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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
Policy and Tactics

Pre Incident

The Novato Fire District had created several wildland firefighting standard operating procedures (SOPs), including the use of Personal Protective Equipment (PPE) and use of the Incident Command System (ICS); however, no specific SOPs existed relating to structure protection, firing or turning down assignments.

The District had developed a Standard Evolution Manual, Tactical and Task level standards, based on state and nationally recognized training curriculum relating to structure protection operations.

No internal process had been utilized to compare established state and national training curriculum with the experience of the members of the District in order to develop internal standard operating procedures in the areas of structure protection, firing or turning down assignments.


The crew of E6162 followed a standard structure protection evolution in accordance with the Districts Standard Evolution Manual and state and nationally recognized training curriculum in the operations that were conducted at 920 Orchard Lane by:

  • Removing light grass fuels, using drip torches and fusees, to create a defensible space below the structure

  • Identifying an Escape Route and Safety Zone using the principles LCES (Lookouts, Communications, Escape Routes and Safety Zones)

  • Observed flame lengths in the brush were 25’ to 30’. Safety Zone standards denote a radius (from the center of the Safety Zone) of four (4) times the flame length for entire circumference of the Safety Zone. In this case the distance from Engine 6162 to the unburned brush below (west) was over 140’. This distance was much further than the 100’ to 120’ required for a Safety Zone. The distance to the unburned fuels to the south was approximately 100’.

  • Assigning a Lookout (Engineer Rucker)

  • Maintaining communications between the crew and confirming and maintaining communications with the Task Force Leader both face to face and via radio on established incident frequencies

  • Wearing protective clothing and equipment in accordance with District policy and industry standards

  • Identifying specific triggers when the crew would use the escape route to access the safety zone and when to seek refuge in the shelter. The collective experience and training of the crew prevented further injury or fatalities

  • Developing a plan collectively, discussing the plan, thinking clearly, calmly and acting decisively when the situation deteriorated.

Post Incident

It is critical that there be mutually agreed philosophy and supporting policy or standard operating procedures between federal, state and local agencies regarding wildland firefighting operations with a focus on firefighter safety and survival. Philosophy derived from experience should be used to develop policy or standard
operating procedures which should in turn drive training and the formation of training curriculum. Training curriculum should not drive organizational philosophy or policy.

It is also crucial that department members are supported by validated policies or standard operating procedures that are based on firefighter safety and provide all members with mitigation options that are irrefutable up to and including refusal of assignments.

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

When reviewing whether Engine 6162 should have taken the assignment at 920 Orchard Lane the following observations can be made:

  • There is no way to conclusively prove that any crew, regardless of experience or training, could have anticipated the outcome of this event due to the casual, contributing and circumstantial factors that combined to create burnover.

  • Post incident evaluation indicates most experienced fire officers would have made the decision to protect the structure at 920 Orchard Lane.

  • In addition to the Crew of Engine 6162, the TFL, other Engine Companies in the TF, the Division and Aircraft in the area described the fire as “backing” or “flanking” in the direction of the homes on Orchard Lane until just before the burn over occurred.

  • These same resources were also protecting structures in the same area, with the same fuel type and conditions.

  • In a structure protection operation parking an engine between the oncoming fire and the structure may result in the engine and crew Novato Fire Protection District being trapped when the flame front passes as occurred at 920 Orchard Lane.

    • The significance of this decision depends on the ability to
      accurately predict the intensity of the approaching fire and the
      capability to assure the survival of the engine without damage
      and the crew without injury.

    • If adequate clearance exists or the fuel, weather, topography
      and fire behavior combine to allow a safe operation this tactic
      may be acceptable.

    • A search for safer alternative should still be conducted to take advantage of the protection of a structure or other feature that will deflect heat from the on coming flame front and allowing for a safer operation.

Implementing a standard of basing all actions on worst case possibilities would simply prevent firefighting personnel from taking any action to suppress a wildland fire or protect a structure.

  • A balance between worst case possibilities and operations that provide for the survivability of the engine without damage and crew without injury must be developed and memorialized in policies or standard operating procedures and reinforced in training.

The philosophy that, “Every Firefighter Deserves a Round Trip Experience” must become the motto of the fire service and the basis for policy, standard operating procedures, and training.

  • In the wildland environment this means that no structure protection operation is worth risking firefighter injuries, near misses situations or fatalities nor are they 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 and a close call for the crew.

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 should be developed and included in department policies, standard operating procedures and implemented in training in addition to LCES.

The following guidelines should become the basis for both policy and training curriculum development:

  • 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 property.

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

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