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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

Cedar Fire Recovery Team

The Recovery Team identified a large number of findings based on their review of the events that led to the Cedar Fire burnover incident; the findings have been organized into nine subject categories:

  1. ALS Equipment
  2. Apparatus
  3. Communications
  4. Equipment
  5. Fire Behavior
  6. Personnel Protective Equipment
  7. Training and Experience
  8. Policy and Tactics
  9. Human Factors

Significant Findings

There were many findings identified for each of the nine subject categories. Some of the findings did not play any role in the Cedar burnover however they were identified as issues that needed to be addressed within the Novato Fire District and in some cases by the fire service in general.

In order to provide the reader with a complete picture of the situation these findings are displayed in three time phases related to the incident, Pre Incident, Incident and Post Incident Considerations.

The Novato Fire Protection District hopes that the information and issues identified in this report will lead to improved firefighter safety and survival in the future.

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