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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

Cedar Fire Lessons Learned
Fire Behavior

Pre Incident

  • There was no previous recorded fire history in the San Diego River Drainage in the immediate area of 920 Orchard Lane for at least 75 years according to available fire history maps. This information was not available to the crew of Engine 6162.

  • The entire Southern California region had been in a drought condition for several years. The specific area of the incident had been in a drought condition for the previous three years with rainfall totals less than 60% of normal. Again, this information was not available to the crew of Engine 6162.

  • The Cedar fire had burned approximately 233,000 acres by the afternoon of October 28.

  • Annual grasses were predominate on the eastern aspect of the San Diego River drainage across from Orchard Lane along with isolated stands of chaparral and live oak. The predominate fuel model on the east side (west aspect) of the San Diego River Drainage, below Orchard Lane, was at least 30 year old chaparral (manzanita) with short annual grasses. Locals state that the chaparral fuel beds were nearly 70 years old. The chaparral fuel beds were approximately 15’ in height with closed canopies. The age of the fuel was not known to the crew of Engine 6162 .

  • Approximately 1.5 miles southwest of the entrapment site, 11 fire fighters were killed in a fire storm on the Inaja Fire. The Inaja Fire started November 25, 1956, under strong Santa Ana winds, the fatalities occurred when the winds turned to the west. (CDF Cedar Fire Green Sheet)

  • On the east slope of the San Diego River Drainage, immediately below the driveway to 920 Orchard Lane, there was a 150’ buffer of short annual grasses and duff between the driveway and the chaparral fuel bed.

  • The slope below 920 Orchard Lane was approximately 20 percent however, the slope did increase to 30-40% near the bottom of the San Diego River Drainage.

  • The elevation of 920 Orchard Lane is 3442’.

  • There were East winds for the first three days of the incident which started on the evening of October 25, 2004 in the Cedar Creek Drainage. On October 28 offshore winds had subsided and the on shore winds developed by late afternoon.

  • By 0900 hours on October 29 the fire was burning in the bottom of the San Diego River Drainage, North of Highway 78/79. A strong on shore pressure gradient developed by 0930 hours on the October 29 and a “Fire Weather Watch” was issued. Winds became increasingly gusty, southwest to west, with speeds of 15 to 30 mph in the higher elevations. Following the burn over, later in the afternoon the Red Flag Watch was upgraded to a Red Flag Warning due to the increased wind conditions and lowering humidity. The fire weather watch information was not made available to the crew of Engine 6162.

  • The Julian RAWS at the time of the accident indicated a sustained wind speed of 17 mph with gusts to 31 mph from the west. The Julian RAWS is 4 miles to the southeast at an elevation of 4420 feet.

  • As stated in the Training Section, The Novato Fire District has found that, in Marin County, the recurrence of the on shore weather pattern in the days immediately following a north/east wind event yield conditions that are most likely to result in a large-loss/acreage fire when fuel moistures are still low and the onshore winds increase.


  • The Task Force stopped in Santa Ysabel at approximately 9:15 hours on the morning of October 29 prior to their first assignment of the day. They were told by their Task Force Leader that their assignment would be structure protection in the Riverwood Estates approximately 2 miles east of Santa Ysabel, off Highway 78/79.

  • FF/PM Smith photographed the fire that had crossed Highway 78/79 enroute to this assignment. At this point the fire was burning primarily in the chaparral and oak woodland, making slow side hill progress under mild wind conditions. The crew states that the fire behavior was uneventful as viewed from Riverwood Estates.

  • The Task Force spent approximately one hour on mop up operations following a firing operation that occurred earlier around the homes in the Riverwood Estates. During this time the fire remained some distance from the homes and was never a direct threat to the area.

  • At approximately 11:30 hours the Task Force left the Riverwood Estates and proceeded East on Highway 78/79 towards Orchard Lane.

  • Around 11:45 the Task Force turned North onto Orchard Lane. Orchard Lane is a single lane dirt road, approximately one mile long, that runs North off of Highway 78/79 parallel to the East side of the San Diego River Drainage. As Engine 6162 reached the end of the road the crew noticed the fire had wrapped around the northernmost end of Orchard Lane and was actively moving in a northeasterly direction. Captain McDonald became concerned that the Task Force was not in a safe location and ordered Engineer Kreps to back Engine 6162 down the road to an area that appeared to be an acceptable Safety Zone.

  • At roughly 1200 hours Engine 6162 was given the assignment to provide structure protection at 920 Orchard Lane. When they reached the ridgeline location of 920 Orchard Lane they observed the conditions in the area as described in the Pre- Incident description. The crew also noted that the clearance of brush below the driveway (buffer zone) provided for a view across the San Diego River Drainage to the west and northwest. Their view to the southwest was obscured by smoke, brush and live oak trees.

  • As the crew looked at the west side of the drainage, they observed a flanking fire backing down towards the bottom of the San Diego River drainage. The crews view to the south and southwest was blocked. Smoke from the fire that had crossed the end of Orchard Lane was visible to the North. The crew describes an up canyon wind, 7-10 mph blowing to the northeast towards 902 Orchard Lane. The crew based their decision to stay at this location on the current observed fire activity and vegetation clearances and the support from the TFL. They expected to encounter a mild flanking fire in surface fuels to proceed toward their location from the end of Orchard Lane to the north.

  • The only other fire activity in the general area was their firing operation in the buffer zone below the driveway and the probability that the CDF Fire Captain, seen near the garage by Captain McDonald, had also conducted some firing in that area.

  • About 50 minutes after they arrived at 920 Orchard Lane, about 12:45 hours, the crew observed increases in fire intensity below them in the chaparral fuels. Shortly thereafter, around 1:00 p.m. the crew observed a rapid increase in fire activity which includes:

    • Rapid rise in ambient air temperature
    • Sudden increase in fire intensity from the ridgeline south of 920 Orchard Lane. There was no previous indication of any fire in this area.
    • Blowing embers
    • Decreased visibility due to increased smoke production
    • Flame front coming from the drainage laying over the driveway, first to the north of the engine and then immediately to the south of the engine

  • Up until the last few moments the fire behaved as expected and predicted by the crew of Engine 6162. The firing operations, mentioned in the CDF Green Sheet, un anticipated wind shifts and gusts may have had an adverse impact on fire behavior that was predicted by the crew of Engine 6162 . The final moments of fire behavior did not match the crew’s predictions or expectations.

Post Incident Considerations

  • The converging factors, known and unknown, should combine to provide the crew with a “Situational Awareness” that will influence their decision to defend or not defend a structure. The known is what is observed and personally experienced and the unknown are those factors that are critical to the situation but are not readily available, obvious or explainable.

  • There were several lateral drainages ran from the bottom of the San Diego River Drainage to the top of the Orchard Lane ridge line. These drainages were generally obscured by the height of the fuel, smoke drift and the increase in slope further down the western aspect. Drainages can potentially effect fire behavior however, it is unknown the extent to which they influenced the incident at 920 Orchard Lane.

  • Firing operations must always be coordinated with adjoining resources and should never be attempted unless their safety can be verified.

  • The ability to recognize the potential of fire behavior changes as a result of changes in fuel, weather and topography is crucial to crew safety. Information on specific areas of concern relating to drought, bug kill and other unusual conditions that may lead to extreme fire behavior should be shared on a state wide basis.

  • A method, including “check backs”, should be developed to advise crews on the line of the issuances of fire weather watches and warnings.

  • See additional comments regarding using technology in the Post Incident Considerations in the Equipment section of Lessons Learned.

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