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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

Cedar Fire Lessons Learned


  • The Novato Fire District cross staffs two Type III engines, with three to four personnel, using crews assigned to engine and truck companies. Engine 6162 operating at 920 Orchard Lane was one of these two engines.

  • The District Type III engines meet NFPA 1901 and 1906 Standards and exceed the FIRESCOPE ICS Primary Mobile Suppression Resources Minimum Standards in pump size, tank size, hose compliment and equipment carried. These engines have been designed to equal capabilities in both the urban interface and pure wildland environment. In regard to features they are very similar to the CDF Model 14.

  • In addition to the FIRESCOPE requirements, all Novato Fire District Type III engines are four wheel drive, equipped with 500 gpm pumps, high band mobile and portable radios, SCBAs with spare cylinders, stored in external compartments, drip torches, fusees, chain saws, 16’ ladder, BLS medical equipment, Class A Foam and 500 gallon water tanks. The engines are 8.5’ wide, mirror to mirror, 9 feet 4 inches in height, 9 feet 8 inches in width, 24 feet in length with a 160 inch wheelbase. A 50’ single jacket engine protection line with nozzle is stored in the engineer’s compartment.

  • The District uses a VHF low band radio system for day to day operations, however, all engines are equipped with a VHF high band mobile and portable radios for mutual aid purposes. External speakers exist for the low band system however; the high band system is not audible through these external speakers. When available, crews responding to “Out of County” incidents are provided additional high band portable radios.

  • Emergency warning, electronic strobe lights exist on all four corners of the engines.

  • All District engines have diamond plate hose bed and live line covers. The ends of all hose beds are secured with vinyl flaps and held in place by nylon straps.

  • All units are custom design built with 4 door enclosed cabs on commercial chassis. Numbers indicating the engine unit inventory number have been placed on the roof of all Type III engines. Unit inventory numbers differ from the engines radio designator.

    1. Example: The unit inventory number for Engine 6162 is Unit 18. U-18 is displayed on the roof of the engine, not Engine 6162.

  • As units are reassigned, the District currently changes their radio designator number to correspond to the station that they respond from for Computer Aided Dispatch purposes (CAD). Example: If Engine 6161 is taken out of service, the reserve unit that replaces it would assume the radio designator Engine 6161.

  • The internal configuration of the cab is standard for a 4 door commercial chassis engine, high back bucket seats in the front, divided by a console and a CAD Mobile Data Terminal on a pedestal. The rear of the cab is configured with standard bench seats.

  • Additional fire shelters are carried in the cab to facilitate the ability of the crew to shelter in the engine. Hooks are provided to provide easy access to member’s wildland FSS web belt with shoulder harness.

  • Sufficient storage space is provided so that combustible material, such as PPE storage bags and personal gear bags are not exposed.

  • The District Type I engines are equipped with spark arrestor screens on all engine air intake ducting to prevent embers from igniting the air filters, however the Type III engines are only equipped with non-combustible air cleaners. Spark arrestor screens are not provided on Type III engines because they obtain their air from under the enclosed hood.


  • At the time the crew of Engine 6162 was operating at 920 Orchard Lane there were two 1.5” wildland single jacket hose lines, each 100’ in length, deployed from a gated wye attached to a rear discharge of the engine. Additionally a there was one 1.5” Nitrile single jacket hose line, 30’ in length, deployed from the front bumper discharge.

  • The engine’s pump was engaged and operating. The engine was backed into the driveway and parked facing out.

  • All windows were rolled up, spotlights were on and turned upward and the headlights and marker lights were on. Emergency lights were not on at the time of the incident.

  • When it appeared that the situation was beginning to deteriorate Engineer Kreps increased the rpm on the engine from the pump panel. The pump was left engaged and the two 1.5” lines were left charged. Up to this point minimal water had been utilized.

  • During the burn over Captain McDonald, Engineer Kreps and Firefighter/Paramedic Smith all reported embers blowing erratically under the engine as well as intense heat from the downhill side of the engine and extreme heat from the rear of the engine. The tires on the engine were utilized as a heat shield prior to seeking safety in the house.

  • As a result of the burn over the charged rear hose lines were destroyed. The remaining water in the tank was emptied through the burned hose lines because the pump remained in gear. The front bumper line was not damaged due to the burn over. The engine did not stall nor did it sustain damage that prevented it from being driven to safety.

  • The engine sustained only a few small paint blisters on the driver’s side near the back of the engine near the top of the cabinets. The vinyl hose bed flaps were burned off on the driver’s side and rear of the engine. The strobe light lenses were melted on the rear, driver’s side and passenger side (excluding the cab). The lenses on the front of the engine showed minimal deforming and remained intact along with those on the cab on the passenger side of the engine. The light bar showed signs of deformation but remained intact.

  • There was no other damage to Engine 6162 and it passed its annual pump test following its return to the District.

  • Several minor air leaks were found in the plastic air lines, however it is unknown if they are related to the burn over.

  • The home at 920 Orchard Lane used a well system for its water supply. At the time of the incident the power was out to the area and there was no water available at the house, therefore there was no effort made to re-supply the engine water supply with a garden hose.

  • The homeowner’s ladder was used to ladder the roof of the house in the area of the front door.

Post Incident Considerations

  • Due to the combustible nature of plastic/rubber air lines, wiring and other critical undercarriage components, these components should be protected from thermal damage during vehicle design. Further consideration should be given to after market modifications for those units currently in service.

  • Care should be given to keeping the undercarriage clean of grease, oil and other combustible products.

  • Specific attention should be given to installing high temperature fuel lines, protecting wiring from the battery to the engine computer system and protecting air lines so that the brakes would operate properly in a burn over or other similar event.

  • The actions taken by Engineer Kreps to throttle up the engine most likely prevented it from stalling during the burn over. Training should include the awareness that abandoned hose lines may burn through and cause the depletion of water supply if discharge valves are left open when the pump is engaged. In this case the pump was left engaged and valves open because the hose lines were needed. When the conditions changed quickly there was no time, nor was it safe to disengage the pump or close the valves.

  • The diamond plate hose bed covers performed appropriately to provide a barrier between the combustible hose bed and the burn over environment. No undeployed hose was damaged in the burn over. However, the vinyl flaps and nylon straps securing the hose beds were destroyed. Hose beds and securing systems, should be fully protected using non-combustible material.

  • There have been several internal debates as to which number should be on the roof of the engines as well as if numbers should be used at all. There was no issue with roof numbering during the burn over of Engine 6162. Concern exists however, that if contact from the air utilizing the U-18 designator was attempted, the crew or the Task Force Leader may not have realized that it was their unit because unit inventory numbers and radio designators are different. A method to clearly identify the District apparatus from the air needs to be developed.

  • The crew of Engine 6162 was able to enter the engine from both sides following the burn over. However, if the entire crew had been forced to enter the cab from the passenger side or rear, the center console and MDT may have prevented the engineer from quickly accessing the driver’s seat, slowing the escape of the crew.

  • The enclosed cab environment maintained the interior cab integrity of Engine 6162 and aided in the survivability of the crew during their escape. While smoke within the cab was not a factor and SCBA cylinders were not placed in the cab, consideration should be given to using SCBA cylinders to pressurize the interior of the cab. However, in this situation the cab remained clear.

  • In 1996 the Missoula Technology and Development Center studies in Los Angeles County determined that the materials inherent in fire engine cab construction caused smoke from gases released from the plastic and vinyl interior components to fill the cab in burn over situations. Additionally it was determined that the engine cab could only be a survivable environment during short duration, low-to moderate-intensity fires. Until recently very little effort has been made to protect the crew inside of the cab of the engine in a burn over situation.

    • There are other methods of protecting the crew currently available and some of which have come from studies of engine burnovers in Australia.

    • Australia has been using an external mounted sprinkler system for some years that has proven to be effective when there is a sufficient on board water supply. Other methods include permanently mounted fire curtains, similar technology to fire shelters, inside the cab of the engine that can be quickly deployed to protect the crew. In addition one engine manufacturing company is building a wildland or wildland interface engine with a track-mounted fire curtain window protection system that includes double-panel thermal windshield glass and high temperature-tempered side windows. The Track system allows for rapid deployment to minimize setup time during emergencies. There are also high-temperature door gasket materials, a fully insulated cab interior and an all aluminum cab for maximum heat dissipation.

  • Engine 6162 experienced difficulty leaving 920 Orchard Lane due to the narrow winding driveway which was obscured by smoke. Research indicates some automobile companies offer nighttime vision aids by projecting near-infrared beams from two lamps in the front bumper. The near-infrared light reflects from objects ahead back to a Charged Coupled Device (CCD) camera mounted inside the vehicle at the top of the windshield.

    • A dedicated computer processes the resulting natural-looking images, which are then projected onto the lower section of the windshield within the driver's field of vision. This results in a picture similar to that on a black and white television. This system delivers clear illuminated images of what is ahead out to a distance of nearly 500 feet. In the event that is necessary to operate the vehicle in a zero visibility situation this system may allow for the safe and quick escape of the crew. Current versions of this system have a field of vision of 1500 feet and cost approximately $10,000.00.

    • Engines carrying Thermal Image Cameras may find them useful in situations when visibility is obscured by smoke.

  • A standard should be developed or refined, such as NFPA 1901 and 1906, for the design and construction of wildland and wildland interface engines with a focus on crew safety and survivability, since the technology appears to currently exist to meet these standards.

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