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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



NIOSH fire fighter fatality investigation

A Career Fire Fighter was Killed and a Career Captain was Severely Injured During a Wildland/Urban Interface Operation - California


Recommendation #1: Fire departments and fire service agencies should ensure that the authority to conduct firing out or burning out operations is clearly defined in the standard operating procedure (SOP) or incident action plan (IAP) and is closely coordinated with all supervisors, command staff and adjacent ground forces.

Discussion: It may be advantageous or necessary to conduct firing or burn-out operations in certain areas during a fire. Each and every fire fighter must be assigned to a team of two or more and be given specific assignments when conducting such an operation.1 Firing out operations is a way of attacking a very intense fire. Burning out is used to widen a control line by eliminating unburned fuels between the control line and an advancing fire front.2 Any firing out or burning-out operation requires considerable preparation, organization and coordination. Safety must be given first priority. No operation, regardless of strategic importance or other critical factors, is worth risking human life.3 Overall fire strategy and authorities must be clear to all personnel employing firing out or burning-out, since fire behavior or fire control operations on adjacent divisions are likely to be affected.4

Regardless of the purpose and which tactic is chosen, certain basic safety procedures should be followed when conducting firing out or burning-out operations because any additional fire may increase the risk to life and property.

The following are examples of safety guidelines pertinent to this incident:

  • Firing operations should be supervised by qualified personnel
  • Firing operations should be coordinated with incident command and crews operating in the area
  • Firing operations should be done by trained personnel that have authorization from their supervisor and the command staff
  • Constant radio communications must be maintained so firing operations can be coordinated with other fireline operations
  • Escape routes and safety zones should be identified and clearly marked before starting firing or burn-out operations
  • If firing out becomes too intense for the crews to control, it should be stopped until control is regained and the firing operation is modified to reduce the intensity
  • Firing operations should be initiated from and terminated at an anchor point.2

Recommendation #2: Fire departments and fire service agencies should ensure that all resources, especially those operating at or near the head of the fire, are provided with current and anticipated weather information.

Discussion: A “Fire Weather Watch” indicates a possible critical fire weather pattern (i.e., strong wind, dry lightning, dry cold front, low relative humidity.) A “Spot Weather Forecast” should be requested for fires that have potential for extreme fire behavior, exceed the initial attack, or are located in areas for which a “Fire Weather Watch” or “Red Flag Warning” has been issued.5

A “Fire Weather Watch” had been issued at 0900 hours for this fire on the day of the incident. The victim’s crew was not aware of the “Fire Weather Watch” issued earlier that day and not provided with a “Spot Weather Forecast.”

Recommendation #3: Fire departments and fire service agencies should stress the importance of utilizing LCES (Lookouts, Communications, Escape Routes and Safety Zones) to help identify specific trigger points (e.g., extreme fire behavior, changes in weather, location of fire on the ground, etc) that indicate the need for a crew to use their escape route(s), and/or seek refuge in a designated safety zone.

Discussion: In the wildland fire environment, Lookouts, Communications, Escape Routes, Safety Zones (LCES) are key to safe procedures for fire fighters. The elements of LCES form a safety system used by fire fighters to protect themselves. LCES is a self-triggering mechanism that allows the lookout to continuously assess and reassess the fire environment and to communicate those threats to fellow crew members.5 Being on the alert to the indicators of extreme fire behavior will help fire fighters identify established trigger points (e.g., increased spotting, approaching weather front or change in wind direction, etc). Trigger points allow crews the necessary time to utilize escape routes to reach safety zones. Seeking refuge in an apparatus or permanent structure should not be considered a safety zone but rather a survival site. Key points regarding shelter deployment, building refuge and vehicle refuge can be found in the Fireline Handbook and the Incident Response Pocket Guide.5, 6

Radio communications allow lookouts, supervisors, crew members and air resources to warn crews of any situational changes in weather and fire behavior. Ample warning of changing conditions would provide fire fighters with the necessary time to utilize escape routes to the designated safety zone(s).

Individual crews observed the fire from their individual vantage points. There were no assigned or designated lookouts for the Task Force or adjacent ground forces operating on or near the ridge to observe and communicate their observations of the fire’s progress up the drainage.

There are numerous examples of where communication was effective among individual crews but not between crews. One example of a successful outcome involved the Hotshot crew operating at the north end of the ridge. Their supervisor, standing in the safety zone, ordered his crew to his location after he observed an increase in fire activity along the ridge. Unfortunately, this radio transmission was made on the Hotshot crew’s tactical channel and was not heard by the victim’s crew or other crews operating on the ridge.

Recommendation #4: Fire departments and fire service agencies should ensure that, at a minimum, high-risk geographic areas are identified (e.g.; topography, fuels, property, etc.) as part of the pre-planning process and that that information is provided to assigned crews.

Discussion: Pre-incident plans are guidelines intended to assist fire officers in establishing priorities and making fireground decisions. The pre-incident plans should be reviewed at least annually and updated as needed.2 Copies of pre-incident plans should be made available to all assigned crews. The pre-incident plans should contain, at a minimum; maps (showing topography, possible staging areas, target hazards, access routes, water sources, and possible facilities such as base camps, helibases, and helispots), list of special concerns/needs (special hazards, fuels, expected fire behavior, etc.) and history of previous fires, an invaluable resource for out-of-area crews providing mutual-aid.

In this incident, none of the officers or fire fighters assigned to the Task Force had ever fought a wildland fire in this region of California. Fire history, fuels, weather, topography and crew training/experience varies throughout the state. This creates a situation where crews may be unfamiliar with local factors affecting fire behavior and is listed as one of the eighteen “Watch-Out” situations taught to all wildland fire fighters - “Unfamiliar with weather and local factors influencing fire behavior”5 that have been identified as a contributing factor in wildland fire fighter fatalities.

The CDF Green Sheet and the report produced by the victim’s fire department both pointed out that an incident involving the deaths of 11 fire fighters, occurred less than 1.5 miles southwest of the entrapment site under very similar weather conditions in November of 1957. This information was not made available to the victim and his crew.

Recommendation #5: Fire departments and fire service agencies should ensure that incident command system (ICS) span-of-control recommendations are maintained.

Discussion: Span-of-control refers to the number of personnel reporting to any given individual. Optimum span-of-control in the incident command system (ICS) is five, with an acceptable spread of two to seven. On a situation that is not yet under control, no one operating under ICS should have more than five personnel reporting to him or her. Span-of-control ratios can be driven by a number of factors such as the training and experience of the fire fighters, complexity of the incident, or the type or timeframe of the incident.7

This incident can best be described as a fast moving complex incident that would have required a tight span-of-control. The span-of-control at the Division level on this incident was 27 to 1 and exceeded the acceptable ratios as outlined by the ICS.

Recommendation #6: Fire departments and fire service agencies should consider the implementation of a carbon monoxide-based monitoring program for wildland fire fighters.

Discussion: Crew members reported that the victim reacted in a confused or disoriented manner during the critical minutes as the fire approached. Hypoxia, the reduction of oxygen in blood or tissues, can cause an altered mental status and the victim had two potential reasons for hypoxia: carbon monoxide poisoning and/or a severe asthma attack.8 An asthma attack of sufficient severity to cause hypoxia typically is preceded by symptoms of respiratory distress such as shortness of breath, difficulty breathing, wheezing, or chest tightness.9 According to his crew members, the victim never displayed any of these symptoms. The NIOSH medical investigator considers asthma an unlikely cause due to the lack of symptoms, coupled with the victim’s relatively mild underlying asthma.

Hypoxia due to carbon monoxide poisoning is a more likely scenario. Although wildland fires generally do not expose fire fighters to high levels of carbon monoxide averaged over an entire work shift, they can expose fire fighters to dangerous concentrations for short periods of time during specific activities.10-12 In addition, carbon monoxide exposures were found to be higher during prescribed burns, presumably because fire fighters feel compelled to keep the fire within prescribed boundaries at all costs.13 “The increasing problem of residential influx to wildland areas may cause more overexposure to smoke as firefighters feel compelled to protect structures despite heavy smoke situations.”13

At approximately 1100 hours, the victim was exposed to carbon monoxide during mop-up operations for about 50 minutes. At approximately 1215 hours, the victim was protecting a residential structure by supervising a “burn pile;” a small “prescribed burn” to reduce fuel load around the home. To control the pile, water was applied to the ground around, and onto, the pile. The latter activity probably increased the pile’s generation of carbon monoxide due to incomplete combustion. He did this for approximately 25 minutes before the fire conditions dramatically deteriorated. In addition, the victim encountered conditions that may have increased the severity of the exposure: exertion related increase in minute ventilation (how fast and deep the individual was breathing), long duration of exposure (approximately 30 minutes at the scene, about 50 minutes of mop-up in the late morning, and at least 12-hours during the previous shift), altitude (3800 feet), simultaneous exposure to airborne irritants (wildland fire smoke), and proximity to engine tailpipe exhaust.14, 15 During the autopsy, a carboxyhemoglobin level of 27% was found, demonstrating his significant exposure to carbon monoxide. Although carboxyhemoglobin levels do not correlate well with clinical findings, profound unconsciousness has been reported with levels less than 20%.16, 17

While these findings can explain the victim’s confused behavior, it is unclear why his Captain and other crew members, working under similar conditions, did not experience symptoms or signs of carbon monoxide poisoning. Upon hospital admission, the Captain had a carboxyhemoglobin level of 4.6%. Prior to hospital admission, the Captain’s resuscitation efforts included intubation and administration of 100% oxygen; measures that speed the elimination of carboxyhemoglobin. Assuming he was intubated and receiving 100% oxygen for about one hour prior to his carboxyhemoglobin level being drawn, the Captain’s estimated peak carboxyhemoglobin level would have been approximately 9.2%.18, 19 Possible explanations for the discrepancy between the Captain’s and the victim’s carboxyhemoglobin levels include: 1) the victim had higher exposures to carbon monoxide due to any of the factors listed in the previous paragraph, or 2) individual variation.

Fire management and safety officers responsible for health and safety of fire fighting personnel should consider using CO monitors to manage fire fighter’s acute overexposure to components of smoke. To monitor acute exposures, field personnel need to calibrate and activate a CO monitor during wildland fire fighting operations. The monitors are already set to alarm at certain levels, and can be used as an “early warning device” to trigger actions to reduce exposures. Managers should also develop a written smoke exposure plan. This plan should focus on responding to CO monitor warning alarms, and include health surveillance, training, and tactics to minimize exposure.5, 20 Since smoking increases CO levels, encourage smokers to quit and non-smokers to not start. The victim and the Captain of E-6162 were non-smokers.


Recommendation #7: State agencies, local municipalities and community organizations should consider developing statewide guidelines and local community plans for managing fuels in the wildland/urban interface.

Discussion: A number of organizations at the state and national levels provide community leaders and citizens with guidelines that can be utilized in identifying specific threats to life and property (i.e., wildfires), best practices and available resources.

The following are links that provide information regarding the wildland/urban interface:

The incident site occurred in a community that was identified and designated by the California Fire Alliance as having a Hazard Level Code of 3, indicating the highest fire threat level. The surrounding communities also had a Hazard Level Code of 3.

These communities were in the process of establishing a committee to deal with the threat of a wildfire when the incident occurred. The homeowners of Residence #2 had cleared a large portion of the wildland brush in all directions surrounding the house.

Approximately 70 feet of brush had been cleared to the east, 180 feet to the west, 100 feet to the south, and 115 feet to the north of the house. There was extensive management of the landscape vegetation and grounds surrounding the incident site that consisted of a mix of herbaceous plantings, a juniper hedge (near patio where victim was found), small woody shrubs, a few small fruit trees and larger diameter oak trees.

Recommendation #8: Fire departments and fire service agencies should provide members with annual medical evaluations consistent with NFPA 1582, Standard on Comprehensive Occupational Medical Program for Fire Departments.

Discussion: The affected fire department had already implemented a comprehensive annual medical evaluation program. In addition, the victim’s personal physician appropriately shared medical information (i.e. his asthma diagnosis) with the fire department physician, but not other fire department or city officials. The fire department physician (employed by a Health Maintenance Organization under contract with the fire department) assessed whether this condition could affect the victim’s ability to safely perform the job. Specifically, they noted the victim never required any of the following for this asthma: hospitalizations, emergency medical care (e.g. a hospital emergency department), oral corticosteroids, or work restrictions. In addition, the victim had normal PFTs as described in the above medical findings section.

According to NFPA 1582, asthma compromises a member’s ability to perform several essential job tasks of structural fire fighter.21 However, the NIOSH occupational medicine physician and investigators believe the fire department physician appropriately evaluated the fire fighter’s underlying lung condition off his asthma medications. Since 1) these PFTs and chest X-rays were normal, 2) his condition was easily controlled with intermittent use of inhalers, and 3) in four years his condition never affected his ability to perform the duties of a structural fire fighter, NIOSH investigators agree with the fire department physician’s decision to clear this fire fighter for unrestricted duty.

Recommendation #9: Standard setting bodies (e.g., NFPA, NWCG, etc.) should consider developing a national standard that fire fighters can utilize during wildfire incidents for identifying and marking wildland/urban interface properties based on the ability to defend the structure(s) located on that property.

Discussion: A structure triage checklist or assessment sheet is an invaluable tool when evaluating and identifying structures that can be successfully protected during a wildland fire incident. The evaluation (triage) of a structure by an officer (preferably a wildland/urban interface protection specialistb) is but one part of the size-up process when determining if a structure can be protected from an approaching wildland fire. The safety of fire fighters must be the primary consideration when evaluating whether a structure can be successfully protected. There are three categories of structures: those that are not threatened, those that are hopeless or too dangerous to protect, and those that will be threatened and have the potential of being saved.4 Determining which category a structure will fall into should be based upon a logical process of determining anticipated fire behavior, estimating the capabilities and availability of resources, and analyzing the defensible space around the structures.

The ability to identify structures that are or are not saveable must be communicated to other fire fighters in the area. A national standard, utilizing alpha-numeric characters or symbols, is needed to provide the wildland/urban interface protection specialist with a means to communicate his findings to other emergency service personnel. Examples include: a large A or 1 spray painted in fluorescent orange on the driveway near the road would indicate that the structure on that particular property is saveable, whereas a large X or 3 would indicate that the structure is not saveable. Symbols such as an X (not saveable), a large circle (not threatened), or a square (threatened but saveable) could also be utilized as a means to communicate the triage findings of the officer (urban interface specialist). A national standard would provide a system that would allow all fire fighters, who may have responded from various regions of the state or country, to understand which structures have been identified as not saveable, not threatened or threatened but saveable.


b A wildland/urban interface protection specialist is an individual that meets or exceeds the minimum requirements outlined in Chapter 9 of NFPA 1051, Standard for Wildland Fire Fighter Professional Qualifications, 2002 edition.

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