NIOSH Cedar Fire Report

Summary

Introduction

Investigation & Medical Findings

Recommendations / Discussions

References

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

Findings

Causal Factors

Contributory Factors

Circumstances

Site Conditions

Graphics – List of Illustrations Table

Description of Supporting Data and Supplementary Information

Novato FPD Investigation Analysis

Table of Contents

Prologue

CDF Green Sheet

Overview

Lessons Learned

• ALS Equipment
• Apparatus
• Communications
• Equipment
• Fire Behavior
• Personal Protective Equipment
• Training and Experience
• Policy and Tactics
• Human Factors

Draft Standard Operating Procedures

• Wildland Structure Protection SOP
• Refusal of Risk SOP
• Wildland Firing Operations SOP

Inaja Fire Tragedy

• Introduction
• Sequence of Events
• Conclusion

Acknowledgements

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

REFERENCES

Salka, JJ [2000]. Essentials of fire fighting and emergency response. New York: Delmar Publishers, p. 685.

IFSTA [2003]. Wildland fire fighting for structural firefighters. 4th ed. Stillwater, OK: International Fire Service Training Association, pp 156 and pp 330.

Perry, DG [1990]. Wildland firefighting: Fire behavior, tactics & command. 2nd ed. Bellflower, CA: Fire Publication, pp. 201-204.

Teie, WC [2001]. Firefighter’s handbook on wildland firefighting. 2nd ed. Rescue, A: Deer Valley Press, pp. 78-82.

NWCG (National Wildfire Coordinating Group) [2004]. Fireline Handbook (National Wildfire Coordinating Group Handbook 3). Boise, ID: National Wildfire Coordinating Group.

NWCG (National Wildfire Coordinating Group) [2004]. Incident Response Pocket Guide. Boise, ID: National Wildfire Coordinating Group.

FEMA [1999]. Incident command system - student manual. 1st ed. Emmitsburg, MD:Federal Emergency Management Agency, United States Fire Administration, National Fire Academy.

Braunwald E [2001]. Hypoxia and cyanosis. In: Braunwald E, Fauci AS, Kasper DL, Hauser SL, Longo DL, Jameson JL, eds. Harrison’s principles of internal medicine. 15th Edition. New York: McGraw-Hill. pp. 214-5.

McFaddem Jr, ER. [2001]. Asthma. In: Braunwald E, Fauci AS, Kasper DL, Hauser SL, Longo DL, Jameson JL, eds. Harrison’s principles of internal medicine. 15th Edition. New York: McGraw-Hill. pp. 1456-62.

USFS [1997] Health hazards of smoke: recommendations of the consensus conference April 1997. B Sharkey, ed. Tech. Rep 9751-2836-MTDC. Missoula, MT: Missoula Technology and Development Center.

Reihardt TE, Ottmar RD [1997]. Smoke exposure among wildland firefighters: A review and discussion of current literature. USDA Forest Service, Pacific Northwest Research Station: General Technical Report PNW-GTR-373. Seattle, WA.

Materna BL, Koshland CP, Harrison RJ [1993]. Carbon monoxide exposure in wildland firefighting: A comparison of monitoring methods. Appl Occup Environ Hyg 8(5):479-87.

USFS [1997] Health hazards of smoke: recommendations of the consensus conference April 1997. B Sharkey, ed. Tech. Rep 9751-2836-MTDC. Missoula, MT: Missoula Technology and Development Center p. 35.

Purser DA [2000]. Interactions among carbon monoxide, hydrogen cyanide, low oxygen hypoxia, carbon dioxide, and inhaled irritant gases. In: DG Penny (ed) Carbon Monoxide Toxicity. CRC Press, Boca Raton, FL.

McGraph JJ [2000]. The interaction effects of altitude and carbon monoxide. In: DG Penny (ed) Carbon Monoxide Toxicity. CRC Press, Boca Raton, FL.

Kindwall EP [1994]. Carbon Monoxide. In Zenz C, Dickerson OB, Horvath EP (Eds). Occupational Medicine, 3rd Edition. Mosby-Year Book, Inc. St Louis, MO.

Piantadosi CA [2002] Carbon monoxide poisoning. NEJM 347:1054-5.

Tomaszewski CA: Carbon Monoxide. In Goldfrank LR, et al (eds): Goldfrank’s Toxicologic Emergencies. 5th ed. East Norwalk, CT, Appleton & Lange, 1994, pp 1199-1214.

Ernst A, Aibrak JD [1998]. Carbon monoxide poisoning. NEJM 339:1603-8.

McCammon JB, McKenzie L [2000]. HETA 98 Health Hazard Evaluation Report (HETA 98-0173-2782), Colorado Department of Public Health and Environment, Colorado. Hazard Evaluations and Technical Assistance Branch, Division of Surveillance, Hazard Evaluations and Field Studies, National Institute for Occupational Safety and Health. Cincinnati, Ohio. Available from URL http://www.cdc.gov/niosh/hhe/reports/pdfs/1998-0173-2782.pdf

NFPA [2003]. Standard on comprehensive occupational medical program for fire departments. Quincy MA: National Fire Protection Association. NFPA 1582- 003.

Additional safety resources for fire fighters who operate in the wildland/urban interface:

1. The Wildland Fire Lessons Learned Center web site http://www.wildfirelessons.net/
2. Firewise - Guide to the wildland/urban interface firefighter safety series and the Wildland/urban interface hazard assessment training. These and other resources are available at http://www.firewise.org/
3. The Federal Fire and Aviation Safety Team (FFAST) and the National Interagency Fire Center (NIFC) present the 6 Minutes for Safety at the following web site http://www.nifc.gov/sixminutes/dsp_sixminutes.php The web site covers a variety of wildland fire related safety issues that include wildland/urban interface-structure protection and wildland/urban interface watchouts.
4. Wildland fire safety & health reporting network (SAFENET) allows front line firefighters a way to be heard and get unsafe situations resolved. SAFENET is a form, and process, that has been in demand by firefighters themselves. It’s a method for reporting and resolving safety concerns encountered in wildland fire, prescribed fire or all risk operations. The information provided on the form will also help collect important, safety-related data at the National Interagency Fire Center, to determine long-term trends and problem areas. SAFENET submissions can be made and read at the following web site http://safenet.nifc.gov/

INVESTIGATOR INFORMATION

This incident was investigated by Mark McFall, Safety and Occupational Health Specialist, and Richard Braddee, Senior Investigator with the Fire Fighter Fatality and Prevention Team, Trauma Investigations Section, Surveillance and Field Investigations Branch, Division of Safety Research, NIOSH. A review of the victim’s medical history was conducted by Thomas Hales, MD, MPH. Dr. Hales is a senior medical epidemiologist with the NIOSH Fire Fighter Fatality Investigation and Prevention Program, Cardiovascular Disease Component located in Cincinnati, Ohio. He is board certified in internal and occupational medicine.

EXPERT REVIEW

Expert review was provided by Dick Mangan, Blackbull Wildfire Services, LLC.

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