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Cramer Fire

Lessons Learned

“Safety 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,
December, 2005

FOIA Request to USFS, December, 2005

FOIA Appeal to USFS,
February, 2006

Management Evaluation Report

Investigation Team Information

Synopsis of the Cramer Fire Accident Investigation

Causal Factors

Contributing Factors


Factual Report

Executive Summary

   (facts 1 - 57)
   (facts 58 - 201)
   (fact 202)
   (facts 203 - 237)


Appendix A
Resources on the Fire

Appendix B
Cramer Fire Timeline

Appendix C
Fire Behavior and Weather
   Prior Conditions
   Initial Phase
   Transition Phase
   Acceleration Phase
   Entrapment Phase

Appendix D
Equipment Found at H-2 and the Fatalities Site

Appendix E
Fire Policy, Directives, and Guides

Gallery of Cramer Fire Report Images

Accident Prevention Plan

OIG Investigation

OIG FOIA Response, February, 2005

2nd FOIA Request to OIG, April, 2006

2nd OIG FOIA Response, August, 2006, (1.4 mb, Adobe .pdf file)

OSHA Investigation

OSHA Cramer Fire Briefing Paper
 • Summary and ToC
 • Sections I-IV
 • Sections V-VII
 • Section VIII
 • Acronyms/Glossary

OSHA South Canyon Fire Briefing Paper

Letter to District Ranger, June 19, 2003

OSHA Investigation Guidelines

OSHA News Release

 • OSHA Citation 1
 • OSHA Citation 2
 • OSHA Citation 3

USFS Response


HFACS—"Swiss cheese" model of Accident Causation

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." (See 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!

Kelly Close
Poudre Fire Authority
Ft. Collins, CO

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