NIOSH Cedar Fire Report
CDF Cedar Fire Report
Novato FPD Investigation Analysis
Draft Standard Operating Procedures
Inaja Fire Tragedy
FIRE PROTECTION DISTRICT
Cedar Fire Incident
Engine 6162 Crew Entrapment,
Fatality, and Burn Injuries
October 29, 2003
Draft Standard Operating Procedures
Title: Wildland Structure Protection Standard Operating
Structure protection is a dangerous task often performed at the most
intense segments of the fire. Due to the inherent dangers of wildland
firefighting in general and structure protection specifically it is imperative
that personnel maintain “Situational Awareness” and focus
on personnel safety and survival at all times.
Situational Awareness is the process used to identify, comprehend, analyze
and react to critical elements of information or events that may impact
the crew’s ability to carry out assignments safely.
The Novato Fire Districts philosophy is based on a simple premise, “Every
Firefighter Deserves a Round Trip Experience”. It must be the
motto of all members that no structure protection operation is worth risking
firefighter injuries, near misses or fatalities.
Structure protection operations are not worth sustaining damage to an
engine. Even minor damage to an engine such as, melted lenses or bubbled
paint should be considered a near miss, a close call for the crew and
investigated as such.
Every structure protection operation must be based on a Situational Awareness
and Structure Protection Assessment, and the development of Structure
Protection, Safety, Survival and Mop Up Plans.
There may be times when it becomes necessary to turn down an assignment
for fear of sustaining firefighter injuries, a potential near miss situation
or possible fatality(s). In these situations the individual in charge
should follow the District Refusing Risk SOP to the extent possible but
without further risking the safety of the crew or engine.
Situational Awareness Assessments must be based on:
Information, events, decisions, orders or actions beginning prior
to dispatch and continuing until the crew and engine are safely back
in quarters, that may immediately or eventually affect the safety and
survivability of the crew and engine
Communication including questioning each other to increase the Situational
Awareness of all crew members.
Structure Protection Assessments must be based on:
The survivability and safety of the crew and the engine
Actions the homeowner has taken to create an adequate defensible space,
nonpyrophytic landscaping and fire resistive construction
Standard Structure Protection Assessment guidelines
The potential for changes in weather and fire behavior
Never accepting or settling for a bad situation
The fact that what works at home may not work elsewhere in the State
and conversely conditions experienced elsewhere can occur at home.
Structure Protection Plans must be based on:
The crew’s ability to identify, in the Situational Awareness
and Structural Assessments, the cumulative circumstances that conspire
to create hazardous situations and their ability to eliminate the hazards
or change tactics in time to make the situation safe for themselves
and their engine including:
The ability of the crew and engine to safely survive the passage
of the flame front without taking refuge in the engine, structure
or deploying a fire shelter
Establishing Trigger Points which cause an immediate re-assessment
of the situation and potential changes in tactics
Identifying safe alternative options such as prepping and leaving
and/or returning after the flame front has passed
The Standard Firefighting Orders, the Watch Out Situations and the
Common Denominators of Fire Behavior on Tragedy Fires
A physical or mental step back to assure that your actions appear
to be in accordance with your plans, and always searching for a safer
*If conditions exist to safely make a direct attack on the fire all
Firefighter Safety and Survival guidelines will be followed.
Safety Plans must be based on:
The crew’s ability to establish Lookouts, Communications, Escape
Routes and Safety Zones (LCES). LCES must be established, re-assessed
and revised as conditions change. As Safety Plans change they must be
communicated to the entire crew. In operation, LCES functions sequentially
and is a self-triggering mechanism.
Lookouts assess – and reassess – the fire environment
and communicate to each firefighter threats to their safety. Firefighters
use escape routes and move to safety zones when threats to safety occur.
Lookouts should be trained to observe the wildland fire environment
and to anticipate and recognize and communicate fire behavior changes.
Lookouts should be positioned where both the hazard and the firefighters
can be seen.
Terrain, cover, and fire size determine the number of lookouts
needed; every firefighter has the authority and the responsibility
to warn others of threats to safety.
Lookouts must be in a position to provide the working crews with
sufficient warning so that they are able to reach their Safety Zone
Set up communications system - radio, voice, or both – by which
the lookout warns firefighters promptly and clearly of an approaching
It is paramount that every firefighter receives the correct message
in a timely manner.
Escape Routes must be verified by actually traversing the route and
assessing the time it takes to reach the Safety Zone.
Preservation of the homeowner’s vegetation, fences, or other
structural features that impede the crew’s use of the Escape Route(s)
should be of minimal concern to the crew and if need be, cleared or
Driveways or access roads must meet the requirements of an Escape
Route if the Safety Zone is not near the structure.
A Safety Zone must be an area where survivability is possible without
fire shelter deployment.
The optimum Safety Zones is four times the maximum flame length, measured
from the center of the Safety Zone to the nearest fuel on all four sides
The optimum area of a Safety Zone may be reduced based on varying
fuel types, topography and structures or other natural objects that
will act as a heat barriers as the flame front passes.
Engines, structures and bodies of water should be considered last
resort survival options not Safety Zones.
Last Resort Survival Plans must be based on:
The crew’s ability to identify, verify, establish and communicate
Last Resort Survival Options before an event occurs. Last Resort Survival
Options must be reassessed, revised and communicated to the entire crew
as conditions change. In operation, Last Resort Survival Options should
be self-triggering when conditions change and Safety Plans are no longer
In the event that Safety Plans fail the survivability of the crew
must become the only priority.
Last resort survival options include taking refuge in an engine,
structure, fire shelter or body of water
The most effective option or combination of options will vary according
to the conditions present at the time of the event
Mop up Plans must be based on:
The crew’s ability access a water supply, the degree to which
the structure was exposed to the flame front, other available resources
and the urgency to take on a new assignment.
A thorough mop up of the area surrounding the structure for a minimum
of 50’ or as dictated by an assessment of the surrounding fuel
Checking and re-checking for potential ignitions sources in the
interior and exterior of the structure
Waiting for a sufficient period of time to determine if re-ignition
No plan to protect a structure should be based on the
anticipated need to seek refuge in the engine, structure or in a fire
shelter when the flame front passes. On the other hand even the best managed
events can change for the worse. In these cases last resort survival options
such as entering the engine, structure, shelter deployment body of water,
or any combination of these options should be identified early, re-assessed
regularly and shared with all crew members.
In no case should policy impede firefighter safety nor should the basic
premise of firefighter safety be forgotten or neglected.
Activities that present a significant risk to the safety of personnel
limited to situations where there is a potential to save endangered
Activities that are routinely employed to protect property shall be
recognized as inherent risks to the safety of personnel, and actions
shall be taken to reduce/avoid these risks or change tactics.
No risk to the safety of personnel shall be acceptable where there
is no possibility to save lives or property.
We Will risk our lives a lot, in a calculated manner, to save SAVABLE
We Will risk our lives a little, in a calculated manner, to save SAVABLE
We Will Not risk our lives at all for lives, property or the environment
that are already Lost/Cannot Be Saved.
continue reading—Novato FPD Report, Refusal of Risk SOP >>>