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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: Risk Refusal Standard Operating Procedure


The Novato Fire Protection District is an all risk organization responsible for responding to and mitigating medical emergencies, vehicle accidents, hazardous material releases, specialized rescue events, structure fires, vehicle fires, and wildland fires. As such we must recognize that there are both acceptable and un-acceptable risks to our personnel that come with this responsibility.


The Novato Fire District philosophy is that “Every Firefighter Deserves a Round Trip Experience”. Therefore, every individual has the right and obligation to refuse an assignment, in accordance with this SOP, if that assignment is likely to result in injuries, near miss situations, or fatalities.


A Risk Refusal is a situation where an individual having conducted a Risk and Situational Awareness Assessment determines that they cannot undertake the assignment because they deem it unsafe.

Assignments may be refused as unsafe when:

  • There is a violation of safe work practices, District Policy, the Firefighting Orders, Watch Out Situations, LCES, etc.

  • Environmental conditions make the work unsafe

  • Crew members lack the necessary qualifications or experience

  • Equipment is defective or unavailable

  • The risk can not be mitigated and/or tactics cannot be changed

  • An adequate Risk and Situational Awareness Assessment cannot be conducted

When an individual or person in charge chooses to refuse an assignment because they deem it unsafe, they must provide their immediate supervisor with the following information immediately:

  • The reason for the for the Risk Refusal

  • To the degree possible, safe alternatives for completing that assignment

The Supervisor who receives the Risk Refusal will make every effort to notify the Safety Officer. If there is no Safety Officer, notification will go to the appropriate Supervisor or to the Incident Commander. This assures accountability for decisions and communicates safety concerns to the entire incident organization.

If the Supervisor who receives the Risk Refusal asks another resource to perform the assignment, they are responsible for informing the new resource that the assignment has been refused and the reasons for that refusal.

If an unresolved safety hazard exists or an unsafe act was committed, the individual or person in charge should also document the Risk Refusal with a memo to their immediate Supervisor and/or the Safety Officer.


These actions do not necessarily stop an operation from being carried out as long as the identified risk can be mitigated. This SOP is integral to the effective management of risk and the timely identification of hazards through the chain of command to promote firefighter safety and accountability.

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 property.

  • 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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