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.
|
United States
Department of
Agriculture |
Forest
Service |
Washington Office |
14th & Independence SW
P.O. Box 96090
Washington, DC 20090-6090 |
File Code: 6730
Route To: |
Date: Jan. 6 2004 |
| Subject: |
Accident Review Board Action Plan, Cramer Fire, Region 4, North
Fork Ranger District, Salmon-Challis National Forest, July 22, 2003 |
| To: |
Regional Forester, R-4, Deputy Chief for Business Operations, Deputy
Chief for State and Private Forestry |
A Chiefs Office Accident Review Board (ARB) was convened on December
5,2003, on a multiple fatality mishap involving a fire on the North Fork
Ranger District, Salmon-Challis National Forest, Region 4.
The Chiefs Office Accident Investigation Team presented the Factual
Report and Management and Evaluative Report at the ARB. These reports
were reviewed and approved after some revision. An action plan was developed
by the Board of Review to focus on key actions that, when implemented,
would best prevent similar mishaps in the future.
I approve the Board's recommended action plan for implementation as
stated for responsible units. Please review the enclosed action plan and
take the appropriate steps to ensure completion of each respective action
by the assigned date.
/s/ Sally Collins
SALLY D. COLLINS
Associate Chief
Enclosure
cc:
Dir, FAM
Dir, OSOH
ACCIDENT PREVENTION PLAN
Cramer Fire
July 22,2003
North Fork/Middle Fork Ranger District
Salmon-Challis National Forest
Salmon, ID
ACTION 1 : Assess current decision making and leadership training programs
for all prospective Type III, IV and V IC's that has been developed under
the direction of NWCG to determine if they are sufficiently comprehensive
and simulation based. Adopt and fully integrate the NWCG program or develop
and implement a new decision making and leadership training program. Candidates
should be certified by the trainers as to whether they are qualified to
be an IC based on real time, high stress simulations that require demonstrated
capacity to correctly analyze multiple, complex inputs and make timely,
sound decisions.
LEAD RESPONSIBILITIES: Director FAM
COLLABORATING PARTIES:
COMPLETION DATE FOR ASSESSMENT: February 2004
COMPLETION DATE FOR TRAINING IMPLEMENTATION AND
CERTIFICATION:
• If
existing training is sufficient, implement by March 2004
• If
existing training is not sufficient, develop new class and implement
by
January 2005
ACTION 2: Develop an interim certification process that is simulation
based for existing Type III IC's for fire season 2004.
LEAD RESPONSIBILITIES: Director FAM
COLLABORATING PARTIES:
COMPLETION DATE FOR INTERIM CERTIFICATION: April 2004
ACTION 3: Develop and implement a procedure to periodically re-certify
the qualifications of Type III IC's.
LEAD RESPONSIBILITIES: Director FAM
COLLABORATING PARTIES:
COMPLETION DATE: November 2004
ACTION 4: Assess the organizational structure and staffing of the Salmon-Challis
National Forest to ensure that the allocation of authorities and management
oversight of fire management actions is effective. Make adjustments in
the structure and staffing as appropriate.
LEAD RESPONSIBILITIES: Regional Forester, Intermountain Region
COMPLETION DATE FOR ASSESSMENT: January 2004
COMPLETION DATE FOR STAFFING: May 2004
ACTION 5: The preparation of this plan has been influenced by the accident
prevention plan prepared in response to the Thirtymile Fire Accident.
That plan contains a number of actions that are responsive to the causal
factors identified in the Cramer Fire Accident Investigation Report. the
specific Thirtymile action items are:
Al, A2, A3a, A3b, A3c, A4, A8a, A8b, A9, A10, A11, A13, A14, A15,
A16, A18, A21, A22, A23, A25, A26
Rather than repeat these action items, a critical review of the Thirtymile
Fire Accident Prevention Plan must be done ensure that substantive progress
has been made and that accomplishments to date are appropriate.
LEAD RESPONSIBILITIES: DEPUTY CHIEF S&PF
COLLABORATING PARTIES:
COMPLETION DATE: March 2004
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