Colorado Firecamp - Cramer Fire, OSHA Briefing Paper

On Saturday, July 19, 2003, a lighting strike ignited a wildfire in steep, rugged terrain undergoing extremely dry drought-like conditions. The fire was located near Cache Bar in the Cramer Creek drainage on the north side of the Salmon River about 50 miles northwest of Salmon, 10. Late afternoon, Sunday, July 20, Long Tom Lookout first reported smoke from the fire.

Monday, July 21, 2003, the fire officially transitioned from a type 4 to a type 3 command structure which was operated out of the Cove Creek Helibase, approximately 7 miles up the Salmon River from the fire and without view of the fire area. By approximately 4:30 pm, the fire had been steadily increasing in size to approximately 60 acres since reported 24 hours prior. Over the next several hours the fire increased in size to approximately 200 acres and remained active until about 3:00 a.m. the next morning.

By Tuesday, July 22, 2003, approximately 70 to 80 personnel were working to contain the fire as a Type 3 incident. Most of the crews were working below and to the east side of the fire to construct fire-line in the draw near Cramer Creek. The previous night the Incident Commander had requested two additional Type-2 medium helicopters to use on the fire that could not be provided due to limited fire resources.

At around 9:40 a.m., two helitack crew personnel had rappelled from a helicopter onto a ridge line above and on the north-west side of the main fire to clear a two- way helispot (H-2) in order for a helicopter to shuttle fireline ground crews to this area. This plan had been decided and agreed upon by the Incident Commander and the acting helicopter foreman (rappel spotter, who later became the helibase manager) during a morning helicopter recon flight. The provision of a lookout
had been discussed, however no lookout was provided for the rappellers. Due to vegetation and changing slopes, the rappellers could not see the active fire from H-2, nor could they see more than approximately 150 to 200 feet down slope in either direction from the ridgeline upon which they were working (See photos from H-2).

For some reason the job took longer than expected, and the rappellers repeatedly stated to the helibase radio operator that more time was needed. It was originally estimated that clearing H-2 would take approximately 1 hour. The rappellers remained working at H-2 for more than 5 hours. Upon inspection of the helispot, it appears that 15 to 20 larger diameter (15 to 30 inches across) ponderosa pine had been felled, requiring an undercut. In addition, a very large number of small diameter trees (less than 4 inches diameter) had also been felled.

As often occurs, fire activity increased into the afternoon due to increasing temperatures, decreasing relative humidity, and afternoon winds. Between 1300 and 1400 many personnel on the fire reported increased fire activity. At around 1400 the fire apparently made a "push" and overran a lower helispot (H-1) near where most of the fire-line crews were working near Cramer Creek. The temperature was nearing 100 °F and humidity was in the low teens.

Several times during the day different individuals on the fire observed low intensity fire backing down into the Cache Bar drainage below where the rappellers were working. Sometime between 2:30 and 2:40 p.m. this fire turned into an active flaming front.

At around 1505, the rappellers requested the Cove Creek helibase for a pick-up from the helispot site due to significant smoke. A rappeller stated "Send them in a hurry." Both helicopters H-193 and H-166 were on the ground at the helibase at the time. At 1509 a rappeller again called the helibase requesting a pickup. When told the helicopter was on the ground but would leave shortly, the rappeller responded, "We need them right now."

At 1510 the helibase manager instructed the radio operator to ask the rappellers if they needed to go to their safety zone. The rappellers replied they were fine, they were just taking a lot of smoke. At 1512, a rappeller again called the helibase. When told H-166 needed fuel but would be leaving right away, the rappeller responded, "Oh God. We just got fire down below us. So the smoke's coming right at us...uh...just make them hurry up." Between 1513 and 1520, the lead plane reported the fire was "blowing-up" on the west side. By the time H-166 reached the helispot around 1520, it notified the rappellers it was too smoky to land. At 1524 a rappeller called again in an excited voice, "Could I get a helicopter up right now?" Shortly thereafter the rappellers stated to the lead plane L41 they were going to "run for it." Apparently no other communication was successful with the rappellers (Radio log and witness statements).

The two rappellers were later found about 420 feet up hill and into the drainage from the helispot. Neither victim was found inside a fire shelter. It appears that at least one of the victims may have attempted to deploy a fire shelter, and the other shelter appeared to be ready for deployment. Preliminary reports from the Forest Service technical equipment experts stated that the temperatures were too extreme for the victims to have survived, even inside properly deployed fire shelters. Temperature estimates were between 1,300 and 2,000 degrees Fahrenheit. The fire apparently quickly spread through a stand of timber below the helispot and fatality site, burning intensely through the crowns of the trees near the victims.

VI. Findings and Causal Factors

A. Extreme Fire Conditions and Local Factors

The managers, incident commander, and key personnel involved with this fire were employees of this District or Forest and were very familiar with the current conditions and local factors contributing to the hazardous conditions involving the fire fighting efforts. The effects of steep terrain, drought, winds, high temperatures and low humidity were all recognized by key personnel, yet tactics were not altered to account for the extremely hazardous conditions.

The fire season on the SCNF normally runs from July 1 to September 15. The Forest is a high fire-load Forest, one of four Forests in Region 4 with a high fire occurrence. Based on the last 10 years, the SCNF averages 120 fires and 52,000 burned acres per year. Recent fire events have increased dramatically in size and severity. Two fires, the Clear Creek and the Salmon-Challis Wilderness, for example, burned 417,000 acres in 2000.

Rugged Topography:
The Salmon River Breaks is "rugged and dangerous country with limited visibility." The terrain transitions rapidly among distinct features-benches, steep slopes (=70%), breaks, and saddles. Vegetation covering the rocky slopes also limits visibility ([————], pp.9, 13).

Because the topography is steep, it has a significant effect on fire behavior, fuels; and weather. Fire behavior in the hotter part of the day can be extreme, with rapid spread through the canyons, draws, and chutes. Steep slopes not only predispose areas to rapid uphill fire growth but also cause fire brands to roll down hill. Historically, a fire that burns in the Salmon River Breaks will burn to the top of the ridges and then downhill to the Salmon River because of the sheer ruggedness and steepness of the terrain (Goheen, p 14; Hafenfeld, p. 26; [————], pp. 9, 13; Forest FMP, Sect. III p. 5, pp. 58-62).

The topography also has a marked effect on fuels, because it contributes significantly to differences in moisture and surface heating from place to place across the landscape. These differences influence variations in the amount of available moisture as a function of elevation and variations in surface heating due to aspect (Forest FMP, Sect. III, pp. 58-62).

Vegetation and Fuels:
Vegetation varies considerably by elevation and aspect. In 1985 a stand-replacement fire burned through most of Fountain Creek drainage and into the adjacent drainage to the south east above the Cache Bar boat ramp (Witness statements about "Old burn"). This occurred in the same Cache Bar drainage above which these rappellers were working when they were fatally burned over.

Southern aspects consist of grass and scattered shrubs, while the northern aspects are a mosaic of rocky patches and nearly continuous stands of 2-4 foot shrubs, primarily shiny-leaf Ceanothus. Large, downed, wood fuels from fallen snags are scattered through these brush fields. Shiny-leaf Ceanothus burns intensely due to volatile oils in the foliage. The potential rate of spread through Ceanothus increases as the growing season progresses from June 20 to September 10. It is possible that the observation of this green foliage during a helicopter recon flight provided a false sense of security as to its potential to burn. http://www.fs.fed.us/database/feis/plants/shrub/ceavel/fire_ecology

At 75%-100% live fuel moisture, fires exhibit extreme fire behavior and burn actively through the night. Live fuel moisture on the SCNF was measured five times during June and July. Moisture levels in conifers, sampled on July 21, 2003, ranged from 80-110%. Shiny-leaf Ceanothus, sampled on July 30, 2003, was 104%. Generally, live conifer fuel moisture levels were comparable to or lower than samples taken in early August, 2000. During the 2000 fire season, more than 417,000 acres burned on the Forest, including the Clear Creek Fire which made a 23,000 acre run in one day (North Zone Fire Danger Pocket Card; Records L. [————] Great Basin Live Fuel Moisture Project).

Weather:
The climate in the Salmon River Breaks varies widely with elevation. Wind patterns in the area are dominated by westerly winds. Topography influences local weather conditions, especially winds. Upslope/up-canyon diurnal winds are common during the summer months. It is normal to have strong winds blowing
up the Salmon River canyon on hot summer afternoons. These winds are primarily from the west. Since these winds are channeled by topography, the local wind conditions are far different from those predicted in the general-area fire weather forecasts. Nighttime thermal zones are common, especially in the deeper canyons, and contribute 10 active fire behavior at night (Forest FMP pp. 58-62).

The Pocatello, ID, office of the National Weather Service (NWS) provides fire weather information and predictive services for this area of the Salmon-Challis National Forest, including daily fire weather forecasts and spot forecasts (forecasts specific for the fire area). The Forest is required to use forecasts from the NWS servicing center in Pocatello, even though those from the NWS servicing office in Missoula, Montana are considered by some on the Forest to be more accurate and useful. In particular, wind predictions from the Pocatello spot weather forecasts are perceived to be unreliable, and the forecasts frequently do not reflect actual conditions on the ground. Weather from previous day is often seen as a more reliable predictor than forecasts from Pocatello (Hershey, pp. 25-27). Note: conditions on the North Fork RD, on which the Cramer Fire occurred, had been the same for several successive days with high temperatures, low humidity, and afternoon winds ([————], 22-26; [————] NWS Pocatello).

The SCNF fire program relies heavily on data provided by seven Remote Automated Weather Stations (RAWS) maintained across the Forest. Maintenance of the RAWS sites is the responsibility of the Forest, however the maintenance service could also be contracted to staff at the National Interagency Fire Center (NIFC) at an increased expense. The Skull Gulch RAWS site is the most representative of the Cramer Fire area, but weather data from this site was inaccurate and unusable due to a temperature and relative humidity sensor that was not functioning properly as well as other weather data being reported erroneously. This problem was not discovered and corrected until after the Cramer Fire. The RAWS on the Forest had not been maintained or calibrated since September 2002 (Statement: [————]; Record Skull Gulch RAWS). The person responsible for RAWS maintenance for the Forest had apparently ordered replacement sensor in June 2003, but was unable to install them and concurrently perform calibration and maintenance prior to the busy fire season ([————] phone interview). Five days after the fatality a NIFC technician inspected and performed maintenance on the Skull Gulch RAWS and detected the sensor problems causing the reporting of incorrect data.
Long Tom lookout generally provides weather information to fire suppression personnel in the area, including the first three days of the Cramer Fire. The difference in elevation between Long Tom and the fire was too great for the lookout's weather observations to be valid for the fire area ([————]; Fogel; Forest Net Radio Log; Long Tom Lookout log).

The combinations of inaccurate RAWS data, inappropriate lookout weather due to elevation differences, and lack of faith in Pocatello National Weather Service reports may be a contributing factor to the limited attention paid to forecasts and why a spot weather was not obtained by the IC the day of the fatalities. Apparently, the electronic spot weather request form used by dispatch has a section where a requestor can input discrepancies from the previous day's forecast, in order for the Weather Service to make adjustments and to make future forecasts more accurate. Apparently this feature is seldom used. Little additional evidence was provided indicating the Forest had taken any steps to try to mitigate weather forecast related concerns.

Fire Hazard Indicators:
Two indices from the National Fire Danger Rating System (NFDRS) are commonly used to express fire danger and track seasonal trends -- the Burning Index (BI) and the Energy Release Component (ERC). The BI reflects the difficulty of fire control. The ERC reflects the contribution that all live and dead fuels have to potential fire intensity and is a good indicator of the overall fire danger resulting from local fuel moisture conditions. These indices communicate expected fire danger to fire personnel and allow them to associate the numeric values with real-life experiences in the area. Forest fire suppression personnel use the ERC to estimate fire growth potential and in complexity analyses (Record FMP; NWCG web site http://famweb.nwcg.gov/pocketcards). The burning index is also presented on the area's Fire Danger Pocket Cards required under the Thirtymile Hazard Abatement Plan. The Forest also uses the Haines Index as an effective indicator of potential fire behavior. The index is included in the daily zone fire weather forecast and is read by dispatch when the daily fire weather forecast is transmitted to field units (Forest FMP, Sect. IV, p. 4-9).

The Forest was experiencing fire conditions comparable to the year 2000 when two fires burned 417,000 acres on the Forest. During July, 2003, the Forest and eastern Great Basin were at Preparedness Level IV. The BIs and ERCs were near the high-end — the Forest BI was well above the 90th percentile and the ERC was in the 96th percentile-indicating dangerous conditions. The Forest had just experienced a 15,000-acre fire on the Leadore Ranger District, a district with historically low fire occurrence and smaller fires. The Eastern Great Basin Coordination Center issued an updated safety alert that was distributed to all personnel, emphasizing both the dangerous conditions and the need for aggressive initial attack. The Fire Danger Pocket Card is a method of communicating information on fire danger to firefighters. A crew on the Cramer Fire had reviewed their Pocket Cards a few days prior to the Cramer Fire and recognized that they were at conditions comparable to those on the Clear Creek Fire in 2000 that burned 217,000 acres (Hand, pp 18-19, 63; Mills, p. 10; Sever, p. 13; Shaddle, p. 21; Eastern Great Basin Coordination Center Safety Alert; NWCG Pocket Card http://famweb.nwcg.gov/pocketcards).

The Forest's Fire Management Plan provides much information about the fire regime and hazards specific to the area such as the trend towards fires with increasing severity. From 1994 to 2001 the data shows that 50% to 75% of the burnt acres were severe, versus historic data indicting only 20% were severe (FMP Sect III, p. 28).

B. Indifference to Core Safety Principles

The lack of consideration to safe firefighting principles extended beyond indifference to just the Ten Standard Orders and Eighteen Watch Out Situations; The Incident Response Pocket Guide (3 inch by 5 inch booklet) is carried by every firefighter and includes a wide variety of safety practices in the first pages of the guide under the Operational section. It includes Operational Leadership Guide; Risk Management Process; Look-Up, Down and Around; Common Denominators of Tragedy Fires; Tactical Watch Outs; LCES; Extended Attack Transition Analysis and more. The Standard Orders and Watch Outs are prominently located on the back cover. (IRPG Included in binder and on CD)

LCES (Lookouts, Communications, Escape Routes and Safety Zones) —
LCES is simplified system to aid firefighters in remembering the four main categories into which the Ten Standard Firefighting Orders are divided (Wildland Fire Fatalities in The United States, 1990-1998).

Lookouts and Communications
Lookouts were not provided for the rappellers at H-2. A competent lookout was not provided with good vantage points of the fire and H-2 (Fogel, pp. 49 and 71-75; Fuller, p. 1; [————], pp. 7, 23, 24, 39-42; Hackett, pp.40, 74-77; Hackett OSHA Recorded statement, Tape 1, 26m50s; Hand 49-54; [————], p. 14; [————], p. 8; Raddatz, p. 20; [————], p. 39). Lookouts are to have knowledge of the escape routes and safety zones as well as knowledge of disengagement trigger points ("Incident Response Pocket Guide" p. 6). It was the candid opinion of many experienced firefighters on the investigation team that the provision of an appropriate lookout would have been the number one factor which could have prevented these deaths.

Communications were not maintained to provide updates on situation changes. The rappellers did not have a direct supervisor to whom they were to report and who would routinely check on their progress (Fogel, p. 11, 12, 70; [————], p. 8). The Incident Commander admitted that he would probably be their supervisor, but that it was common to put experienced firefighters into an area to cut a helispot without direct supervision (Hackett, p. 93).

The rappellers occasionally communicated with the radio operator at the Cove Creek helibase, as well as some communications with aerial support over the fire ([————], p. 6; Fogel, pp. 11-12 and 70). The incident commander did not have direct communication with the rappellers. The rappellers were not informed of the decision to abate the plan to fly crews into H-2, nor were they provided information on the progression of fire in the drainage below them.

Safety Zones and Escape Routes
It appears that the primary safety zone designated for the victims was either an open area west of the helispot across and into the Cache Bar drainage, or down the ridge into the blackened area that had burned the first three days of this fire. The interview statements were not consistent as to which area was to be considered the primary safety zone ([————] , p. 22; Fogel, pp. 6, 8, 19, 66, 67; Fuller, p. 1; Hackett, pp. 24, 27, 41-44, 99-100; Hackett written statement).

The "open area" was considered "old burn," presumably from the 1985 Fountain Creek fire. It would have been necessary to have "burned out" the area prior to use, and it was not large enough to be considered a safety zone. By definition, a safety zone is to be large enough to be survivable without the deployment of a fire shelter. As a guideline for a safety zone, the "distance between the firefighter and the flames must be at least 4 times the maximum flame height" (Interagency Standards for Fire and Fire Aviation Operations, pp. 4-10). This area experienced intense fire during the blow-up which claimed the lives of the rappellers (USFS Accident Investigation Report, Fire Behavior Analysis Appendix A, Entrapment Phase).

The other possible safety zone into the black (low intensity surface fire from first day) was downhill from the helispot. The escape route along the ridgeline was rocky with unburned fuels along the route between H-2 and the black. In addition, with fire burning in the Cache Bar drainage, the escape route is likely to have been compromised from the heat of the fire and fuels on the slope below the ridge on the Cache Bar side. Furthermore, with smoke and fire advancing from the same general direction as the down slope safety zone, without a lookout it would have been difficult for the rappellers to know where the fire was, and if the escape route and safety zone had been compromised.

Once conditions had changed, such as an active flaming front below Helispot-2, no attempt had been made to reevaluate the safety zones and escape routes, and if necessary identify an adequate alternate escape route and safety zone. No other measures had been taken to mitigate this hazard. The helicopter had become the rappellers' primary route to safety ([————], p. 8; Fogel, p. 13).

C. Management and Organization

Decentralized — Over the past few years, since the arrival of the new Operations Staff Officer, the Forest has shifted to a very decentralized structure of fire management. For fires from small Type 5 incidents to significant Type 2 incidents, primary responsibility for decisions has been delegated to the Districts. Only for Type 1 Commands does the Forest Supervisor become involved (Bates, 35-36; Dudley, 4-7,19-22; Goheen, p. 14; Hafenfeld, pp. 20-21, 83-84; [————], 43-45; Matejko, 10-12, 14-16; Mills, p. 14-15; Forest FMP Sect. IV, p. 21; Memo From Forest Supervisor to District Ranger on delegation of authority).

The Operations Staff Officer at the Forest level is tasked under the Forest Supervisor with addressing and ensuring fire operations are handled appropriately. The Staff Officer has oversight of the Forest FMO and Deputy FMO, who in turn provide assistance when needed to the District FMOs. The Operations Staff Officer is also responsible for addressing effectiveness with the District Rangers (Hafenfeld, p. 84). There is a concern among many in the Forest staff that the Operations Staff Officer could not provide an appropriate level of supervision over the District Ranger for the North Fork and the Middle Fork Districts, as that Ranger is also the Staff Officer's spouse (Dudley, p. 7; Goheen, pp. 7-8, 11-12; [————], 32-33; Matejko, p. 39).

Accountability — It could not be demonstrated at any time during the past year that any firefighting personnel or others up the chain of command had ever been disciplined, removed from their position, or formally addressed concerning unsafe behavior during firefighting. All SCNF personnel involved with supervising or managing firefighting, from incident commanders, through the district level to the forest level were not evaluated based upon their ability to fight fires safely and in accordance with core firefighting safety principles (Performance Plan and Appraisal form FS-6100-37 9/97).

Fire staff at the Forest Supervisor's Office did not play a role in ensuring appropriate safety measures at the Cramer Fire. The Forest Fire Management Officer, Forest Operations Staff Officer, and Central Idaho Dispatch Manager were all made sufficiently aware that the fire had grown substantially each day, suppression strategies and tactics of the ICs had not been successful, and the two medium helicopters requested by the IC were not available. On the evening of the 21st, the Incident Commander requested assistance with overhead and handling logistics (Hackett statement, pp. 18-19, 88-89; Sever, pp. 9-11). The forest fire managers responded that resources were spread too thinly and such support was not available. The Operations Staff Officer and Forest FMO were both involved with a regional fire preparedness review on July 22, 2003 (Hafenfeld, pp. 9, 34-35; Mills, pp. 3, 5, 8). None of the forest-level or district-level fire staff appeared to have taken any further steps to review the circumstances around the fire and to ensure the appropriate safe level of incident response was being applied.

On the evening before the fatality, concerns about disorganization and the competency involved with the Cramer Fire had been brought to the attention of forest-level fire management by the Forest Aviation Officer (Bates, p. 31; Hafenfeld, pp. 65-68, Sever, pp. 29-32). These concerns were forwarded to and later discussed with the North Fork District Ranger on the morning of July 22. None of the concerns about competency and perceptions of disorganization were addressed or looked into further ([————], pp. 7-10, 13-14, 25-26, 29-37).

Despite recognition by the Forest Service of the hazardous nature of smaller fires (see "Common Denominators of Tragedy Fires" in Willful Justification below), the Forest Service continued to fail to adequately monitor safety on this Type 3 fire. No one monitored safety, which could have included any of the following: the incident commander (Hackett statements); a safety officer at the fire (none designated); line officers such as the District Ranger (Bates statements, p. 6-7 plus); the district FMO (vacant); the zone duty officer — not involved ([————], pp. 2-8, 32); forest-level fire staff, such as the Forest FMO/Forest Duty Officer (Hafenfeld, Mills, Sever).

Resources Spread Thin - Delayed Hiring of District FMOs — For approximately 12 to 18 months, including the previous 2002 fire season, the North Fork District FMO position was vacant (Bates pp. 33-35; Matejko, pp. 18, 23). In absence of the DFMO, acting DFMOs were assigned on a couple of occasions. During the period leading up to the Cramer Fire there was no acting DFMO for this District and the Assistant DFMO assumed the responsibilities for the North Fork. This Assistant DFMO was also the Cramer Fire Type 3 IC, who was in command at the time of the fatal accident (Hackett, pp. 4-5, Hafenfeld, p. 7).

The decentralized structure of fire management in the forest placed responsibility on the District to manage fires up to a Type 2 incident (see first heading, "Decentralized" under paragraph C, above);
No FMO was assigned to the North Fork District at the time of the Cramer Fire (Hackett, pp. 4-5);
Most FMO duties were then to fall to the Assistant FMO, Alan Hackett, who was also the Type 3 Incident Commander for the Cramer Fire (Dudley, p. 18-19;, Hackett, pp. 4-5);
The District Ranger for the North Fork was also the Middle Fork District Ranger, which were logistically separated by a considerable geographic distance (Goheen, p. 21). This Ranger was also preoccupied with "higher priority" fires elsewhere on her districts and was unable to provide the oversight as designed in the decentralized fire structure. (NOTE: 85% of fire activity normally occurs in her North Fork and Middle Fork Districts; Bates, p.17; Mills, pp.14-15);
By the beginning of August 2003, 28 fires had occurred in the Salmon- Challis National Forest, 14 of which occurred in the North Fork Ranger District with no Fire. Management Officer, and with the District Ranger also overseeing the Middle Fork Ranger District (Bates OSHA recorded interview, 32m15s). On July 21 and 22, the District Ranger was occupied with the Crystal and Dutch Lake fires in the Middle Fork District (Bates statements, p. 6-7 plus);
The North Zone Duty Officer for the day (also the Salmon-Cobalt DFMO) was not providing oversight or keeping in regular communication with the Cramer IC ([————], pp. 2-8, 32);
The Supervisors Office and Central Idaho Dispatch did not provide oversight to the fire, even though they were aware of the extreme conditions, fire growth, and concerns about competency had been brought to their attention (Hackett statement, pp. 18-l9, 88-89; Hafenfe1d, pp. 9, 34-35, 65-68; [————], pp. 7-10, 13-14, 25-26, 29-37; Mills, pp. 3, 5, 8; Sever, pp. 9-11, 29-32).

Management failed to ensure that the evolution of the Incident Command System was commensurate with the fire threat. The decentralized fire management structure in the Forest placed most of the oversight responsibilities on the District. In short, the incident commander for the fire was essentially left to his own devices without any form of formal oversight.

District FMO positions had also not been filled on the Middle Fork and Yankee Fork Ranger Districts (Matejko, p. 18; Forest Org Charts). The prolonged vacancies of key fire management positions in the districts appear to conflict with the Forest's goal of decentralized fire management to the district level.

Almost as soon as ground forces arrived at the fire, the potential for spread was noted and a Type 3 Incident Commander was ordered (Dispatch Log, McCall Jumper Ship J41, 07/20/03, 1708, and Moyer Helitack, 1938; [————] p. 5; Sever, pp. 6-7). Each day the fire grew significantly and the potential for significant spread was observed. The potential for blow-up and significant growth should have been extremely evident to those working on the fire as well as to the zone duty officer (not involved), dispatch center, District Ranger (did not attempt to be involved), the Forest FMO and Forest Operations Staff Operations Officer.

The Salmon-Challis National Forest Fire Management Plan (FMP) requires "If initial action is unsuccessful, a WFSA (Wildland Fire Situational Analysis) will be prepared to determine the next set of management responses" (Sect III, p 10).

Under these requirements, a WFSA would have been necessary no later than the afternoon of Monday, July 21. A WFSA was not created for the Cramer Fire until Wednesday, July 23, 2003 at 0800. At that time the fire size was approximately 5,400 acres after more than three days of suppression activities, two to three operational periods after the fire had gone from initial attack to extended attack.

D. Firefighting Culture

The wildland firefighting community still has a long way to go before they truly have a zero tolerance for infractions of firefighting safety standards and procedures. Except after a tragic event, it appears upper level management has rarely been held accountable for safety on the fireline. The most basic safety rules for federal wildland firefighters, the Ten Standard Fire Orders, were written in the 1957 and have been in place since then with only minor adjustments (http://www.fs.fed.us/fire/safety/10_18/10_18.html). Yet men and women are killed due to violations of these basic rules.

Employees and supervisors are rewarded for aggressively fighting fires and taking serious risks. Firefighters are often provided hero status for their exposure to hazardous working conditions. The can-do culture throughout the fire fighting ranks is likely to be a very significant contributor to these unfortunate incidents. Personnel are often promoted to higher prestige positions that infer risk in their position titles, such as "Hotshots." In contrast, there still appears to be no effective incentives for safe behavior.

Another example of the risk taking culture is the current tendency among Forest Service "regulars" (federal Forest Service fire fighting employees) to criticize private contract firefighting crews for being too willing to withdraw from a perceived dangerous situation (Hackett, p 10, 51-52: Sever, p. 9, 18-20). This begs the question, Are contract crews overly-cautious, or are 'regular' crews too willing to routinely accept serious risk? Most fireline crews strongly prefer working long hours on a fireline versus idling waiting. The typical fireline crew member has significant financial incentives when actively working a fireline, such as overtime, per diem, and hazard pay.

One of the measures used to evaluate the effectiveness of wildland firefighting activities is the percentage of fires suppressed during initial attack and prevented from escaping and becoming large. Another measure has to do with the percentage of threatened structures in the wildland urban interface that were protected or destroyed (http://www.nifc.gov/fireinfo/2002/summary.html). It is understandable that other pressures to suppress fires are very real and valid. Uncontrolled wildfire can be very costly and damaging for a wide variety of interests. However, this merely is another example of the motivations of fire fighters, supervisors, and management.

VII. Other Investigators

A. Interagency Accident Investigation Team (AIT)

Name	Position on Team	Agency
Linda Donoghue	Team Leader	USFS/NCRS
Gearge Jackson	Chief Investigator	USFS/MTDC








Whitlock, Chuck

Team Technical Support

B. USDA Office of Inspector General

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Cramer Fire Dedication

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HFACS—"Swiss cheese" model of Accident Causation

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

V. Accident Description