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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


On October 29, 2003, a 38-year-old male career fire fighter (the victim) was killed and a 48-year-old male career Captain was severely injured when fire overran their position. The incident occurred during the protection of a residential structure during a wildland fire operation that eventually consumed more than 280,000 acres. The victim and his crew were part of a task force assigned to protect a number of residential structures located along a ridge on the flank of the fire. The victim’s crew was in the process of preparing to defend the structure when the fire made a slope and wind-driven run through heavy brush directly toward their position. The crew retreated to the residential structure to seek refuge from the oncoming fire. Two of the four crew members were able to get into the structure while the Captain was attempting to assist the victim as the fire reached their position. The victim died near the structure and the Captain, who was seriously burned, had to be assisted into the structure by the other crew members.

NIOSH investigators concluded that, to minimize the risk of similar occurrences, 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

  • ensure that all resources, especially those operating at or near the head of the fire, are provided with current and anticipated weather information

  • 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

  • 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 provide this information to assigned crews

  • ensure that incident command system (ICS) span-of-control recommendations are maintained

  • consider the implementation of a carbon monoxide-based monitoring program for wildland fire fighters


  • State agencies, local municipalities and community organizations should consider developing statewide guidelines and local community plans for managing fuels in the wildland/urban interface

  • 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

  • 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

Incident Scene

<<< continue reading—NIOSH Report, Introduction >>>

The Fire Fighter Fatality Investigation and Prevention Program is conducted by the National Institute for Occupational Safety and Health (NIOSH). The purpose of the program is to determine factors that cause or contribute to fire fighter deaths suffered in the line of duty. Identification of causal and contributing factors enable researchers and safety specialists to develop strategies for preventing future similar incidents. The program does not seek to determine fault or place blame on fire departments or individual fire fighters. To request additional copies of this report (specify the case number shown in the shield above), other fatality investigation reports, or further information, visit the Program Website at or call toll free 1-800-35-NIOSH

<<< continue reading—NIOSH Report, Introduction >>>


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