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Cramer Fire

Lessons Learned

“Safety Zone” newsletter, July, 2004

Lessons Learned
author, date unknown

One-Year Anniversary Letter by Kelly Close, FBAN

Declaration on Cramer Redactions, by James Furnish, April, 2005

FSEEE v. USFS, FOIA Civil Lawsuit Order,
December, 2005

FOIA Request to USFS, December, 2005

FOIA Appeal to USFS,
February, 2006

Management Evaluation Report

Investigation Team Information

Synopsis of the Cramer Fire Accident Investigation

Causal Factors

Contributing Factors


Factual Report

Executive Summary

   (facts 1 - 57)
   (facts 58 - 201)
   (fact 202)
   (facts 203 - 237)


Appendix A
Resources on the Fire

Appendix B
Cramer Fire Timeline

Appendix C
Fire Behavior and Weather
   Prior Conditions
   Initial Phase
   Transition Phase
   Acceleration Phase
   Entrapment Phase

Appendix D
Equipment Found at H-2 and the Fatalities Site

Appendix E
Fire Policy, Directives, and Guides

Gallery of Cramer Fire Report Images

Accident Prevention Plan

OIG Investigation

OIG FOIA Response, February, 2005

2nd FOIA Request to OIG, April, 2006

2nd OIG FOIA Response, August, 2006, (1.4 mb, Adobe .pdf file)

OSHA Investigation

OSHA Cramer Fire Briefing Paper
 • Summary and ToC
 • Sections I-IV
 • Sections V-VII
 • Section VIII
 • Acronyms/Glossary

OSHA South Canyon Fire Briefing Paper

Letter to District Ranger, June 19, 2003

OSHA Investigation Guidelines

OSHA News Release

 • OSHA Citation 1
 • OSHA Citation 2
 • OSHA Citation 3

USFS Response


HFACS—"Swiss cheese" model of Accident Causation

Adobe PDF and Microsoft Word versions of documents related to the Cramer Fire can be downloaded from the U.S. Forest Service website.


Accident Investigation Factual Report

Cramer Fire Fatalities
North Fork Ranger District
Salmon-Challis National Forest
Region 4
Salmon, Idaho - July 22, 2003

Appendix D—Equipment Found at H-2 and the Fatalities Site

Equipment used by Jeff Allen and Shane Heath for rappelling from H-193 to the ground and for construction of the helispot was found at H-2. The equipment had been readied for transport. One of the saws had been wrapped with chain saw chaps, the hand tools had been wrapped in fiberglass tape, and all of the equipment was stacked in a single pile.

Photo 1—H-2, chain saws, and rappel equipment.

Though severely damaged by fire, the stack appears to have contained helicopter rappel equipment, a radio, three hand tools, and two chain saws with associated maintenance tools. Only steel, glass, brass, and some aluminum were still intact. The rest of the material was either consumed or melted by the fire. Some pieces of cast aluminum melted, indicating material temperatures of at least 1,000 ºF (photos 1 and 2).

Photo 2—H-2, chain saws, rappel equipment, and melted aluminum.

The remains of two fire shelters, personal items such as watches, cameras, keys, and belt buckles, and work-related items, including a radio, carabiners, and batteries were found at the fatalities site. Only steel, glass, and brass items were intact. The glass watch face was distorted as if it had softened. Glass begins to soften when it reaches about 1,100 ºF. Two flight helmets on the site were charred, easily compressed, and brittle (photo 3).

Photo 3—Fatalities site, fire shelters, and flight helmets.

The fire shelters were the older style (NSN# 4240-01-121-8698, NFES# 0169), which meet agency requirements (photo 4). The shelters were separate from other materials, which indicates they had been removed from their packs. One of the shelters was accordion folded in the same shape in which it was packaged, indicating that it had not been unfolded prior to the burnover. The exposed top layers of the folded shelter had no remaining foil and the fiberglass layer was white and very fragile. Where foil was present on the more protected layers, it was completely delaminated from the fiberglass cloth. Aluminum used in the shelters melts at about 1,200 ºF. The fiberglass used in the shelters softens between 1,350 and 1,611 ºF. The condition of the exposed fiberglass indicates that material temperatures were within this range.

Photo 4—Fatalities site where fire shelters were not deployed.

The second fire shelter was unfolded lengthwise but almost completely folded width-wise. This indicates that the shelter was removed from its plastic bag and partially unfolded prior to the burnover. The foil had melted from 10 of the 12 layers of the shelter and was present on the two layers that lay closest to the ground. Foil that remained had completely delaminated from the fiberglass layer. The fiberglass cloth was white and extremely brittle, indicating that it had reached a softening temperature between 1,350 and 1,611 ºF.

Crown fires studied with instruments by MTDC have reached temperatures over 2,000 ºF. Temperatures from approximately 1,300 ºF have damaged fire shelters, melting aluminum, and fracturing and disintegrating fiberglass cloth. Conditions inside fire shelters tested in these conditions were not survivable. The condition of the partially unfolded fire shelter found at the fatalities site resembled fire shelters tested under these severe conditions. This indicates that the shelter was subjected to temperatures from 1,300 ºF to potentially over 2,000 ºF.

<<< continue reading—Appendix E>>>


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