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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


Effected the occurrence or outcome but was not causal. Avoiding or eliminating would not necessarily prevent the occurrence.

The firing operation from the Inaja Memorial to Santa Ysabel was not completed on the morning of October 29. It was in this area that the fire jumped Highway 78/79 and established itself in the San Diego River drainage on the north side of the highway.

At the time the fire crossed Highway 78/79 between the Inaja Memorial and Santa Ysabel, aviation assets that were assigned in the Branch III area, including three fixed-wing air tankers, had been returned to base due to the inability of the ATGS to contact ground resources.

Engine 6162 was originally placed to shield the portion of the escape route across the patio to the southeast corner of the house. To facilitate the burning of brush piles, the engine was moved further south. The net result was not only an increase in the overall travel distance along the entire escape route, it also increased the distance that would need to be covered without the shelter the engine had provided. This exposed the crew to intense thermal and convective conditions for a longer duration while traveling the escape route.

An independent firing operation was conducted at 930 Orchard Lane, south of Engine 6162’s location. The firing operation appears to have had an effect in drawing both the main fire and the fire at 930 Orchard together near the accident site, and likely caused a minor but potentially significant decrease in the amount of time available to react to the changing conditions. Simulations run without the firing operation indicate that one to two minutes of additional spread were likely needed for fire to impinge on the accident site.

It had been the practice on this incident to identify operational safety concerns as the dynamics of the operation changed. The safety concerns were communicated from the Safety function to the Operations/Branch and Division/Group level at the daily operational period briefing. These functions then verbally communicated both the operational assignments and the safety message to the ground resources during tailgate briefings at various locations on the incident. The incident Safety Officer read the safety message at the operational period briefing on the morning of October 29 and specifically discussed were the subjects of previously exhibited fire behavior and changing wind direction. There was not an ICS 215-A completed for the October 29 operational period, however, there was a generic safety message contained in each ICS-204 (Division Assignment List) as part of the IAP. This safety message directed resources on the line to identify and mitigate hazards.

The fact that all of the crewmembers of Engine 6162 were wearing all of their Personal Protective Equipment, including nomex shirt/trousers, gloves, helmet with chinstrap, goggles, protective shroud and Hot Shield devices (only Captain McDonald and Engineer Rucker had Hot Shields) substantially lessened the severity of their injuries. Without this protection in place it is doubtful that the rescue attempt by Captain McDonald, the travel to the engine by Engineer Kreps, and the eventual escape in the engine could have taken place without more serious injuries.

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