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
Cedar Fire Lessons Learned
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 addition to the FIRESCOPE requirements, all Novato Fire District
Type III engines carry the following equipment pertinent to this incident
and not covered in other sections of this report.
One wyed bumper discharge with one 1.5” Nitrile single
jacket hose line, 30’ in length with a 20/60 gpm wildland
fog nozzle and one 1.5” Nitrile single jacket hose line,
30’ in length with a 30/50 gpm stacked smooth bore wildland
nozzle. Both nozzles are equipped with removable bales.
Two liveline crosslays, 1.5”, synthetic, double jacket,
150’ in length with combination 30-200 gpm fog nozzles.
Both nozzles are equipped with removable bales.
One rear wildland liveline, 1.5” cotton single jacket,
150’ in length with a 20/60 gpm wildland fog nozzle and
removable bale. A Siamese is inserted at end of the first 50’
length to facilitate another engine taking over the supply of
Wildland Hose Packs
8 hose packs carrying two 100’ sections of 1.5” single
jacket, cotton wildland hose each (for a total of 1600’).
The packs are made of a nylon type material and are capable of
deploying individual lengths of hose without pack removal. One
length of hose in each pack is equipped with a 1.5” x 1”
tee. Each pack weighs 46.5 pounds. Four of the packs are carried
in the left rear compartment and four are carried in the front
left of the supply hose bed.
Mop Up Kits
4 hose packs carrying two 100’ sections of 1” single
jacket, cotton wildland hose each (for a total of 800’).
The packs are made of a Cordura nylon material. Each pack carries
a 1.5” x 1” tee, Forester style hose clamp, 10/24
gpm wildland fog nozzle without bale. *1” wildland hose
is only used for mop
Engine Protection Line
- Two orchard style drip torches
- One 2.5 gallon dip torch fuel can
- One case of wildland fusees
- 4 fusee removable pouches, made of Cordura nylon, capable of
being attached to the FSS web gear and shoulder harness with 5 fusees
- One 031 Stihl with XX” bar with wood cutting chain
- One combination fuel/oil can
- One falling kit including, chaps, hearing protection, wedges and
saw repair kit
Out of County Kits
The District maintains several kits that are placed on engines
at the time of dispatch intended to provide personal support and
essential equipment. These kits contain personal hygiene items,
sleeping, cooking and rations. The kits are carried in the FSS
style “Red Bags”. Prior to departure a cooler is also
added and filled with bottled water and sports drinks. Room is
designated on each engine for this equipment. No other comfort
or entertainment items are carried and no combustible items are
allowed on the exterior of the engine.
Medical , see ALS equipment
At the time the crew of Engine 6162 was operating at 920 Orchard
Lane the following equipment was utilized:
The wyed bumper discharge 1.5” Nitrile single jacket hose
line, 30’ in length with a 20/60 gpm wildland fog nozzle
was deployed to control the burning operation on the existing
brush piles near the engine. The brush piles were ignited by the
crew to reduce the fuel load near the house. Engineer Rucker was
using this line to maintain control of the intensity of the brush
This line was left charged and placed on the front bumper of
the engine as fire conditions began to intensify. As Engineer
Kreps exited the house for the first time to locate Engineer Rucker,
he found the line charged and intact. Engineer Kreps was able
to utilize the line for approximately 15 seconds until the water
supply was exhausted. Subsequently, when the crew entered the
engine to depart 920 Orchard Lane the bumper line was still deployed
and intact. In exiting the driveway the line was driven over and
At the time the crew of Engine 6162 was operating at 920 Orchard
Lane there were two 1.5” wildland single jacket hoselines, each
100’ in length, deployed from a gated wye attached to a rear
discharge of the engine. This is a standard Novato Fire District company
evolution for structure protection operations. District personnel
are discouraged from using hose lines over 200’ in length for
One of the eight wildland hose packs was used to form the two 1.5”
structure protection lines attached to the rear of the engine. These
lines were deployed and charged in preparation for structure protection
and fire control. These lines were not staffed until the crew took
refuge behind the engine. At that time Engineer Rucker staffed one
of these lines near the tailboard of the engine on the passenger side.
FF/PM Smith staffed the other line near the front bumper on the passenger
side of the engine.
Both hose lines were substantially burned as a result of the burn
over and unusable. The nozzles and gated wye remained structurally
The remnants of a second hose pack were found on the concrete patio
near Engineer Rucker’s body following the burn over.
The drip torches were used by FF/PM Smith and Engineer Kreps to conduct
a low intensity burnout operation including the ignition of a existing
burn pile, light down slope surface fuels and ornamental vegetation
along the west facing driveway near the home. Captain McDonald threw
several fusees down slope into the manzanita below the grass line.
The operation using the drip torches was effective in reducing the
grass and ornamental vegetation below the engine and along the driveway.
The fusees had little or no effect in igniting the manzanita.
The chainsaw was initially used to remove a few overhanging limbs
and a minor amount of brush along the driveway to 920 Orchard Lane
to improve access/egress. It was later placed on the patio along the
escape route to the house. The chainsaw was burned beyond operability.
The weather kit was not utilized to monitor weather conditions during
the operations at 920 Orchard Lane. It should be noted that the weather
conditions, obtainable by a belt weather kit, just prior to the burnover
were not necessarily indicative of what was going to occur. The temperature
was in the low 70s and the relative humidity was approximately 30%.
Winds were estimated to be 7-10 mph.
A falling axe from Engine 6162 was placed by the rear door of the
house prior to the burn over and used to force entry into the house.
A McLeod was placed at the rear of the engine on the passenger side,
next to the rock wall.
Post Incident Considerations
The single jacket structure protection hose lines burned through.
Research should be conducted to evaluate alternate hose types that
would offer improved survivability in similar conditions, e.g. the
30’ nitrile hose on the front bumper did not burn.
Due to the combustible nature of the hose packs, consideration should
be given to the materials used in there construction or to the ease
that they can be removed in an emergency.
This fire, even after several days, was understandably still being
fought using initial attack and “bump and run” strategies
without adequate overhead supervision. To effectively and safely operate
under these conditions it is essential for the Strike Team/Task Force
Leader to have the ability to quickly access key accurate situational
information, such as spot weather forecasts, fire history maps, live
and dead fuel moisture and fire behavior predictions.
Consideration should be given to providing all Strike Team/Task Force
Leaders or engine companies with the training and capability to quickly
and continuously access current and expected weather conditions (preferably
from local RAWS locations), topographical maps, street maps, aerial
photos, current and predicted fire behavior and conditions, expected
local weather conditions, fire weather watches and warnings, fire
history and any other pertinent information that would improve situational
awareness and safety. Technology in the form of wireless communications
capable of linking to an incident web site may provide this information
quickly and continuously to the resources that need it to operate
Regardless of the perceived weather conditions weather should be
taken on a regular basis using what ever means that are available
to the crews or Strike Team/Task Force Leader.
All responding resources should be appropriately equipped for the
assignment. This responsibility falls on the agency filling the assignment,
the responding crew, and ultimately on the STL or TFL.
GPS units may provide crews with information regarding local topography
and geographical locations in the event of an emergency.
continue reading—Novato FPD Report, Lessons Learned, Fire Behavior