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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




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


  1. 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.

  2. 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:

    1. 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.

    2. 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.

    3. Quiet appearance of the fire as viewed from the rim.

    4. The night overhead personnel had not seen the terrain in daylight.

    5. Lack of detailed scouting of the canyon on sector G during the day.

    6. Absence of contact with the bosses of the division across the canyon who had a different vantage point for viewing the situation.

  3. 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.

  4. 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.

  5. 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.

  6. 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.

  7. 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

  1. 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.

  2. 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.

  3. 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.


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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