardous enough to comply with the requirement to provide a lookout (Hackett, p. 107). Other personnel on the fire who may have perceived the potential hazards believed a lookout to be present and/or that leadership was aware of the hazards and was taking appropriate measures. The IC stated that if fireline ground crews had been flown into H-2 as planned, he "probably would have had a lookout" (Hackett OSHA recorded interview).

There were two prior high-profile willful violations of the Fire Orders and Watch Outs not mitigated. The South Canyon and Thirtymile fires.

The incident commander, District and Forest fire managers, and line officers were familiar with Thirtymile fatalities and the basic requirements of the Hazard Abatement Plan. The HAP is to be monitored by the Regional Office for compliance (Dudley, p. 10; Kulesza, p. 8; Matejko, p. 48). The following requirements of the Thirtymile HAP were not followed (Forest Service Manual National Headquarters FSM 5100 - Fire Management, Chapter 5130 Wildland Fire Suppression, Interim Directive 2130-2003-3, Effective April 24, 2003, expires October 24, 2004):

5130.3 (4)(b): The fire was not managed as a potentially life-threatening event during the especially dangerous transition from initial attack to extended attack.
5130.3 (4)(d): When fire behavior thresholds at which large fires typically occur were approached (exceeded), fire program managers did not request additional supervisory and suppression support.
5130.45 (4)(a): The IC did not immediately delay, modify, or abandon firefighting action where strategies and tactics cannot be safety implemented.
5130.45 (4)(c): The IC did not ensure that all firefighting actions are in full compliance with the Ten Standard Fire Orders and that the mitigation of the applicable Eighteen Watch Out Situations has been accomplished.
5130.45 (4)(d): The IC did not maintain command and control of all fireline resources.
5130.45 (6): The IC did not personally conduct inspections for safety and health hazards including compliance with the Ten Standard Fire Orders and Eighteen Watch Out Situations on Type 3, 4, and 5 fires and document the inspections in the unit logs and include the documentation in the incident records.

No precautions, mitigations, or other action was attempted to limit the hazards to which employees at H-2 were exposed.

C) History:

These elements violated were almost identical to those Forest Service violations from the well known and high profile South Canyon Fire and the Thirtymile Fire fatalities.

In 1995 the Forest Service and Bureau of Land Management received willful citations for the same violations of core wildland safety rules contributing to the deaths of 14 firefighters in the July 1994 South Canyon Fire.

Again in 2002, the Forest Service received willful citations for the same violations of core wildland safety rules.

The circumstances and violations involved in these historic fatal accidents is well known among firefighters and fire management. Policies have been revised and conveyed to fire management in order to prevent the hazards from occurring again. Even so, indifference to the recurring hazards and the safety policies intended to prevent them continues. The agency has not provided sufficient accountability at the local levels to ensure these same conditions do not continue to contribute to tragic accidents.

(See Section IV. Forest Service History)

D) Incentives:

There are numerous incentives to aggressive fight fire that may involve overlooking safety rules. The incentives exist at levels from the Forest Service as a whole, through public land managers, down to the first year fireline crew member.

District Rangers and Forest Supervisors stand to gain in many ways by overlooking agency safety standards.

Less money is spent when fires are controlled quickly with fewer crews and resources. There is significant pressure for the wildland firefighting agencies to minimize the enormous costs involved in fighting fires.
When timber resources (even in the designated wilderness) are destroyed, complaints are registered and pressure is placed on the agency from a variety of sources ranging from locals and industry to national-level elected officials (Off the record statement).
If a fire damages privately owned structures or crosses jurisdictional boundaries to privately owned land, the agency may be held accountable for not aggressively attacking the fire.
Firefighters gain public esteem for doing a difficult and dangerous job quickly. (See the discussion on "Culture" in paragraph C of Section VII. Findings and Causal Factors)

E) Accountability:

After several high-profile fatal accidents and the ensuing OSHA citations. Forest Service Accident Review Team reports, and the TriData report, the Forest Service still has yet to ensure that fire program managers and line officers are held accountable for safety.

The Agency Chief, Regional Foresters, Forest Supervisors and District Rangers can preach safety as the number one priority, but until all levels of managers and line officers become accountable (as recommended in the 1998 TriData Report) hazardous firefighting activities will continue to be common practice on the lines.

There have been no documented or reported instances in the Salmon-Challis National Forest where safety violators have been identified and removed from their position, other than after the occurrence of a serious accident such as these fatalities.

Safety performance has not been considered in supervisor and management performance evaluations, even after the Thirtymile citations were issued for not including safety performance. The requirement to conduct performance an evaluation relating to a supervisor's safety and health performance was not Included in the nationwide Thirtymile Hazard Abatement Plan.

The alleged willful violations of the Fire Orders are not meant to point blame at the Incident Commander. As with most safety problems, it is with the lowest level of supervision where the "rubber meets the road." Higher-level fire program managers and line officers did not provide oversight or direction, and did not make critical decisions. Not only were the increasing complexities and hazardous conditions apparent to leadership at the fire, at several times information was provided (or should have been provided) to the Zone Duty Officer, the District Ranger, the Central Idaho Dispatch Manager, the Forest FMO, and the Forest Operations Staff Officer about the hazardous conditions, uncontrolled fire growth, and perceived inability of the IC to competently handle the situation.

The decentralized fire management structure in the Forest placed most of the oversight and decision-making responsibilities on the districts; however key district-level fire program management positions were vacant due to long-term position funding concerns with a management priority of staffing initial attack positions (Matejko, 18-23, 33).
The District Ranger was distracted with other duties including higher priority fires in another district. This Ranger was responsible for two Districts where approximately 85% of the Forest's fire activity occurs. Half of the fires occurring in the Forest up to the Cramer Fire had occurred in the North Fork Ranger District.
The District where this fire occurred did not have an FMO and no interim FMO was assigned. Most FMO responsibilities went to the Assistant FMO, Alan Hackett, who was delegated responsibility as the Type 3 Incident Commander for the Cramer Fire.
According to management and line officer statements, in the absence of a District FMO for the North Fork District, the north zone duty officer apparently had the next level of responsibility for general oversight and complexity decision making (Bates, pp. 11-12, 35-37, 43). The duty officer's attention was focused on other larger and higher priority fires in the Middle Fork District. He provided no oversight for the Cramer Fire from the evening of Sunday, July 20, until after the fatalities had occurred Tuesday evening, July 22.
A discussion was held the evening before the fatal accident between the IC, the Forest FMO, and the Central Idaho Dispatch Manager. Cramer Fire leadership provided information indicating the potential of continued fire growth and the lack of success containing the fire thus far. Upon ordering a Type 3 incident command, the fire had officially moved from initial attack to extended attack requiring the preparation of a WFSA (Wildland Fire Situational Analysis) per the Forest's Fire Management Plan (FMP). The District Ranger was not informed that the fire required a WFSA, but was involved in delegating the type 3 incident commander. No other follow up or oversight was provided. In addition to the WFSA requirement, the FMP emphasizes the importance of treating transition fires with care (Sect. II, p. 2).
The IC requested two additional helicopters. The helicopters were not available but the IC still believed he could "catch" the fire with the resources available.
There was no apparent discussion about strategies and tactics between the IC and fire program managers (Statements: Bates, Hafenfeld, [————], and Mills). The same strategies and tactics were used on the day of the fatalities, even though they had not achieved any degree of success in the preceding days.
On the evening before the fatality, concerns about competency involved with fighting the Cramer Fire situation had been brought to the attention of Forest-level fire management including the Operations Staff Officer and the Dispatch Manager. Later the concerns were also discussed with the District Ranger. However none of the concerns were addressed to determine validity. The District Ranger apparently stated the IC was qualified for a type 3 incident, and that was the end of the discussion ([————], 7-10, 13-14, 25-26, 29-37).

Management failed to ensure that the evolution of the Incident Command System was commensurate with the fire threat. In short, the incident commander for the fire was essentially left to his own devices without any form of formal oversight.

The 1998 TriData report conducted in response to the South Canyon fatalities included the following goal:

“For extended attack (and larger) someone needs to monitor operations to ensure compliance with established safety requirements, procedures, policies and standards."

No such monitoring was performed during the Thirtymile incident, and again, no such monitoring occurred during this Cramer Fire fatality.

Summary:

Most, if not all the key players involved in this accident were experienced seasonal fire fighters from this Forest, and many were full-time year round fire affiliated employees. All of the employees and management were familiar with the extreme fire conditions, and all had knowledge of the local fire weather and behavior including regular afternoon diurnal canyon winds, and increased erratic fire activity. The interviews repeatedly indicated that they were aware of the safety rules and extreme fire conditions, but did not think the situation warranted compliance with the safety standards. These violations are symptomatic of the lack of "sufficient management oversight" in regards to safety that continues to permeate the fire culture.

Key incident personnel on the fire were aware of the safety rules. They believed that the conditions did not present enough danger for the safety rules to apply. As in most cases where an accident occurs, the safety rules were violated directly because the judgment of personnel and management did not feel the rules applied to their situation or that it was necessary to follow the rules. They, along with fire program managers in the Forest and District, failed to respond quickly to the numerous indicators that made the Cramer Fire a highly hazardous situation.

Repeat Notice

Notice 3, Item 1 - 29 CFR 1960.11: The agency did not ensure that the performance evaluation of any management official in charge of an establishment, any supervisory employee, or other appropriate management official, measures that employee's performance in meeting requirements of the agency's occupational safety and health program:

Performance evaluations did not have elements relating to meeting the requirements of. the agency's safety and health programs for all fire supervisors, fire program management officials, and line officers. The 2003 performance evaluation criteria for line-officers, fire managers, and fireline supervisors did not include an element including compliance with Ten Standard Firefighting Orders and Eighteen Watch Out Situations.

The U.S. Forest Service was previously cited for a violation of this occupational safety and health standard, which was contained in OSHA Inspection Number 303757231, Citation Number 01, Item Number 02, issued on 02/08/2002.

NOTE on Abatement Methods

Only general abatement method options were provided for general duty clause violations. One of the reasons these violations meet the criteria for Willful "plain indifference" is similar to the reasoning for not providing very specific feasible abatement methods. The Forest Service has numerous (too many according to some) policies, procedures, and checklists available to abate the well known hazardous conditions. The problem instead can be directly tied to the actual implementation on the fireline. The problem appears to be overextended decentralized management, insufficient safety assistance for Type III and IV fires, leadership failures, and insufficient management commitment to ensure safety and accountability for safety throughout the fire ranks.

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Cramer Fire Dedication

Lessons Learned

Management Evaluation Report

Factual Report

Gallery of Cramer Fire Report Images

Accident Prevention Plan

OIG Investigation

OSHA Investigation

HFACS—"Swiss cheese" model of Accident Causation

—OSHA Briefing Paper—

Citations for U.S. Forest Service Salmon-Challis National Forest Intermountain Region 4

VIII. Proposed Citations U.S. Forest Service, Cramer Fire - #117886150

Serious Notices

Willful Notice

Willful Justification - The Willful classification is based upon the following: (Refer to Findings and Casual Factors, Section VI for references and more detailed discussion)