Zone” newsletter, July, 2004
Lessons Learned —
author, date unknown
One-Year Anniversary Letter
by Kelly Close, FBAN
Declaration on Cramer
Redactions, by James Furnish, April, 2005
FSEEE v. USFS, FOIA
Civil Lawsuit Order,
Request to USFS, December, 2005
FOIA Appeal to USFS,
Management Evaluation Report
Investigation Team Information
Synopsis of the
Cramer Fire Accident Investigation
(facts 1 - 57)
(facts 58 - 201)
(facts 203 - 237)
Resources on the Fire
Cramer Fire Timeline
Fire Behavior and Weather
Equipment Found at H-2 and the Fatalities Site
Fire Policy, Directives, and Guides
OIG FOIA Response,
2nd FOIA Request to OIG,
2nd OIG FOIA Response,
August, 2006, (1.4 mb, Adobe .pdf file)
OSHA Cramer Fire Briefing Paper
• Summary and ToC
• Sections I-IV
• Sections V-VII
• Section VIII
OSHA South Canyon Fire
Letter to District
Ranger, June 19, 2003
OSHA Investigation Guidelines
OSHA News Release
• OSHA Citation 1
• OSHA Citation
OSHA FOIA Letter
Adobe PDF and Microsoft Word versions of documents related to
the Cramer Fire can be downloaded from the U.S.
Forest Service website.
Cramer Fire Fatalities
North Fork Ranger District
Salmon-Challis National Forest
Salmon, Idaho - July 22, 2003
A causal factor, developed from the findings, is defined as an act,
omission, condition, or circumstance that either starts or sustains an
accident sequence. A given act, omission, condition, or circumstance is
a causal factor if correcting, eliminating, or avoiding it would prevent
the accident or mitigate damage or injury.
1. Management oversight was inadequate.
From July 20-22, 2003, line officers and forest fire staff did not provide
adequate management oversight and direction to the Cramer Fire incident
commanders (ICs). Consequently, no effective communication, discussion,
or validation of the ICs' strategies and tactics were accomplished. Even
when concerns about management of the fire were raised, forest fire staff
and line officers failed to recognize that additional fire management
resources were necessary (findings: 9, 13b,
18, and 44).
- The forest aviation officer (FAO) raised concerns about the management
of the fire to the operations staff officer, who passed on the concern
to the district ranger (finding: 44f).
- Once informed of the concern, the district ranger did not follow up
assertively to assess the suppression situation to determine whether
or not problems existed (finding: 44f).
- There was a failure to fully respond to the IC's request for additional
operational and logistical support and to evaluate and react to the
information the forest fire staff received from the IC (findings: 13h,
16f, and 18g).
- The forest fire staff and the district ranger were occupied with other
priorities, both fire and nonfire (findings: 44a,
44d, and 44e).
2. The IC did not adequately perform his duties to execute safe and
effective suppression operations.
- He maintained confidence in his ability to contain the fire on July
22, even though fire behavior had exceeded suppression capabilities
and containment efforts the previous day (findings: 13c,
- He failed to modify his plan the morning of July 22 as he faced extreme
fire behavior potential and steep, rocky terrain, with a shortage of
resources (findings: 13, 22,
27, and 28).
- He failed to post adequate lookouts (finding: 29).
- He failed to identify effective safety zones (finding: 30).
- He was disengaged from the fire, managing the fire from the helibase
for most of the day on July 22, affecting the cohesion and integration
of his suppression forces (findings: 16h,
38c, and 38e).
- He was not in control of his forces on the fireline, deferring operations
to his strike team leader. He did not supervise and adequately contact,
monitor, or coordinate with the H-2 operation (findings: 13i,
- Despite signs that some of his tactics were unsuccessful on July 22,
he was slow to adjust and respond in the afternoon (findings: 13i,
- He placed the rappellers, hand crews, and a member of the Moyer helitack
crew at risk during the afternoon of July 22 (findings: 13k,
35, and 38d).
- He did not act on his decision to abandon his plan for the upper
helispot (H-2). The rappellers continued to execute the original plan,
which delayed their departure from the site (findings: 13i,
13k, and 31).
3. The IC'S attention was diverted to issues other than the Cramer Fire.
The IC Type III was performing collateral duties, diluting his attention
to Cramer Fire management on July 22 (findings: 38c
4. There was a failure to comply with policy.
Selected personnel involved with the fire did not comply with policies
and procedures in the fire management plan and with agency fire management
directives ( appendix e) that provided direction
- Prepare a complexity analysis (IC Type III) (findings: 1a,
8, and 9).
- Prepare a wildland fire situation analysis (district ranger) (findings:
1a, 8, and
- Use safety officers on Salmon-Challis National Forest (SCNF) incident
teams (IC Type III, forest fire staff) (findings: 16f
- Make adjustments in midslope tactics based on fire suppression hazards
(IC Type III) (findings: 1b, 13c,
- Understand and know how to implement the Ten Standard Firefighting
Orders ( appendix e; findings: 13a,
- Recognize and mitigate the 18 Watch Out Situations ( appendix
e; findings: 13d, 13i,
29, and 35)*
* It is not known, nor will it ever be known for certain from
the investigation, the degree to which the rappellers failed to
comply with policy - especially the Ten Standard Firefighting Orders
and the 18 Watch Out Situations.
5. There was a failure to recognize and adjust suppression strategy
and tactics when initial fire suppression efforts failed.
After initial attack efforts did not contain the fire, fire managers
failed to perform required additional analyses upon which to base a successful
suppression strategy. They also failed to continually reevaluate the situation
and modify the plan as fire conditions changed and as requested resources
were not available.
- A complexity analysis and a wildland fire situation analysis were
not prepared for the Cramer Fire (findings: 1a,
8, 9, and
- A key management position on the fire - a safety officer - was not
filled (findings: 16f and 38a).
- Operational plans were an extension of the initial-attack response
with no trigger points to reevaluate strategy. There were also no clearly
articulated suppression objectives and no effective contingency plans
(findings: 1a, 8,
9, 12, and
- Suppression strategies were not adjusted based on the nature and availability
of the resources (findings: 13d, 13e,
13h, and 13j).
6. There was a failure to accurately assess the fire situation, hazards,
and risks on the Cramer Fire.
Cramer Fire personnel failed to recognize and/or address the severity
of the fire conditions, which impeded their ability to make timely decisions
and take appropriate actions on July 22.
- Fire personnel were unaware of the severe fire behavior potential
of the ceanothus brush field, as indicated by its designation as a safety
zone for the rappellers, and they failed to recognize the potential
of the fire in the lower Cache Bar drainage on July 22 (findings: 26d,
- Of the four preidentified safety zones, the black near H-1 was the
only appropriate safety zone (findings: 30,
- There was inadequate change in oversight, strategy, or tactics on
the Cramer Fire in response to the extreme fire danger and changing
fire conditions (findings: 12, 13,
- There were inadequate briefings and alerts to acknowledge extreme
fire danger and fire behavior potential in the Cramer Fire area (findings:
26, and 27).
- Adequate safety mitigation measures were absent in the tactical plan.
The integrity of H-2 was dependent on keeping fire below H-2 and out
of the Cache Bar drainage. This was not established as an incident objective
(findings: 13, 16f,
- No action was taken on the fire below the west ridge in the Cache
Bar drainage (findings: 35a and 35c).
- Though they were asked if they needed to go to a safety zone shortly
before the burnover, the rappellers did not seek a safety zone, because
they were told a helicopter was coming. They were not directed to safety
zones as warning signs increased (findings: 31,
32, and 35c).
- Fire behavior in the Cramer Creek drainage and the eventual burnover
of H-1 focused the attention of fire personnel and distracted their
focus away from H-2 (findings: 13j, 16i,
- H-2 was perceived as a safe place even though visibility was limited
and conditions changed (findings: 13g,
17, and 35).
7. There was inadequate integration of the H-2 operation into the Cramer
The rappellers, after being dropped at H-2, were largely disconnected
from ongoing operations and were busy accomplishing a single task. Communications
with them were inadequate.
- The rappellers did not have adequate supervision to provide for their
safety, and there was confusion as to who their supervisor was (findings:
38 and 42).
- There was no agreed upon course of action to mitigate the changing
and dangerous situation for the H-2 operation until it was too late
(findings: 13b, 13g,
- The rappellers' obscured view of the fire below them, the focus on
their task of clearing a helispot, and lack of awareness about changing
fire activity resulted in insufficient information upon which to make
appropriate decisions and caused them to act as if they were in a secure
position (findings: 13e, 13i,
35a, and 35c).
8. There was a delay in formulating and executing a plan to retrieve
the rappellers from H-2.
- The IC's decision to retrieve personnel from H-2 was not effectively
communicated or implemented until the personnel on H-2 requested helicopter
retrieval (findings: 13i and 31).
- A helicopter retrieving a firefighter east of H-1 could have removed
personnel from H-2 during the same flight (findings: 16h
- Because helicopters were unavailable, they could not retrieve the
rappellers at a critical point in time (findings: 18j,
32, and 33).
- A helicopter was not launched the first and second time it was requested,
but the rappellers were told that a helicopter was on its way (facts:
189, 190, and 195).
- Lead plane 41 assumed that the rappellers had been retrieved from
H- 2 (finding: 18i).
9. The rappellers were caught in a burnover.
The rappellers were overrun by fire outside of the two previously identified
"safety" zones for H-2 and died without deploying their fire
shelters. Conditions at the fatality site were not survivable in a fire
shelter. One of the designated "safety" zones for H-2 may have
been survivable in fire shelters (findings: 30,
33, 34, and