Cramer Fire
Dedication

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

Gallery of Cramer Fire Report Images

Accident Prevention Plan

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

HFACS—"Swiss cheese" model of Accident Causation

Adobe PDF and Microsoft Word versions of documents related to the Cramer Fire can be downloaded from the U.S. Forest Service website.

—OSHA Briefing Paper—

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

Inspection #117886150
Six Month Issuance Date — January 22, 2004

I. Introduction

The inspection of the Salmon-Challis National Forest (SCNF) in Forest Service Region 4 resulted from the fatality of two wildland firefighters (helitack crewmen / rappellers) which was reported to the office by the Forest Service. Upon notification of the fatality, Compliance Officer [————][————] was assigned to conduct the inspection. Due to experience with similar wildland firefighter fatality investigations, [————][————] from the Regional Office assisted with the inspection. The OSHA representatives conducted a joint investigation into the fatalities along with members of a Forest Service Accident Investigation Team (AIT), and investigators and auditors with the U.S. Department of Agriculture's Office of Inspector General (OIG). The purpose of the joint effort was to assist each entity in the fact finding and information gathering stage. However, incident findings will be (have been) determined independently. The Forest Service public report on its finding is expected to be released to the public in January 2004.

II. Background

On July 22, 2003, two USFS helitack crewmen / rappellers were killed when they were caught in a blow up and burnover at the Cramer Fire about 50 miles northwest of Salmon, ID. The site was located on the north side of the Salmon River in steep and rugged country known as the Salmon River Breaks. The fire was part of the North Fork Ranger District in the 4.3 million acre Salmon-Challis National Forest in the Intermountain Region 4. The terrain where the fire occurred is considered by experienced firefighters as "dangerous country with limited visibility, transitioning rapidly among benches, steep slopes (greater than 70%), breaks, and saddles" (Pence, pp. 9, 13; Forest FMP, Sect. III p. 5, 58-62)

Around the time the fire was occurring the Salmon Challis Forest was experiencing several large and growing fires (Hafenfeld, pp. 18-22, 33). In the past years, this Forest has shifted to a decentralized structure where most fire management has been delegated to the district level (Dudley, pp. 4-5; Hafenfeld, pp. 2, 51; Matejko, pp. 10-16; Mills, pp. 14-15). Many of the fires were occurring on Middle Fork and North Fork Ranger Districts which were also overseen by the same District Ranger. These larger fires were receiving most of the Forest and District's fire management attention (Bates, pp. 6-10). Little direction or attention had been given to the Cramer Fire prior to the deaths of the two rappellers (refer to Accountability heading under Sect. VI).

The two helitack crewmen / rappellers killed were experienced seasonal employees stationed at the Indianola Helibase on the North Fork Ranger District. One of the rappellers was in his sixth fire season with the Forest Service, while the other was in his fourth season (Training and Qualifications Master Record). The two were working together, unsupervised and isolated from the main firefighting activities, attempting to construct a two-way helispot on a ridge line (Hackett, p. 93). The helispot #2 (H-2) was located on the northwest side of the fire, upslope of the fire activity. The helispot was planned to be used to shuttle a hand crew into this area to build downhill fireline and connect with crews working the lower portion of the fire. The job of clearing H-2 took longer than expected (over 5 hours versus an estimated 1 hour). The rappellers repeatedly stated to the Cove Creek Helibase radio manager that additional time was needed to complete the job ([————], pp. 6-8; Fogel, pp 11 and 70).

Fire conditions prior to the Cramer Fire had been recognized by many in the Forest, including those involved with the fire, as near record extremes ([————], p. 19; Hackett, p. 103; [————], p. 24; Mills, p.10; Sever, p. 13). The burning index (BI), energy release components (ERC), and percent live fuel moisture were all comparable to the severe levels experienced during the 1988 Yellowstone Fires as well as the 2000 Clear Creek Fire in the Salmon-Challis Forest which made a 23,000 acre run in one day (Fire Danger Pocket Card; Bates, pp. 45-47; Dudley, p, 23; Hand, pp. 18-19, 26, 63; [————], 34-35; Mills, p. 10; Shaddle, p. 21). The weather trend for the days from when the Cramer Fire was reported to the fatality was increasing hot temperatures and decreasing relative humidity ([————], p. 2; Hackett, pp. 26, 103; Sever, p. 21).

Key Persons Involved
(See enclosed organization charts)
* FOIA Rules May Apply *

III. Applicable Standards

Federal agencies, including the U.S. Forest Service, under section 19 of the OSH Act and Executive Order 12196, are required to follow 29 CFR Part 1960 - Elements for Federal Employee Occupational Safety and Health Programs. Many of the issues regarding safety inspections other adequate safety resources are addressed in Part 1960.

OSHA does not have specific standards addressing wildland firefighting safety and must address most aspects of fire safety under the general duty clause paragraph 29 CFR 1960.8(a) "to furnish each employee employment and a place of employment which are free from recognized hazards that are causing or are likely to cause death or serious physical harm."

The National Wildfire Coordinating Group (NWCG), the Federal Fire Leadership Team (FFLT), as well as each respective firefighting agency frequently propose, revise and issue their own guidelines and policies for firefighting.

Fire safety for federal firefighting agencies, such as the Forest Service, Bureau of Land Management (BLM) and National Park Service (NPS), and Fish and Wildlife Service (FWS) is detailed in several documents including, but not limited to:

The Interagency Standards for Fire and Fire Aviation Operations 2003
(Also commonly referred to as the "Red Book" or "Fireline Handbook")
http://www.fire.blm.gov/Standards/redbook.htm

and

The Incident Response Pocket Guide (NWCG, NFES 1077, PMS 461)
http://www.nwcg.gov/pms/pubs/ipgall_web.pdf

The Forest Service also has many of its own documents relating to safety which include:

National Headquarters Forest Service Manual (FSM) 5100- Fire Management Chapter 5130-Wildland Fire Suppression, Interim Directive 2130-2003-3, Effective April 24, 2003, Expires October 24,2004
Covers requirements under the Thirtymile Hazard Abatement Plan
http://www.fs.fed.us/fire/safety/investigations/30mile/index.html

and

- The Forest Service Health and Safety Code Handbook (FSH 6709-11)
http://www.fs.fed.us/im/directives/fsh/6709.11/6709.11.pdf

Additional Reference:
U.S. Forest Service Fire & Aviation Management Wildfire Safety Homepage
http://www.fs.fed.us/fire/safety/index.html

IV. Forest Service History

The hazards associated with wildland firefighting are well known. In 1910 in North Idaho, 72 federal firefighters were killed from a burnover. In 1957 the Ten Standard Fire Orders were developed by a task force studying ways to prevent firefighter injuries and fatalities. Shortly after the Standard Fire Orders were incorporated into firefighter training, a list of Watch Out Situations was developed. There are currently 18 Situations that Shout Watch Out identified. The Ten Standard Orders are never to be violated. The Watch Out situations are more specific and cautionary than the Standard Fire Orders and may be present, but must be mitigated to ensure fire safety. These Orders and Watch Outs are considered core 'principles of firefighting safety. (NIFC website, www.nifc.gov/safety_study/10-18-lces.html )

A Forest Service study on wildland firefighter entrapments, including Federal, State and rural firefighters, found from 1976 to 1999 that 28 different fire entrapment incidents occurred resulting in 105 burnover fatalities. In that same period, 240 different entrapments were reported involving 1,692 firefighters. Note: These were statistics were compiled before the Thirtymile and Cramer fires, each resulting in multiple fatalities.

It is believed by safety experts that for every serious accident, many more near misses and even more unsafe conditions go unreported. Based upon the number of fatalities and entrapments, the Forest Service report estimated approximately 23,000 unsafe conditions occurred on wildland fires between 1976 and 1999 (Wildland Firefighter Entrapments, 1976 to 1999, October 2000).

The Salmon-Challis NF has a history of known entrapments and shelter deployments from three other fires in the Forest. Two shelter deployments with one fatality on the Ship Island Fire in 1979. 82 shelters were deployed with no fatalities on the Lake Mountain Fire in July 1985. Also in July 1985, there were 73 deployments with zero fatalities on the Butte Fire (Records SCNF Fire management Plan (FMP), MTDC Investigation, NIFC website www.nifc.gov/reports).

To date, OSHA has conducted over 300 inspections of the Forest Service nationwide. Related to firefighter entrapments within the past 10 years, Notices of Unsafe or Unhealthy Working Conditions were issued to the Forest Service for two very similar high-profile fatality investigations. Most recently, notices were issued in the state of Washington involving the deaths of four firefighters in the Thirtymile Fire (#303757231). Prior to the Thirtymile Fire, notices were issued in Colorado involving the deaths of 14 firefighters (5 BLM and 9 USFS) in the South Canyon Fire (a.k.a. 'Storm King') (#116185406). The conditions, circumstances, findings, causal factors, and violations issued in these two fatality investigations were extraordinarily similar and in many respects compare very closely to conditions found surrounding these fatalities on the Cramer Fire.

The South Canyon Fire in 1994 brought to national attention many of the longstanding problems with wildland firefighter safety including the core problem that basic firefighting rules were not followed on an almost routine basis.

Willful violations issued from OSHA's Denver, CO Office to the Chief of the Forest Service and Director of the Bureau of Land Management included:

1. Not effectively communicating the identity of the Incident Commander;
2. Adequate safety zones and escape routes were not established and identified to employees;
3. Available weather forecasts and fire behavior information was not provided;
4. Adequate lookouts were not used for employees engaged in downhill fireline construction into dense fuels where they could not view the fire and potential hazards such as fire spotting.

In addition, serious violations included:

5. Failure to provide comprehensive information to firefighters including fuel type, fuel moisture, topography and weather forecasts;
6. Failure to ensure that the evolution of the Incident Command system was commensurate with the fire threat;
7. Failure to heed the safety practices contained in the Fireline Handbook ('Red book", now the Interagency Standards for Fire and Fire Aviation Operations); and
8. Failure to conduct adequate inspections of firefighting operations to ensure safe firefighting practices are enforced on fires.

In response to the South Canyon Fire, the main firefighting agencies including the Forest Service chartered a study to identify and change aspects of the underlying organizational culture that negatively impact firefighter safety. The TriData Report of March 1998 identified the lack of safety accountability as the major factor in need of change. Six suggested strategies for implementation of safety accountability were as follows: (1) A policy of removing safety violators from the job; (2) Follow Up on reported safety infractions; (3) Consider safety performance In performance reviews and promotions; (4) Add training accountability; (5) Include accountability in operational guidelines; (6) Provide guidelines for accountability.

Seven fire seasons later, the fatalities from Thirtymile Fire in 2001 revealed that many of the core safety policies and procedures continued to be disregarded and that serious unnecessary risks were still considered to be simply a part of firefighting. A system of accountability was still lacking within the Forest Service.

Willful violations issued from OSHA's Bellevue, WA Office to the Forest's Regional Office included:

1. All of the Ten Standard Fire Orders were violated and ten of the Eighteen Watch Out Situations were present and not mitigated. (NOTE: violations of the Fire Orders almost mirror violations which occurred at the Cramer Fire)
2. Management failed to conduct inspections of firefighting operations to ensure firefighting practices are enforced; and
3. After-action reports/reviews prepared for out-of-forest crews on Type 3, 4, and 5 wildfires did not identify safety and health hazards.

In addition, serious violations included:

4. Work rest cycles were not followed resulting in a lack of situational awareness and impairing judgment;
5. An Incident Commander was not clearly assigned or formally passed between leaders;
6. Fire shelter deployment procedures had not been developed for firefighters whose escape routes were compromised;
7. Evaluations of supervisory and management officials above the level of crew boss did not have performance elements relating to meeting the requirements of the federal agency safety and health program; and
8. A crew member assigned as squad boss had not yet completed his task book.

As one learns about each of these three fires, South Canyon, Thirtymile and Cramer, the similarities between conditions, violations of safety rules, and failures of management and accountability become readily apparent.

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