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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

Draft Standard Operating Procedures

Title: Wildland Structure Protection Standard Operating Procedure


Structure protection is a dangerous task often performed at the most intense segments of the fire. Due to the inherent dangers of wildland firefighting in general and structure protection specifically it is imperative that personnel maintain “Situational Awareness” and focus on personnel safety and survival at all times.

Situational Awareness is the process used to identify, comprehend, analyze and react to critical elements of information or events that may impact the crew’s ability to carry out assignments safely.


The Novato Fire Districts philosophy is based on a simple premise, “Every Firefighter Deserves a Round Trip Experience”. It must be the motto of all members that no structure protection operation is worth risking firefighter injuries, near misses or fatalities.

Structure protection operations are not worth sustaining damage to an engine. Even minor damage to an engine such as, melted lenses or bubbled paint should be considered a near miss, a close call for the crew and investigated as such.

Every structure protection operation must be based on a Situational Awareness and Structure Protection Assessment, and the development of Structure Protection, Safety, Survival and Mop Up Plans.

There may be times when it becomes necessary to turn down an assignment for fear of sustaining firefighter injuries, a potential near miss situation or possible fatality(s). In these situations the individual in charge should follow the District Refusing Risk SOP to the extent possible but without further risking the safety of the crew or engine.


Situational Awareness Assessments must be based on:

  • Information, events, decisions, orders or actions beginning prior to dispatch and continuing until the crew and engine are safely back in quarters, that may immediately or eventually affect the safety and survivability of the crew and engine

  • Communication including questioning each other to increase the Situational Awareness of all crew members.

Structure Protection Assessments must be based on:

  • The survivability and safety of the crew and the engine

  • Actions the homeowner has taken to create an adequate defensible space, nonpyrophytic landscaping and fire resistive construction

  • Standard Structure Protection Assessment guidelines

  • The potential for changes in weather and fire behavior

  • Never accepting or settling for a bad situation

  • The fact that what works at home may not work elsewhere in the State and conversely conditions experienced elsewhere can occur at home.

Structure Protection Plans must be based on:

The crew’s ability to identify, in the Situational Awareness and Structural Assessments, the cumulative circumstances that conspire to create hazardous situations and their ability to eliminate the hazards or change tactics in time to make the situation safe for themselves and their engine including:

  • The ability of the crew and engine to safely survive the passage of the flame front without taking refuge in the engine, structure or deploying a fire shelter

  • Establishing Trigger Points which cause an immediate re-assessment of the situation and potential changes in tactics

  • Identifying safe alternative options such as prepping and leaving and/or returning after the flame front has passed

  • The Standard Firefighting Orders, the Watch Out Situations and the Common Denominators of Fire Behavior on Tragedy Fires

  • A physical or mental step back to assure that your actions appear to be in accordance with your plans, and always searching for a safer solution.

*If conditions exist to safely make a direct attack on the fire all Firefighter Safety and Survival guidelines will be followed.

Safety Plans must be based on:

The crew’s ability to establish Lookouts, Communications, Escape Routes and Safety Zones (LCES). LCES must be established, re-assessed and revised as conditions change. As Safety Plans change they must be communicated to the entire crew. In operation, LCES functions sequentially and is a self-triggering mechanism.


  • Lookouts assess – and reassess – the fire environment and communicate to each firefighter threats to their safety. Firefighters use escape routes and move to safety zones when threats to safety occur.

  • Lookouts should be trained to observe the wildland fire environment and to anticipate and recognize and communicate fire behavior changes.

  • Lookouts should be positioned where both the hazard and the firefighters can be seen.

    • Terrain, cover, and fire size determine the number of lookouts needed; every firefighter has the authority and the responsibility to warn others of threats to safety.

    • Lookouts must be in a position to provide the working crews with sufficient warning so that they are able to reach their Safety Zone safely.


  • Set up communications system - radio, voice, or both – by which the lookout warns firefighters promptly and clearly of an approaching threat.

  • It is paramount that every firefighter receives the correct message in a timely manner.

    Escape Routes

  • Escape Routes must be verified by actually traversing the route and assessing the time it takes to reach the Safety Zone.

  • Preservation of the homeowner’s vegetation, fences, or other structural features that impede the crew’s use of the Escape Route(s) should be of minimal concern to the crew and if need be, cleared or removed.

  • Driveways or access roads must meet the requirements of an Escape Route if the Safety Zone is not near the structure.

Safety Zones

  • A Safety Zone must be an area where survivability is possible without fire shelter deployment.

  • The optimum Safety Zones is four times the maximum flame length, measured from the center of the Safety Zone to the nearest fuel on all four sides

  • The optimum area of a Safety Zone may be reduced based on varying fuel types, topography and structures or other natural objects that will act as a heat barriers as the flame front passes.

  • Engines, structures and bodies of water should be considered last resort survival options not Safety Zones.

Last Resort Survival Plans must be based on:

The crew’s ability to identify, verify, establish and communicate Last Resort Survival Options before an event occurs. Last Resort Survival Options must be reassessed, revised and communicated to the entire crew as conditions change. In operation, Last Resort Survival Options should be self-triggering when conditions change and Safety Plans are no longer an option.

  • In the event that Safety Plans fail the survivability of the crew must become the only priority.

  • Last resort survival options include taking refuge in an engine, structure, fire shelter or body of water

  • The most effective option or combination of options will vary according to the conditions present at the time of the event

Mop up Plans must be based on:

The crew’s ability access a water supply, the degree to which the structure was exposed to the flame front, other available resources and the urgency to take on a new assignment.

  • A thorough mop up of the area surrounding the structure for a minimum of 50’ or as dictated by an assessment of the surrounding fuel models

  • Checking and re-checking for potential ignitions sources in the interior and exterior of the structure

  • Waiting for a sufficient period of time to determine if re-ignition will occur


No plan to protect a structure should be based on the anticipated need to seek refuge in the engine, structure or in a fire shelter when the flame front passes. On the other hand even the best managed events can change for the worse. In these cases last resort survival options such as entering the engine, structure, shelter deployment body of water, or any combination of these options should be identified early, re-assessed regularly and shared with all crew members.

In no case should policy impede firefighter safety nor should the basic premise of firefighter safety be forgotten or neglected.

  • Activities that present a significant risk to the safety of personnel shall be
    limited to situations where there is a potential to save endangered lives.

  • Activities that are routinely employed to protect property shall be recognized as inherent risks to the safety of personnel, and actions shall be taken to reduce/avoid these risks or change tactics.

  • No risk to the safety of personnel shall be acceptable where there is no possibility to save lives or property.

Simply stated:

  • We Will risk our lives a lot, in a calculated manner, to save SAVABLE lives.

  • We Will risk our lives a little, in a calculated manner, to save SAVABLE

  • We Will Not risk our lives at all for lives, property or the environment that are already Lost/Cannot Be Saved.

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