NIOSH Cedar Fire Report
CDF Cedar Fire Report
Novato FPD Investigation Analysis
Draft Standard Operating Procedures
Inaja Fire Tragedy
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NOVATO
FIRE PROTECTION DISTRICT
Investigation Analysis
of the
Cedar Fire Incident
Engine 6162 Crew Entrapment,
Fatality, and Burn Injuries
October 29, 2003
Cedar Fire Lessons Learned
Human Factors
Pre Incident
-
The Novato Fire District provided physicals for its members
- Members under 40 receive physicals every two years
- Members over 40 receive physicals annually
- Physicals are typically provided by the member’s primary
physician
-
Due to legal requirements the District is only provided with general
information regarding member health and fitness i.e.:
- Fit for Duty
- Fit with Restrictions
- Unfit for Duty
-
All District fire stations are equipped with a full complement of
exercise equipment
- Treadmills
- Elliptical Trainers
- Weights
- Members are generally provided time to work out each shift between
07:00 hrs and 09:30 hrs
-
The District has been in the practice of conducting third party fitness
evaluations for all members annually.
- Fitness evaluations had not been conducted in Fiscal Year 2002-2003
due to issues with the third party evaluator
-
Firefighters are expected to make appropriate decisions in stressful
and occasionally life threatening situations
- The District does not have program to develop critical thinking
skills in stressful situations nor does it have a program to determine
if members possess or lack this critical ability.
-
Prior to responding to the Cedar Incident, the crew had just returned
from a four day break.
- They had received adequate rest and had not worked any overtime
shifts
- The shift, prior to dispatch, was relatively uneventful.
-
The total combined fire service experience of the Crew of Engine
6162 was 55.5 years.
-
Captain McDonald had =19 years of firefighting experience, plus an
additional 7 years experience as a paramedic. His experience included
17 years with Novato Fire and one year with Marin County Fire Department.
-
Engineer Kreps had 16 years of firefighting experience and 15 years
experience as a licensed paramedic. His experience included seven
years with Novato Fire and one season with the CDF.
- Engineer Rucker had 12.5 years of firefighting experience and 15 years
as a paramedic. His experience included 11 years with Novato fire and
two seasons with CDF.
-
Firefighter Paramedic Smith had 8 years of firefighting experience
and 2 years experience as paramedic. His experience included one year
with Novato Fire and three seasons with CDF.
Incident
-
At the time of the incident the crew of Engine 6162 had all been
cleared for regular duty, by their physicians, without restrictions.
- Engineer Rucker had been issued a recent prescription for an inhaler,
typically associated with Asthma.
- The District was not aware of this prior to the incident
- NIOSH preliminary investigations indicate there is no evidence
that Asthma was a factor in the incident.
-
It is unlikely that fitness was a factor in this case since it was
a short distance that the crew had to travel to the safety of the
structure.
-
There are several potential explanations for the delayed reaction
and subsequent response of Engineer Rucker when the order was given
to move to the house.
- Intake of extremely hot air or fire gases resulting in breathing
or respiratory issues
- Tripping over hose lines or equipment located in the general area
- An unidentified medical condition
- A combination of the above
-
There is no definitive proof that any of these factors contributed
to the situation.
-
It should be noted that all four crew members were in the same general
area at the time of the burnover and were exposed to the same general
environmental conditions.
-
Engineer Kreps, standing closest to Engineer Rucker, was forced to
cover his mouth with his gloved hand and take shallow breaths due
to the intense heat.
-
All crew members felt that they had received adequate rest prior
to the incident.
-
The collective experience of the crew and their ability to remain
calm, think clearly, and respond according to an established plan
was paramount in the survival of three members.
Post Incident
-
In September of 2003 the District implemented the IAFF/IAFC Joint
Labor Management, Wellness-Fitness Initiative.
- All members now receive annual physicals by a designated District
physician.
- Peer fitness testing will be conducted internally and shared with
the designated District physician
-
District members are now required to pass a the Pack Test in order
to participate in “Out of County Assignments”
- A annual mandatory physical agility testing is being considered
for all safety members
-
As it relates to asthma and firefighters, the 2003 edition of NFPA
1582, Comprehensive Occupational Medical Program for Fire Departments
states:
- Asthma compromises a member’s ability to safely perform
essential job tasks
- Acute hyper-reactivity on the fire ground environment can induce
immediate or progressive clinical asthma (bronchospasm and wheeze)
that can lead to sudden incapacitation from status asthmaticus and/or
cardiac ischemia
- Certain types of asthma now prevent individuals from being hired
because it can inhibit the performance of essential job functions
-
The military and the aviation industry have developed methods to
analyze their members ability to think clearly and act decisively
in stressful situations
- This factor has been identified as a causal factor in other firefighter
fatalities
- The fire service needs to implement similar methods in an effort
to prevent injuries and fatalities in emergency situations
- Testing for the predictors of dangerous traits should also occur
at the entry level and for those already working on the line
- Methods to improve members performance in stressful situations,
through training, must be developed
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