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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



California Department of Forestry and Fire Protection
Review Report of Serious CDF Injuries, Illnesses, Accidents and Near-Miss Incidents

Engine Crew Entrapment, Fatality, and Burn Injuries

October 29, 2003
Cedar Fire
Southern Region


The evening of October 28, 2003 a decision is made and direction is given to fire-out along Highway 78/79 from Pine Hills Road to Santa Ysabel, approximately seven miles, to keep the fire south of the Highway. The firing operation continues throughout the night eventually being completed to the Inaja Memorial at about 6:00 a.m. on October 29. There are some delays in the operation as it extends into and through the San Diego River drainage due to concerns about the fire already in the canyon, however the firing operation to the Memorial holds and the line is secure. As the firing operation continues from the Inaja Memorial toward Santa Ysabel it is terminated after about 20 minutes and extinguished by the assigned resources due to unsettled conditions. No attempts are made to re-initiate the firing operation. The main fire eventually comes out of the canyon and at approximately 9:00 to 9:15 a.m. jumps Highway 78/79 at this location.

The morning of October 29, 2003 Jim Watkins, the Strike Team Leader for XAL-2005A attends the operational period briefing at the Incident Base in El Cajon. That briefing includes a discussion of the general weather forecast, previously exhibited fire behavior, and the need to identify specific hazards and mitigations. Strike Team Leader Watkins learns they will be assigned to Brach III, Division I and briefly meets with the assigned Division Supervisor, Dan Runnestrand. He then briefs the strike team telling them of the assignment and passing on safety information. The strike team then proceeds to a staging area in Santa Ysabel where they meet up with Division Supervisor Runnestrand and receive further instructions.

At about 8:30 a.m. Air Tactical Group Supervisor (ATGS) Ray Sauceda is on scene and assigned to Branch III along with three fixed wing air tankers. There is a request for helicopters which are still at the helibase. ATGS Sauceda is unable to contact ground resources and believes there may be a problem with the communication plan. He returns all aircraft to base and holds the helicopters on the ground until the communication issue is resolved. At some time between 9:00

a.m. and 10:00 a.m., ATGS Sauceda returns to Branch III.

Shortly after 9:00 a.m. the ground resources assigned in the area of the Inaja Memorial attempt to contain the fire that jumps the highway but due to erratic fire behavior, they disengage. This fire continues to burn to the north along the ridge on the west side of the San Diego River north of Highway 78/79. Plans are then developed to use bulldozers to work the west flank of the slop-over.

It is at about this time that Division Supervisor Runnestrand meets with Strike Team Leader Watkins in Santa Ysabel and briefs him on the fire activity the day before, what was going on during the current day, and what to expect.

At about 9:30 a.m. discussion between Branch III Director Ray Chaney and Division Supervisor Runnestrand leads to a plan to deploy resources to the south flank of the fire and go with direct suppression tactics.

At about 10:20 a.m. Strike Team XAL-2005A, including Engine 6162, is assigned to do structure protection in Riverwood Estates. When Engine 6162 arrives at Riverwood Estates the structures have been fired-out around and mop-up operations are occurring. They describe the fire in that area as calm and can see the fire burning past them to the west across the highway. Strike Team Leader Watkins describes this fire as being pushed slowly by the wind with the column going up about 1000 feet then bending over them to the east. After assigning the engines in Strike Team XAL-2005A, Strike Team Leader Watkins meets up with an additional strike team, 2004A that had arrived in the Riverwood Estates area. He then starts out to the highway to recon the area and locate Division Supervisor Runnestrand whom he cannot contact on the radio.

At about 11:00 a.m. Deputy Branch III Director Mike Wakoski meets with Division Supervisor Runnestrand to develop a plan to re-allocate resources to contain the slop over north of the highway. This includes re-assigning the bulldozers from the west flank to the east flank. Strike Team Leader Watkins finds Division Supervisor Runnestrand on Highway 78/79 and advises him of the arrival of the additional strike team. It is at this time that Division Supervisor Runnestrand directs Strike Team Leader Watkins to move his strike team to Orchard Lane.

By about 11:35 a.m. several helicopters arrive and begin making bucket drops along a dirt road on the east side of the San Diego River (dry at this time) just north of where Highway 78/79 crosses the river. The objective of this action is to keep the fire on the west side of the river drainage and away from structures in the area. The helicopters are directed by the ATGS to choose their own targets with the priority to protect structures.

Meanwhile the fire on the west side of the drainage has moved up canyon and gained elevation. Coming under the influence of the westerly wind the fire higher up the drainage spreads toward the northeast burning to and past the northeast corner of the northernmost property on Orchard Lane (902 Orchard Lane). The fire is now established on the eastern side of the drainage in a hooking move to the northeast.

Strike Team XAL-2005A groups up and begins to move toward Orchard Lane. At about 11:45

a.m. Strike Team Leader Watkins drives north on Orchard Lane while the strike team stages at the intersection of Orchard Lane and Highway 78/79. Strike Team Leader Watkins can see the fire at the north end of Orchard and realizing it is a long road, he calls back for the strike team to start moving up.

Approximately 11:50 a.m. the pilot of Helicopter 523EH, working in the bottom of the canyon near the highway, notices spot fires around the structure at 902 Orchard and advises the ATGS. The helicopter operation is then moved to the ridge on the east side of the drainage to protect houses along Orchard Lane.

About the same time Strike Team XAL-2005A arrives near 915 Orchard Lane, Strike Team Watkins begins to size-up structures along Orchard Lane, beginning with the northernmost structure at 902 Orchard Lane, while the strike team stages along Orchard Lane.

Also arriving at approximately 11:50 a.m., are Fire Captain (FC) John Childe and Fire Apparatus Engineer (FAE) Isaac Sanchez in Utility 3334. They are not assigned to the division, or the incident, but have been in the area most of the morning scouting and offering suggestions on potential firing operations to Division Supervisor Runnestrand. Also arriving at Orchard Lane are two bulldozers, one from Los Angeles County and one from Los Angeles City, who off-load near Orchard Lane and the highway and begin “walking” north through the meadow to the east of Orchard Lane.

Strike Team Leader Watkins finishes assessing the structures and begins assigning engines. He does not assign an engine to the residence at 902 Orchard due to narrow access and too much preparation needed to defend the structure. Engine 6162 is assigned to the residence at 920 Orchard and begins backing up the cement driveway at that location. Engine 1541 is assigned to 915 Orchard which is a metal farm building said to contain pesticides. He does not assign an engine to 930 Orchard as he determines it to be too risky. This grouping of structures is directly across a saddle from the residence at 920 Orchard. Engine 24 is assigned to the residence at 1038 Orchard and due to the long driveway, 1126 Orchard Lane is skipped. Engine 71 is assigned to the next residence south of 1126 Orchard Lane. Engine 334 remains unassigned and is staged along Orchard Lane.

As the engines are deploying to their assigned locations FC Childe and FAE Sanchez drive north past the engines eventually arriving at 902 Orchard. At this location FC Childe observes the fire has burned past that location and the fire is now flanking across the slope to the southwest. Based on this observation he instructs FAE Sanchez to begin firing out around the structure. While FAE Sanchez is firing out FC Childe returns to Orchard Lane in Utility 3334 and instructs Engine 334 to go up to the structure at 902 Orchard and support the firing operation. The crew of Engine 334, believing that FC Childe had coordinated with Strike Team Leader Watkins calls Watkins on the radio to advise of the assignment. Strike Team Leader Watkins, believing FC Childe would be there coordinating the operation, gave Engine 334 the OK to proceed with the assignment. It is after this that he sees FC Childe back down on Orchard Lane.

At about this time the El Cariso Hot Shots and the two bulldozers arrive at the north end of Orchard Lane. One of the bulldozers and part of the hot shot crew start working near 902 Orchard and begin direct perimeter control in that area.

At 920 Orchard the crew of Engine 6162 are backing the engine up the driveway and using a chainsaw to clear brush to prevent scratching the engine. Captain McDonald on Engine 6162 went ahead of the engine to assess the situation. From a location near the 90 degree bend in the driveway below the garage he looks towards the residence and has concerns about the site conditions. He contacts Strike Team Leader Watkins who advises him to come out if he is not comfortable. Captain McDonald and two crew members, Engineer Rucker and Fire Fighter/Paramedic Smith, return up the driveway to re-assess. Near the top of the driveway they see a flanking fire to the north near 902 Orchard and determine it to be the threat. After walking past the residence to the end of the driveway they see that the brush had been cleared to the west of the residence for a distance of about 150 feet. Because of the clearance they can see west across the San Diego River drainage however, tall brush and drifting smoke restrict visibility to the southwest. At this time the decision is made to stay and defend the residence.

After Engine 6162 arrives at the top of the driveway at 920 Orchard, Captain McDonald conducts a briefing with the crew. The engine is spotted and the crew begins preparing to defend the structure. This includes placing an axe at the rear door of the structure (which has been identified as a refuge), placing a chain saw on the cement patio after clearing some brush, laddering the building (using the homeowner’s ladder), deploying and charging two 100 foot long, one and one-half inch hose lines, and charging the front bumper line to use for engine protection should they need to drive out to the meadow (which was discussed as a safety zone). The prominent fire at this time is still the flanking fire from the north near 902 Orchard. The crew does notice a seven to10 mile per hour wind blowing from the southwest.

FAE Sanchez completes firing around the west side of the residence at 902 Orchard and returns to find FC Childe and the utility gone. He starts down toward Orchard Lane and sees Engine 334 coming up the driveway. He returns to 902 Orchard where he is later joined by FC Childe. With FAE Sanchez in the rear of the utility FC Childe drives out to Orchard lane and proceeds south to and up the driveway at 930 Orchard. Just prior to their arrival at 930 Orchard Strike Team Leader Watkins had returned to re-evaluate placing an engine there. Once at 930 Orchard, FC Childe instructs FAE Sanchez to fire-out, which he does in an arc from south to north about 100 to 150 feet along the west of the structures. FC Childe then instructs FAE Sanchez to take a line of fire to the next house to the north (which is 920 Orchard where Engine 6162 is deployed). The firing operation quickly generates fire spread to the east, which at one point is knocked down by a helicopter bucket drop, and FAE Sanchez discontinues firing to the north.

FC Childe and FAE Sanchez then proceed back down to Orchard Lane and up the driveway at 920 Orchard. They park in the area of the 90 degree turn in the driveway below the garage. FC Childe instructs FAE Sanchez to take fire from this point north toward the driveway and unimproved building site at 914 Orchard. Captain McDonald sees this from the top of the driveway near the residence. Captain McDonald and FC Childe do not make contact and Captain McDonald returns to his crew before FC Childe leaves.

Captain McDonald returns to the crew who are continuing to prepare the structure by removing more brush and burning brush piles. One pile is near the front of the engine and the heat prompts them to back the engine further south down the drive way. Captain McDonald advises the crew a CDF fire fighter is burning out near the garage and then instructs the crew to burn out the grass below the driveway. Engineer Kreps walks north down the driveway to the garage and observes fire already on the ground behind the garage and in the brush to the north. He begins strip-firing from that location south along the edge of the driveway. Captain McDonald throws fusees down slope to the west into the heavy brush below the strip-firing.

The Superintendent of the El Cariso Hot Shots, who is in the meadow east of Orchard Lane, has been observing unexplained fire on the ridge. The first fire he sees is between 930 and 920 Orchard, then he sees more fire between 920 and 902 Orchard. He contacts his crew twice to see if they are firing-out. After the second time they tell him they’re not firing, he directs them to come off the ridge and return to his location.

As FAE Sanchez continues firing to the north, FC Childe returns down the driveway of 920 to Orchard Lane where he contacts Strike Team Leader Watkins. FC Childe asks Strike Team Leader Watkins why he does not have an engine at the residence at 920 Orchard. He states that he does and now concerned about the disposition of Engine 6162, he proceeds up the driveway to 920 Orchard. It was at about 12:35 p.m. that he met up with the crew of Engine 6162 and discussed their progress. Strike Team Leader Watkins observes the crew conducting their strip burn and sees they are about to throw fusees into the brush. He also observes the fire is backing down from the north and is about 300 yards from the house. The sky overhead is clear and winds are moderate up-canyon / up-slope.

After confirming the disposition of Engine 6162 Strike Team Leader Watkins proceeds back to Orchard Lane when he is contacted by Engine 334 at 902 Orchard. Engine 334 states their egress has been cut off by spotting from a firing operation. He tries to move to their location but is cut off by a dozer working in that area.

FC Childe and FAE Sanchez meet up and proceed down Orchard Lane to 1038 Orchard where Engine 24 is deployed. They begin firing-out at that location. The crew of Engine 24 states that prior to the firing operation there is little or no wind and no sign of the fire being close. The crew reports the firing operation spreads to the brush and ignites an outbuilding. The fire intensifies and crosses over the driveway cutting off their egress. This fire then encircles their location and the wind changes direction and becomes erratic.

At about this time and shortly after, resources along Orchard Lane notice a change in conditions and fire activity. Within about eight minutes of Strike Team Leader Watkins departure, the crew of Engine 6162 notices the fire activity increase below them. Strike Team Leader Watkins notices the fire picking up but he still believes it to be coming from the northwest. He can also begin to hear the fire.

Los Angeles County dozer operator Jeff Vidrinskas is notified by his transport operator, located at Highway 78/79 and Orchard Lane, that the fire is getting very active. Vidrinskas is working in a westerly/southwesterly direction downhill from 902 Orchard in a flanking action. Within a few minutes of the message from the transport operator he pushes over a tree. As he does this he observes a wall of fire in front of him. It is described as 100 feet tall and 300 yards wide. He abandons his line construction and returns to 902 Orchard.

The crew of Engine 6162, noticing the increase in fire intensity, gathers at the engine and moves to the passenger side away from the radiant heat. Fire Fighter/Paramedic Smith staffs a one and one-half inch hose line at the front passenger side of the engine. Engineer Rucker staffs a similar hose line at the rear passenger side of the engine. Engineer Kreps is standing at the right rear duals with his back to the engine. The exact location of Captain McDonald is not clear but Smith and Kreps place him somewhere near the rear of the engine. Captain McDonald believes he was between Smith and Kreps.

Fire Fighter/Paramedic Smith notices embers have ignited juniper bushes along the cement patio and he attempts to extinguish them. All members of the crew state that at this time the conditions deteriorate rapidly. The sky becomes dark and orange, winds increase and heat intensity increases dramatically, a constant stream of embers are going past the engine, and the sound of the fire increases (described by Engineer Kreps as “the freight train coming”).

Winds now increase significantly and a flaming fire front is observed blowing across the driveway in the direction of the garage, cutting off the crew’s egress. It is at this time that Strike Team Leader Watkins observes the fire “blowing through” the area between the ridge north of Engine 6162 and 902 Orchard.

The juniper and boxwood bushes along the patio have now burst into flame. Captain McDonald gives the order for the crew to deploy to the refuge of the house. Fire Fighter/Paramedic Smith immediately drops the hose line and runs in the direction of the raised patio. Immediately upon leaving the protection of the engine he experiences severe thermal conditions. He proceeds to the stairs and leaps past the burning bushes onto the patio. He is followed by Engineer Kreps who runs to the steps, stumbles and falls to his knees at the top of the steps, recovers and continues to retreat to the rear of the house following Fire Fighter/Paramedic Smith. The two continue to the rear door of the house and use the axe and their feet to force entry into the house.

Captain McDonald and Engineer Rucker are still at the engine. Captain McDonald states that after he sees Fire Fighter/Paramedic Smith and Engineer Kreps move onto the patio Engineer Rucker is still at the rear of the engine. He states that as Rucker starts to move toward the patio he falls down and gets onto his hands and knees and then stands up. He states that Engineer Rucker then turns and faces toward the southeast, maybe even taking a step. Engineer Rucker then turns back, steps towards him, and then turns toward the patio and falls face down into the burning bushes. Captain McDonald then goes to Engineer Rucker, who was already helping himself up, and assists him. Captain McDonald states that Engineer Rucker says “I’m burning up”. Captain McDonald assists Engineer Rucker to the steps with Engineer Rucker making it up the steps onto the patio under his own power with Captain McDonald following.

Partially across the patio Captain McDonald sees Engineer Rucker fall face down. He makes an attempt to get Engineer Rucker up but cannot. Strike Team Leader Watkins heard a “man down” radio call on the tactical channel from Engine 6162 at this time.

Evidence at the scene shows the King hand-held radio from Engine 6162 was on the patio near Engineer Rucker’s body on the side closest to the steps. Captain McDonald was in possession of the radio and though he does not recall making a transmission

Captain McDonald then turns around 180 degrees and attempts to pull Engineer Rucker toward the rear of the house. He calls for the other crew members to help but they cannot hear him.

Feeling himself getting burned he retreats to the rear corner of the house. He then returns to the patio in another attempt to rescue Engineer Rucker. He observes that Engineer Rucker’s body is on fire and determines he cannot help him. He returns back behind the house where he is met by Fire Fighter/Paramedic Smith and Engineer Kreps who have come back out of the house to see where Captain McDonald and Engineer Rucker are. Captain McDonald tries to convince them to return for Engineer Rucker. They determine the area is untenable and retreat into the house.

Physical evidence on the patio indicates that Captain McDonald’s web gear was failing at the top of the stairs, demonstrating he had already taken significant heat prior to that. There was also evidence of a wildland hose pack on the patio. One length was located approximately three feet from Engineer Rucker’s feet and one length was at his head.

Inside the residence Captain McDonald feels he is burning and removes his web gear. He is unable to find the hand-held radio. The decision is made to check the front door to see if they can exit. When the door is opened, intense heat surges through the opening. After a few minutes they try again and Engineer Kreps is able to make it out and down the driveway to the engine. Heat forces him to take refuge in the engine which is still running. Concerned that Fire Fighter/Paramedic Smith and Captain McDonald will come looking for him Engineer Kreps returns to the front door and into the house.

The house is now involved in flame and smoke is banking down to waist level. The decision is made to evacuate and the three make their way out the front door and down the driveway to the engine, Captain McDonald is assisted into the passenger’s seat. Engineer Kreps gets into the driver’s seat, and after disconnecting the rear hose lines (which burned through emptying the tank) Fire Fighter/Paramedic Smith gets into the right passenger’s seat.

Engineer Kreps is eventually able to maneuver the engine through heavy smoke down the driveway and out to Orchard Lane. While moving down the driveway Captain McDonald broadcasts additional information over Command Net.

Once on Orchard Lane the crew proceeds, with one stop, out to the intersection of Orchard Lane and Highway 78/79. They arrive at this location at 1:10 p.m. where they are met by the Plumas Hot Shot Crew. Medical treatment is provided for the crew members. Engineer Kreps and Fire Fighter/Paramedic Smith using equipment on Engine 6162 start I.V.s on Captain McDonald. All three are transported by CDF helicopters to Ramona Airport where they are transferred to Mercy Air Ambulance and transported to UC San Diego.

At 1:11 p.m. USFS Engine 39 arrives at the treatment area and then proceeds to 920 Orchard to conduct a search and rescue. At the base of the driveway to 920 Orchard Engine 39 meets up with Strike Team Leader Watkins. Engine 39 proceeds up to the residence while the Strike Team Leader remains on Orchard Lane. Once at the residence they discover the body and announce an “11-44”. Not long afterwards, a propane tank starts venting with flames and all resources leave the area.

Once the tank stops venting USFS Engine 39 and CDF Division Chief Bill Clayton return to the scene. Shortly after this, personnel from the San Diego County Sheriff’s Office arrive at the site, secure the scene, and initiate their investigation.

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