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.
Open Letter on the Cramer Fire Anniversary
written by Kelly Close, FBAN
re-printed by permission of the author
A couple pulaskis at the fatality
site, looking down Cache Bar drainage.
Photo by Kelly Close. September, 2004.
Dear Wildland Firefighters:
It has been one year since the firefighter fatalities on the Cramer Fire.
At 1524h on July 22, 2003, the last radio communication was received from
two helitack crew members as a fast-moving fire front was nearly upon
them. For me, the Cramer Fire became much more than something I would
simply read about in the news from hundreds of miles away. It soon became
the toughest fire assignment I have ever had - FBAN on a fatality investigation
team. And as difficult as it was, it may have been one of the best things
to happen to me as a Fire Behavior Analyst. It made me stop, re-examine
things, and continue to ask questions and look for answers. I sat down
and started writing down some random thoughts, and decided to toss them
out there for others. Some may agree, some may disagree, and that's fine.
If nothing else, it would be good just to keep the discussion going.
In the months that passed after the fire, and then after the release
of the investigative report, a few things became clearer. I don't know
that I will ever fully understand everything that happened on that fire,
but have at least been able to come to terms with a few things.
Once the report became public, I began to talk about it with others -
in small presentations/discussions, local Annual Refresher classes, and
less formally, over beers with local fire folks. One particular refresher
class still sticks with me, one where I helped the AFMO (USFS) put together
a sand table exercise for his seasons and staff. The class was split into
small groups, and they were to develop an action plan based on the initial
scenario, and respond to changes as the scenario progressed. They were
not told until the end of the exercise that it was the Cramer Fire, and
no one recognized it as such. I still clearly remember the look of puzzlement,
frustration, and even anger on many faces during the exercise. That spoke
volumes, as did some of the verbal feedback... This was entirely unrealistic.
We can't work with this. Who made up this scenario? What the %#&@!
This is insanity. Are you kidding?
I perhaps learned as much from discussions and interactions this past
winter and spring as I did walking the hillside above the Salmon River
last July. What exactly did I learn? For one, the unthinkable not only
happens, it happens again. History doesn't repeat itself - but it rhymes.
Too many previous accidents become lessons *not* learned. To date, I'm
not aware of any publications about "lessons learned" from the
Cramer Fire. One can only speculate why, but I suspect in part this is
because so many of the events and occurrences on the South Canyon Fire
that led to bulleted lists in "Lessons Learned" publications
were once again repeated on the Cramer Fire. The parallels and similarities
between the two are striking, if not chilling.
What else? That human factors and error chains (or "slices of Swiss
Cheese") are still powerful vulnerabilities we have yet to fully
reconcile. The term "cognitive dissonance" comes to mind - "...a
psychological phenomenon which refers to the discomfort felt at a discrepancy
between what you already know or believe, and new information or interpretation."
for a good discussion). In this case, a perception or "cognition"
of "just another day, another fire" that at some point changes
into a dangerous situation that wasn't supposed to happen, doesn't fit
the known "norms," and begins to repeat undesirable things that
have happened on well-known tragedy fires. Few firefighters out there
don't know something about 30-mile and South Canyon. But those things
only happen to someone else, of course....
To be fair, this is not always the case. The interagency wildland fire
community has done much over the years to improve firefighter safety at
all levels, and many lessons do become true "lessons learned.."
As a result, thankfully, fires like Cramer are a rare exception. There
are many fires every year that go very well from a safety standpoint.
I have had the pleasure of witnessing first-hand more than one fire where
conditions deteriorated, the original action plan had to be re-thought
from top to bottom, but people did all the right things - develop/revise
strategies and tactics appropriate for the situation, monitor and recognize
changes in the situation, formalize "rules of engagement," set
trigger points and pre-determined actions, and engage/disengage/adapt/revise
appropriately. Commissary Ridge (SW Wyoming, 2002) comes to mind. So how
could Cramer happen, in this day and age, given all we know, all we have
been through, and all we teach and preach to both new and seasoned firefighters?
I wish there was one simple answer. I know a lot is getting through and
making a difference.
But some still isn't. I suspect it's a combination of human factors,
group-think, leadership, not resolving "cognitive dissonance,"
inexperience, and many other subtle (and not so subtle) factors. I do
have to wonder... for every Cramer or South Canyon, how many "whew-that
was close" fires do we not hear about. Anyone out there personally
experienced or witnessed a close-call that could have easily gone the
other way? Yup.
I don't have all the answers, and will always be searching and learning.
The Cramer Fire has forever changed how I look at my role as an FBAN.
Not just on fires, but in interagency training courses and firefighter
training and annual safety refresher classes within my own organization.
It's becoming very apparent to me that the primary role of FBAN *must*
be for firefighter safety. That's the way the job started out in its original
form, after Mann Gulch, and I think it's time to re-focus on the basics.
OK, before I get pummeled by Plans Chiefs out there, yes, I realize that
supporting Plans is also an important role of the FBAN and indirectly
also supports firefighter safety. But in my own mind, there's no doubt
on any incident who and what I should be working for - the firefighters,
and their safety.
Thanks for listening!
Poudre Fire Authority
Ft. Collins, CO