NIOSH Cedar Fire Report
CDF Cedar Fire Report
Novato FPD Investigation Analysis
Draft Standard Operating Procedures
Inaja Fire Tragedy
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NOVATO
FIRE PROTECTION DISTRICT
Investigation Analysis
of the
Cedar Fire Incident
Engine 6162 Crew Entrapment,
Fatality, and Burn Injuries
October 29, 2003
The Inaja Forest Fire Disaster
(Pronounced Inn•ah•HAH)
November 25, 1956
Cleveland National Forest, California Region
Conclusions
-
Fire Behavior. The disastrous flareup of the Inaja
fire was caused by a critical combination of highly flammable fuels,
steep topography, and adverse weather. The lull in the fire before
and at the time of arrival of the night crews created a false sense
of security, even though existing conditions of fuel, topography,
and weather were critical.
-
Crew location in canyon. The men were taken down
the line into the canyon owing to a lack of information to show possible
danger from the fire in the canyon below. The contributing factors
were:
-
Absence of specific information on the fire status in San Diego
Canyon available for the briefing at the base camp, due to poor
conditions for aerial reconnaissance.
-
Emphasis placed on the danger of the burning-out fire rather
than on the main fire in the canyon below, when the day division
boss briefed the night overhead personnel.
-
Quiet appearance of the fire as viewed from the rim.
-
The night overhead personnel had not seen the terrain in daylight.
-
Lack of detailed scouting of the canyon on sector G during the
day.
-
Absence of contact with the bosses of the division across the
canyon who had a different vantage point for viewing the situation.
- Trail location. The location of the fire trail on
the specific ridge where it was built instead of the spur ridge up the
canyon was questionable. The previous behavior of the fire and the position
above and alongside a precipitous chimney made the chosen location hazardous.
- Burning-out. Sound fire fighting principles call
for burning out the intervening fuels between the control line and the
fire edge. The effect of the burning-out fire on the behavior of the
main fire and of the planned escape routes is a vital factor influencing
decisions on when, where, and how to burn out, and where to place men.
Fire behavior is not well enough understood to firmly establish the
possible effect of the burning out fire in sucking the main fire rapidly
up the chimney at the site of the disaster. Other factors would have
permitted the explosive run without the presence of the burning-out
fire. Furthermore, the burning-out fire did not cut off the escape
route.
-
Lookout. The crew cutting line into the canyon received
warning to come out when a crew boss on the upper part of the line
saw the fire heating up at a point below the men. It is uncertain
in the Inaja fire disaster that a specifically designated lookout
would have given warning any sooner. However, it is vital that a lookout
be designated when crews are in a potentially dangerous location.
-
Water. Exhausting the water supply from the tanker
at the time of the flareup did not cause or contribute to the tragedy.
the flames that raced up the canyon slope were of such height and
were extended so far in advance of the burning fuel, that water available
from one or several ground tankers would not have had a material effect.
-
Personnel. The leaders on the Inaja fire were capable
and experienced. They were trained in accordance with recognized Forest
Service standards. There is, however, need for more intensive fire
behavior training for key fire supervisory personnel.
Line crews on the sector where the tragedy occurred were experienced,
trained fire fighters. Moreover, on this sector there were experienced
overhead personnel from the local forest and from other forests.
Recommendations of the Investigating Team
-
It was strongly brought out by the investigation that better knowledge
of fire behavior must be developed as an essential means of preventing
future fire tragedies. Research studies even more comprehensive and
penetrating than past and current fire behavior research must be carried
our to determine means of fighting mass fires and the behavior of
fires in forested areas, especially in rough topography. In addition
to progress in fire control methods already made, new and more powerful
methods of attacking mass fires are needed and must be developed.
Such methods, like use of aerial attack with water and chemicals,
may provide the means of controlling dangerous fires with less risk
to human lives.
-
More experts on fire behavior must be developed for assignment to
critical fires. These highly skilled experts would evaluate situations
and assist fire bosses in making decisions for safe, effective fire
fighting.
-
The investigators pointed out that in general, although not related
in particular to the Inaja fire, present Government salary and wage
rates make it difficult to obtain and hold competent fire control
personnel. Controlling mass forest fires is a difficult and highly
technical job. The specifications for these positions should be further
reviewed with appropriate Department and Civil Service Commission
officials.
Working Notes and Data
The investigating team’s voluminous notes, maps, photographs,
analyses of weather records, fuel moisture measurements, fire behavior
observations, information on training and experience of leaders, etc.,
are to be filed with the office copy of this report. Further study will
be made of this material and a Service memorandum will be prepared covering
points which may be helpful to Forest Service officials having fire control
responsibilities.
Glossary
Base camp.--Same as main camp, in this case. See
Main camp.
Control line.--See Hand line.
Division.--A unit of a complex fire perimeter between
designated topographical or cultural features (such as ridges, streams,
and roads) organized into two or more sectors for control.
Fire trail.--Same as fireline. See Hand line.
Fire weather.--Weather factors that affect the probability
that forest fires will start and their rate of spread after starting.
It is the composite of elements such as drought conditions, wind, and
air temperature and relative humidity.
Flanks of a fire.--The parts of a fire’s perimeter
that are roughly parallel to the main direction of its spread or progress.
Hand line.--A fireline or control line made with
hand tools rather than machines such as bulldozers. A strip a few inches
to several feet wide is scraped or dug to mineral soil so that fuel
is absent and the fire’s progress may be halted when it reaches
the fireline. Sometimes a fireline is located some distance from the
main fire and then the intervening vegetation and fuels are purposely
burned to make a much wider strip devoid of fuel. This is called backfiring
or burning out.
Lookout.--A person designated to detect and report
forest fires, from a vantage point such as a tower or a natural elevation.
Main camp.--Headquarters of a the fire boss, who
is responsible for all suppression and service activities at a fire.
Same as fire headquarters.
Sector.--A designated segment of fire perimeter or
control line comprising the suppression work unit for two or more crews
under one sector boss.
Tanker.--A truck equipped to carry water or other
liquids used in suppressing a fire.
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