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
There was no previous recorded fire history in the San Diego River
Drainage in the immediate area of 920 Orchard Lane for at least 75
years according to available fire history maps. This information was
not available to the crew of Engine 6162.
The entire Southern California region had been in a drought condition
for several years. The specific area of the incident had been in a
drought condition for the previous three years with rainfall totals
less than 60% of normal. Again, this information was not available
to the crew of Engine 6162.
The Cedar fire had burned approximately 233,000 acres by the afternoon
of October 28.
Annual grasses were predominate on the eastern aspect of the San
Diego River drainage across from Orchard Lane along with isolated
stands of chaparral and live oak. The predominate fuel model on the
east side (west aspect) of the San Diego River Drainage, below Orchard
Lane, was at least 30 year old chaparral (manzanita) with short annual
grasses. Locals state that the chaparral fuel beds were nearly 70
years old. The chaparral fuel beds were approximately 15’ in
height with closed canopies. The age of the fuel was not known to
the crew of Engine 6162 .
Approximately 1.5 miles southwest of the entrapment site, 11 fire
fighters were killed in a fire storm on the Inaja Fire. The Inaja
Fire started November 25, 1956, under strong Santa Ana
winds, the fatalities occurred when the winds turned to the west.
(CDF Cedar Fire Green Sheet)
On the east slope of the San Diego River Drainage, immediately below
the driveway to 920 Orchard Lane, there was a 150’ buffer of
short annual grasses and duff between the driveway and the chaparral
The slope below 920 Orchard Lane was approximately 20 percent however,
the slope did increase to 30-40% near the bottom of the San Diego
The elevation of 920 Orchard Lane is 3442’.
There were East winds for the first three days of the incident which
started on the evening of October 25, 2004 in the Cedar Creek Drainage.
On October 28 offshore winds had subsided and the on shore winds developed
by late afternoon.
By 0900 hours on October 29 the fire was burning in the bottom of
the San Diego River Drainage, North of Highway 78/79. A strong on
shore pressure gradient developed by 0930 hours on the October 29
and a “Fire Weather Watch” was issued. Winds became increasingly
gusty, southwest to west, with speeds of 15 to 30 mph in the higher
elevations. Following the burn over, later in the afternoon the Red
Flag Watch was upgraded to a Red Flag Warning due to the increased
wind conditions and lowering humidity. The fire weather watch information
was not made available to the crew of Engine 6162.
The Julian RAWS at the time of the accident indicated a sustained
wind speed of 17 mph with gusts to 31 mph from the west. The Julian
RAWS is 4 miles to the southeast at an elevation of 4420 feet.
As stated in the Training Section, The Novato Fire District has found
that, in Marin County, the recurrence of the on shore weather pattern
in the days immediately following a north/east wind event yield conditions
that are most likely to result in a large-loss/acreage fire when fuel
moistures are still low and the onshore winds increase.
The Task Force stopped in Santa Ysabel at approximately 9:15 hours
on the morning of October 29 prior to their first assignment of the
day. They were told by their Task Force Leader that their assignment
would be structure protection in the Riverwood Estates approximately
2 miles east of Santa Ysabel, off Highway 78/79.
FF/PM Smith photographed the fire that had crossed Highway 78/79
enroute to this assignment. At this point the fire was burning primarily
in the chaparral and oak woodland, making slow side hill progress
under mild wind conditions. The crew states that the fire behavior
was uneventful as viewed from Riverwood Estates.
The Task Force spent approximately one hour on mop up operations
following a firing operation that occurred earlier around the homes
in the Riverwood Estates. During this time the fire remained some
distance from the homes and was never a direct threat to the area.
At approximately 11:30 hours the Task Force left the Riverwood Estates
and proceeded East on Highway 78/79 towards Orchard Lane.
Around 11:45 the Task Force turned North onto Orchard Lane. Orchard
Lane is a single lane dirt road, approximately one mile long, that
runs North off of Highway 78/79 parallel to the East side of the San
Diego River Drainage. As Engine 6162 reached the end of the road the
crew noticed the fire had wrapped around the northernmost end of Orchard
Lane and was actively moving in a northeasterly direction. Captain
McDonald became concerned that the Task Force was not in a safe location
and ordered Engineer Kreps to back Engine 6162 down the road to an
area that appeared to be an acceptable Safety Zone.
At roughly 1200 hours Engine 6162 was given the assignment to provide
structure protection at 920 Orchard Lane. When they reached the ridgeline
location of 920 Orchard Lane they observed the conditions in the area
as described in the Pre- Incident description. The crew also noted
that the clearance of brush below the driveway (buffer zone) provided
for a view across the San Diego River Drainage to the west and northwest.
Their view to the southwest was obscured by smoke, brush and live
As the crew looked at the west side of the drainage, they observed
a flanking fire backing down towards the bottom of the San Diego River
drainage. The crews view to the south and southwest was blocked. Smoke
from the fire that had crossed the end of Orchard Lane was visible
to the North. The crew describes an up canyon wind, 7-10 mph blowing
to the northeast towards 902 Orchard Lane. The crew based their decision
to stay at this location on the current observed fire activity and
vegetation clearances and the support from the TFL. They expected
to encounter a mild flanking fire in surface fuels to proceed toward
their location from the end of Orchard Lane to the north.
The only other fire activity in the general area was their firing
operation in the buffer zone below the driveway and the probability
that the CDF Fire Captain, seen near the garage by Captain McDonald,
had also conducted some firing in that area.
About 50 minutes after they arrived at 920 Orchard Lane, about 12:45
hours, the crew observed increases in fire intensity below them in
the chaparral fuels. Shortly thereafter, around 1:00 p.m. the crew
observed a rapid increase in fire activity which includes:
- Rapid rise in ambient air temperature
- Sudden increase in fire intensity from the ridgeline south of
920 Orchard Lane. There was no previous indication of any fire in
- Blowing embers
- Decreased visibility due to increased smoke production
- Flame front coming from the drainage laying over the driveway,
first to the north of the engine and then immediately to the south
of the engine
Up until the last few moments the fire behaved as expected and predicted
by the crew of Engine 6162. The firing operations, mentioned in the
CDF Green Sheet,
un anticipated wind shifts and gusts may have had an adverse impact
on fire behavior that was predicted by the crew of Engine 6162 . The
final moments of fire behavior did not match the crew’s predictions
Post Incident Considerations
The converging factors, known and unknown, should combine to provide
the crew with a “Situational Awareness” that will influence
their decision to defend or not defend a structure. The known is what
is observed and personally experienced and the unknown are those factors
that are critical to the situation but are not readily available,
obvious or explainable.
There were several lateral drainages ran from the bottom of the San
Diego River Drainage to the top of the Orchard Lane ridge line. These
drainages were generally obscured by the height of the fuel, smoke
drift and the increase in slope further down the western aspect. Drainages
can potentially effect fire behavior however, it is unknown the extent
to which they influenced the incident at 920 Orchard Lane.
Firing operations must always be coordinated with adjoining resources
and should never be attempted unless their safety can be verified.
The ability to recognize the potential of fire behavior changes as
a result of changes in fuel, weather and topography is crucial to
crew safety. Information on specific areas of concern relating to
drought, bug kill and other unusual conditions that may lead to extreme
fire behavior should be shared on a state wide basis.
A method, including “check backs”, should be developed
to advise crews on the line of the issuances of fire weather watches
See additional comments regarding using technology in the Post Incident
Considerations in the Equipment section of Lessons Learned.
continue reading—Novato FPD Report, Lessons Learned, Personal Protective