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NIOSH Cedar Fire Report



Investigation & Medical Findings

Recommendations / Discussions


Glossary of Terms

Maps and Photographs

CDF Cedar Fire Report

Table of Contents

Review Team Process

Overview of Accident

Summary of Events

Sequence of Events


Causal Factors

Contributory Factors


Site Conditions

Graphics – List of Illustrations Table

Description of Supporting Data and Supplementary Information

Novato FPD Investigation Analysis

Table of Contents


CDF Green Sheet


Lessons Learned

Draft Standard Operating Procedures

Inaja Fire Tragedy



California Department of Forestry and Fire Protection
Review Report of Serious CDF Injuries, Illnesses, Accidents and Near-Miss Incidents

Engine Crew Entrapment, Fatality, and Burn Injuries

October 29, 2003
Cedar Fire
Southern Region


Any behavior, condition, act, or omission that starts or sustains an accident occurrence. Avoiding or eliminating would prevent the occurrence.

Due to fire establishing itself north of Highway 78/79, along the west side and across the north end of the San Diego River drainage, the decision was made to re-position ground resources and to defend the structures along Orchard Lane, including the decision to deploy at the structure at 920 Orchard Lane.

This action positioned resources on a ridge top (downwind from the fire for the predicted gradient westerly wind) with unburned fuel between them and the fire and without the ability to see the fire as it progressed into and through the drainage. The resources assigned to Orchard Lane felt the fire was going to be approaching from the north and northwest and were basing their actions on that expectation.

This also created a transitional situation as the resources changed geographical areas and tactical environment. The most notable changes were from direct perimeter control and mop up around structures to one of structure defense on and near a ridge top with unburned fuel below them.

The flank of the main fire transitions with a slope reversal accompanied by a temporary wind shift that, by mass transport of embers, introduces fire into a receptive fuel bed below the resources along the ridge. As this fire continues upslope the westerly winds, which were not significant in the canyon bottom, intercept the fire near the ridge top and change the fire from a flanking fire to a head fire and push a convective column from near vertical to near horizontal.

Captain McDonald and Engineer Rucker did not immediately proceed to the refuge (house) when the order was given.

The full reason for the delay may never be fully explained. Engineer Rucker fell three times, as he and Captain McDonald proceeded along the escape route.

There was no assigned/dedicated lookout for operations on Orchard Lane.

Although resources assigned to operations along Orchard Lane were observing the fire from their individual vantage points there was not a specified lookout in position to observe and communicate the status of the flanking fire’s progress into the drainage, or the establishment of the fire on the west facing slope of the drainage.

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