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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


Human Behavior

All four members of Engine Co. 6162 reported to work at 8:00 a.m. on October 27, after all had a full four days off. (Tab Sections 26, 27, 28; Item #224, 147, 148)

In the previous 24 hours, up to the point of the accident, the crew of Engine 6162 acquired six hours of sleep at the incident base (the night of Oct. 28). By rotating drivers, they were able to take additional short periods of rest on the drive to Southern California. (Tab Sections 24, 26, 27, 28; Item #60, 224,147, 148)

Fire Captain McDonald changes his mind about defending the structure after discussion with the crew of 6162. (Tab Section 26; Item # 224, pg. 3&4)

All four members of the crew of Engine 6162 move to the passenger-side of the engine prior to the command being given to seek refuge in the structure. (Tab Section 26; Item # 238, pg. 21, line 16)

Fire Fighter-Paramedic Smith and Engineer-Paramedic Shawn Kreps immediately react to the order to go to the house via the escape route. (Tab Section 26; Item # 224, pg. 6, line 14)

Engineer Rucker did not immediately proceed to the refuge (house) with the rest of the crew when ordered. (Tab Section 26; Item # 224, pg. 6, line 13)

Captain McDonald noted that Engineer Rucker remained standing near the southeast corner of the engine when the order to seek refuge was given. (Tab Section 26; Item # 224, pg. 7, line 1)

While on the passenger side of the engine, traversing the escape route, Engineer Rucker falls twice. Captain McDonald moves toward him to assist. (Tab Section26; Item # 224, pg. 7, line 8)

Engineer Rucker falls for the final time on the concrete patio. (Tab Section 26; Item # 224, pg. 23. line 12)

While on the patio Captain McDonald, in an attempt to rescue (drag) Engineer Rucker, turns to face the oncoming fire. (Tab Section 26; Item # 224, pg. 7, line 19 – pg. 8, lines 1-5).

While on the patio, Captain McDonald is subjected to enough heat and flame that he is forced to leave Engineer Rucker and retreat behind the house. (Tab Section 26; Item # 224, pg. 8.)


While Engine 6162 suffered minor damage, melted lens and light covers, it remained running at a high idle throughout the event. (Tab Section 246; Item # 101)

There is limited access to the driver’s seat, from the other areas of the cab, due to the internal crew compartment configuration of Engine 6162. (Tab Section 118; Photo # W1, W2, W3, W4, W5)

All appropriate PPE was in use. (Tab Section 27; Item # 147, pg. 45)

Captain McDonald was wearing a hot-shield face piece. (Tab Section 27; Item # 147, pg.45)

Engineer Rucker was wearing a hot-shield face piece. (Tab Section 27; Item # 147, pg. 45)

Captain McDonald’s web-gear was burned to the point that the contents of the utility bag; appliances, hose clamp and flagging fall to the patio. (Tab Section 115; Photo # DSCN0203)

Captain McDonald removed his remaining web-gear inside of 920 Orchard Lane. (Tab Section 26; Item # 224)

A length of one and one-half inch wildland hose (part of a hose bundle) is found immediately next to the right-side of Engineer Rucker’s head, and burn marks on the patio indicate another length of hose was approximately 3 feet from his feet. (Tab Section 115; Photo # DSCN0204, DSCN0207, DSCN0214)

A set of D-rings, grommets and a clasp, representative of the kind used on Novato F.D. hose packs , were found on the ground immediately adjacent to the top of Engineer Rucker’s head. (Tab Section 112; Photo # DSCN1039)

The two hose lines attached to the rear discharge of the engine burn through and the tank was pumped dry. (Tab Section 28; Item # 148, pg. 29, para. 3: Tab Section 112; Photo # DSCN 0969, 0970)

Fuel/Weather/Topography/Fire Behavior

The Incident Command Team did not request a spot weather forecast. General weather forecasts were downloaded from a Boise Weather site. (Tab Section 6; Item # 246)

A general weather briefing is given during the operational briefing at the incident base on the morning of October 29. It is read by the PSC. (Tab Section 16; Item # 254, pg 11,12 )

A Fire Weather Watch is issued at 9:30 a.m. by the San Diego office of the National Weather Service for increasing gusty southwest to west winds of 15-10 miles per hour in the mountains with locally higher gusts (Tab Section 239; Item #79, pg 6)

Between 9:00 a.m. and 9:15 a.m. on October 29 the fire crosses Hwy 78/79 just west of the Inaja Memorial (Tab Section 22)

At about 11:00 a.m. to 11:30 a.m. the fire burns up the west side of the drainage to the north and east of 902 Orchard Lane. (Tab Section 59; Item # 71, pg. 2, para 2&3)

920 Orchard Lane sits at a high point on the ridge with a chimney/saddle immediately to the north and south of the structure. Fire had been introduced into both these saddles by firing operations. (Figure # 7)

The upper 200 feet of the slope below 920 Orchard Lane is exposed to the prevailing westerly wind due to a saddle on the ridge directly across the San Diego river drainage to the west. (Figure # 7)

In the area immediately west of the accident site there was nearly complete consumption of live fuels and complete consumption of dead fuels with duff consumed to the top of mineral soil and significant scouring of the ground surface leaving only compacted soil and imbedded rocks. (Tab Section 121; Photo # 5, 41)

RAWS data from the Julian Station at the approximate time of the accident indicate sustained winds of 17 miles per hour with a peak gust of 31 miles per hour out of 252 degrees. (Tab Section 239; Item # 200)


Incident Command Team #5 received their transition briefing on October 26. (Tab Section 6)

Incident Command Team #5 assumed management of the incident on the morning of October 27 at 7:00 a.m. The production of the first IAP and operational period briefing completed the transition process. (Tab Section 6,7)

The Incident Command Post and Incident base were moved from Ramona Community Park to El Cajon (Heartland Training Facility and Gillespie Field) during the October 28 operational period. (Tab Section 6)

Span of control for Division I on the October 29 IAP was a ratio of 27 to 1. (Tab Sections 204,205; Item # 36,37)

One of the control objectives identified in the Incident Action Plan for October 29-30 was to “Keep the fire south of Hwy 78 to Hwy 79” (Tab Sections 204,205; Item # 36,37, ICS-202)

The control operations identified on the ICS-204 for Branch III, Division I for the October 29-30 operational period were “Protect Structures and control perimeter as necessary”. (Tab Sections 204,205; Item # 36, 37)

Air Tactical Group Supervisor returned three air tankers (due to a perceived communication problem) to base during the period of time the fire crosses Hwy 78/79 at the San Diego River drainage. (Tab Section 56; Item # 171, para. 2)

The Incident Meteorologist, and the Fire Behavior Analyst positions were ordered on October 26 but not filled until October 30. (Tab Section 6,11)

On October 29, after the occurrence of the burn-over, Division I learns that F.C. Childe, while not assigned to his division, was “doing stuff” (firing out) on his division that was not part of the plan. (Tab Section 23; Item # 154, pg. 15, line 2)


Strike Team 2005-A was using a VHF high-band radio frequency for a “tactical” or “crew net”. (Tab Section 26: Item # 224, pg. 11, line 16)

Strike Team 1190-K was operating on tactical net “Blue 5.” (Tab Section 55; Item # 213, para 4)

Mike Rodan (Transport driver for LA County Dozer #4) sees an increase in fire behavior and communicates this on “Blue 5” to LA County Dozer #4. (Tab Section 55; Item # 213, Vidrinskas, pg. 21, line 10)

The El Cariso Hotshots were operating on their own tactical net, U.S.F.S. Crew Net. (Tab Section 52 – see Wall supplement)

Jay Bertek (El Cariso Hotshot Superintendent) observes unexplained fire behavior between 902 and 930 Orchard Lane and contacts his hotshots, on their crew tactical net, to exit the ridge and return to the meadow. (Tab Section 52 #, pg. 16, lines 3 to 9).

Air Tactical Group Supervisor is unable to communicate with assigned resources in Branch III in the morning on October 29, due to a perception that the frequencies assigned for air to ground communications were incorrect. (Tab Section 56; Item # 171)

There was one VHF handheld portable radio available to the crew of Engine 6162 at the time of the accident. (Tab Section 26; Item # 224)

Copter 202 attempts, but is unable to talk to Engine 334 @ 902 Orchard Lane on Air-to-Ground frequency. (Tab Section 59; Item # 71)

Division I had to listen to OES White Fire 2 (assigned structure group tactical frequency) because “our communications were so poor” (Tab Section 23; Item # 154, pg 20, line 10)

Division I could not make radio contact with the S/T Leader of 2005-A, Branch III, or Air Ops at the time of the accident due to dead batteries in his hand-held portable radio. (Tab Section 23; Item # 154, pg 12, line 1)

Assigned frequencies in the October 29 IAP; Communication Plan, ICS 205; Air Operations Summary ICS 220; and Branch III/Division I: ICS 204, were consistent. (Tab Section 205; Item # 37)

The only change in the IAP assigned frequencies from the October 28 operational period to the October 29 operational period is the command net which was moved from a simplex frequency to a duplex frequency on October 29. (Tab Sections 202, 205; Items # 35, 37)

The air to ground frequency for the October 28 operational period was handwritten onto the ICS- 205 in the IAP, and no Air to Ground frequency was listed on the ICS-204 for Branch III. (Tab Section 202; Item # 35)

Strike Team leader Watkins attends the morning operational period briefing at the ICP. The crew of Engine 6162 does not attend. (Tab Section 24; Item # 150)

While at the ICP Strike Team Leader Watkins briefs Strike Team 2005-A regarding the operational period assignment and relevant safety information. (Tab Section 24; Item # 150)

Division I provides Strike Team Leader Watkins a briefing on the fire activity the day before, what was occurring that day, and what to expect. (Tab Section 24; Item # 60)

FAE Sanchez does not have a portable radio at 902 Orchard Lane. (Tab Section 51; pg 12)

Deputy Branch III contacts Air Tactical Group Supervisor on Air to Ground frequency following burn over. (Tab Section 17; Item # 214)

Situational Awareness

During the morning of October 29 the crew of Engine-6162, Strike Team Leader Watkins, and Engine-24 have several opportunities to observe the fire behavior in the area of the Inaja Memorial and the San Diego River drainage. The behavior was described as moving slowly with the wind, backing down slope, with the column rising approximately 1000 feet then bending to the east. (Tab Section 24; Item # 150. pg. 15. line 20)

The El Cariso Hotshot superintendent observes unexplained fire behavior and increased spotting in the area of the meadow and subsequently pulls his crew out. (Tab Section 52; pg. 16)

The LA County bulldozer transport driver observes increased fire behavior and communicates it to the LA County bulldozer. (Tab Section 55; Item # 213, para 4)

Fire Captain McDonald initially did not think the structure at 920 Orchard Lane was defendable based on his observation point from the 90-degree turn in the driveway. (Tab Section 26; Item # 224, pg. 3,4)

In order to avoid scratching the paint on Engine 6162, the driveway at 920 Orchard Lane needed to be brushed in order to back the engine up the driveway. (Tab Section 28; Item # 197)

The crew of Engine 6162 believes the fire will approach 920 Orchard Lane from the north. (Tab Section 26; Item # 224, pg. 18, line 14)

While at 920 Orchard Lane, the crew of Engine-6162 observes a seven to 10 mph wind coming from the southwest. (Tab Section 27; pg 25,26)

Captain McDonald recognizes that there is heavy brush below and to the west of 920 Orchard Lane. (Tab Section 26; Item # 224, pg 6, line 8)

Prior to the decision to go into the structure, the crew is exposed to intensified levels of heat, which causes them to move around to the passenger side of the engine and use it as a shield. (Tab Section 26; Item # 224, pg. 21, line 14.)

At about noontime on Oct 29, eyewitness Mitchell, who lives at 1126 Orchard Lane, observes the wind shift out of the west as the fire moves down into the canyon bottom and “starts shooting up” to the north of his position. (Tab Section 44; Item # 153, pg 4).

After the blowup, Division I is surprised the fire is so far south on the ridge along Orchard Lane. He expected it to come from the north. (Tab Section 23; Item # 154, pg. 18, line 21)

Strategy / Tactics

The firing operation from Pine Hills Road to the town of Santa Ysabel is not completed as of 6:00 a.m. on the morning of October 29. The uncompleted section stretches from the Inaja Memorial to Santa Ysabel. (Tab Section 20; Item # 62, pg 2, para. 3)

At 11:55 a.m., Strike Team 2005-A resources are assigned to structures along Orchard Lane. (Tab Section 24; Item # 60)

Engine 6162 was initially spotted by the steps leading to the patio at 920 Orchard Lane, by the southwest corner of the house. The engine was then moved in a backwards (southward) direction to facilitate burning a debris pile. The final resting place of the front bumper was approximately 35 feet to the south from the patio steps. It remained there until moved during the crew’s escape down the driveway. (Tab Section 26; Item # 224, pg 5)

The crew of Engine 6162 deployed three, one and one-half inch hose lines (two, 100-foot protection lines from the wyed rear discharge and one 30-foot hose from the front bumper discharge). (Tab Section 27; Item # 147, pg. 29)

The crew of Engine 6162 removed the grass, down slope and to the west of the engine, by burning out. (Tab Section 27, pg 33 : Tab Section 28, pg 21-23)

The crew of Engine 6162 burns brush piles to the west of the engine. The crew moves further down the slope and continued to enlarge the burned out area to the west of structure. They conclude this burning operation by throwing 10 to12 fusees even further down the slope, into the brush, west of their position. (Tab Section 26; Item # 224)

Independent firing operations took place around and between; 902, 920, 930, & 1038 Orchard Lane. Personnel not assigned to the Branch or Division I conducted these. (Tab Section 23; Item # 154, pg. 15)


The crew of Engine 6162 originally identified the meadow, east of Orchard Lane, as a safety zone prior to being assigned to 920 Orchard Lane. (Tab Section 26; Item # 224, pg. 6, lines 8-10)

Once at 920 Orchard Lane, Captain McDonald identifies the house as a refuge, with the escape route being the patio. (Tab Section 26; Item # 224, pg. 6)

Although personnel in the Orchard Lane area were observing fire behavior, their was no
assigned, dedicated, lookout for Branch III, Division I, the Orchard Lane area, Strike Team 2005-A, or Engine Company 6162. (Tab Section 23; Item # 154, pg. 22, line 28)

There was no ICS 215A completed for the October 29 operational period. (Tab Section 16; Item # 254, pg 12)

The incident safety message on October 29 was repeated from the previous operational period. (Tab Section 203; Item # 11)

A hedge of Boxwood bushes, (approx. forty feet long and up to four feet high, in a raised rock wall that is three feet tall), alongside Engine 6162 ignites and exposes the retreating crew to direct flame and heat. (Tab Section 27; Item # 147, pg. 39, para. 1)

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