Accident Investigation
Factual Report
Cramer Fire Fatalities
North Fork Ranger District
Salmon-Challis National Forest
Region 4
Salmon, Idaho - July 22, 2003
Appendix E—Fire Policy, Directives, and Guides
FSM 5100—Fire Management
FSH-6709.11—Health and Safety Code Handbook
Interagency Standards for Fire and Fire Aviation
Operations 2003
Incident Response Pocket Guide
Thirtymile Hazard Abatement Monitoring Plan
Salmon-Challis National Forest Fire Management Plan
Ten Standard Firefighting Orders
18 Watch Out Situations
FSM 5100—Fire Management
5130—Wildland Fire Suppression
3. A Wildland Fire Situation Analysis (WFSA) shall be used to
document suppression strategy decisions for an incident that is expected
to exceed, or has exceeded, the action planned for in the fire management
plan (FSM 5131.1)…Consider fire behavior, the availability of suppression
resources, the values of natural resources and property at risk, direction
in the Forest land and resource management plan, and the potential cost
of suppression.
5131—Suppression of Wildfires
5131.03—Policy
4. Request the appropriate level of Incident Management Team
based upon the complexity findings of the WFSA (FSM 5131.1).The responsible
line officer shall ensure that the designated Incident Commander is briefed
regarding wildfire suppression objectives, considerations, and constraints.
5131.11—Preparation Requirements
A WFSA must be completed when:
1. Wildfire escapes initial action or is expected to
exceed initial action.
5133—Organization and Management of Wildfire Suppression
Operations
5133.1—Wildland Fire Management Organization
Assign the appropriate level of incident management team based on a complexity
analysis done within the WFSA.
5135—Fire Suppression Safety
All activities shall reflect a commitment to firefighter and public safety
as the first priority.
5135.4—Safety Guidance
The Fire Orders, Lookouts/Communications/Escape Routes and Safety Zones
(LCES), and Watch Out Situations contain important basic guidance for
safe fire management activities.The FSH 5109.32a, Fireline Handbook, and
FSH 6709.11, Health and Safety Code Handbook, list the Fire Orders and
Watch Out Situations. During fire assignments, all employees shall be
alert continuously for Watch Out Situations. Wildfire suppression actions
must comply with the Fire Orders and incorporate appropriate mitigation
measures based on the Watch Out Situations and LCES.
FSH-6709.11—Health and Safety Code Handbook
25—Protection and Development
25.13—Wildland Firefighting
25.13a—Safety Practices
Conduct risk assessments on an ongoing basis and take measures to mitigate
risks to prevent accidents. Basic safety and health practices for wildland
firefighting are:
1. The 10 Standard Fire Orders.
2. The Watch Out Situations.
7. Fire Situation Assessment.
a. Conduct continual situation assessment and
followup, which is essential.
c. Ensure that firefighter safety is not compromised.
Do not deviate from established safety practices.
d. Post qualified lookouts with adequate communication
for crews and in position to see danger points.
Interagency Standards for Fire and Fire Aviation
Operations 2003
Chapter 10—Incident Management
Introduction—The Incident Complexity Analysis and the WFSA assist
the manager in determining the appropriate management structure to provide
for safe and efficient fire suppression operations.
Incident Response Pocket Guide
There are eighteen decision points on the Extended Attack Transition
Analysis dealing with fuels, weather, communications and resources. If
you check yes on three or more items out of the 18 to consider ordering
an incident management team. A quick run through of the analysis, brings
up four yes answers.
Thirtymile Hazard Abatement Monitoring Plan
Implementation action—Prepare a complexity analysis on every plan
at time of initial attack as part of the size up. Documentation Required.
Responsibility—Line officers, fire management officers, incident
commanders.
Implementation action—Monitor the effectiveness of the planned
strategy and tactics and to:
- Immediately delay, modify, or abandon firefighting action on any
part of a wildland fire where strategies and tactics cannot be safely
implemented.
- Execute suppression actions when and where they are safe and effective.
- Ensure that all firefighting actions are in full compliance with the
Ten Standard Fire Orders and that the mitigation of the applicable Watch
Out Situations has been accomplished.
- Maintain command and control of all fireline resources.
Responsibility—Incident commander.
Salmon-Challis National Forest Fire
Management Plan
Section II—Relationship to Land Management Planning and
Fire Policy
B. Management Policies Concerning Fire.
- Firefighter and public safety is the first priority in every fire
management activity.
- Sound risk management is a foundation for all fire risk management
activities.
The Salmon-Challis National Forest is well versed in the many policies
following the Thirtymile Fire. These policies, aimed at improving firefighter
safety and directing the implementation of actions in the Thirtymile Accident
Prevention Plan of December 14, 2001 and the Thirtymile Hazard Abatement
Plan of March 26, 2002, have been incorporated into the development of
this Fire Management Plan.These plans and the recent Interim Directives
(5100-2003-1, 5120-2003-2, and 5130-2003-3) for 2003 have been included
in appendix p. Also included in the same appendix are the Monitoring Plan
and Incident Checklist for use in implementing the abatement actions of
the Thirtymile Hazard Abatement Plan. These documents have been distributed
to the districts for use in safety sessions, and to develop procedure
for incident management.
Section III—Wildland Fire Management Strategies
B. Wildland Fire Management Goals.
Achieve a program where firefighter and public safety is the highest priority
in every fire management activity.
C. Wildland Fire Management Options.
1. Wildland Fire Suppression
All wildfire starts are sized up to determine fire cause, potential for
spread and potential to cross jurisdictional boundaries.
An appropriate management response is implemented on all fires unless
the fire is determined to be a wildland fire use incident.
All wildfires that escape initial attack will have a Wildland Fire Situation
Analysis (WFSA) completed in a timely manner.The WFSA will serve as the
decision record for the selection of the appropriate management response.
D. Description of Wildland Fire Management Strategies by Fire Management
Unit
Control problems and dominant topographic features
Suppression Non-WUI FMU
The topography in steep areas has a significant effect on fire behavior,
fuels and weather. Steep slopes predispose areas to rapid uphill fire
growth as well as contribute to a major problem with rolling firebrands.
Fire line construction at midslope is very dangerous and on these slopes
underslung fire lines are hard to secure and even more difficult to hold.Topography
across the area has a very mark effect on fuels because of the differences
in moisture and surface heating across the landscape; fuel type varies
as a result of the differences in elevation, available moisture and differences
in aspect. In addition to the direct physical affects that can be seen
on fuels and fire behavior, topography also influences local weather conditions,
specifically winds. Differential heating across the landscape results
in the development of local upslope/ upvalley breezes and these are very
common often very pronounced during the summer months. Canyon topography
in the area also tends to channel winds and often results in local wind
conditions far different from those predicted in general area fire weather
forecasts. Night time thermal zones are also common within the unit especially
in deeper canyons. These thermal zones, which contribute to active fire
behavior at night, are particular common on fires burning in the lower
Salmon River Canyon.
Topography also has a very significant effect on spotting. Firebrands
lofted from elevated positions on slopes or ridges can travel very significant
distances and can contribute to long range spotting during severe weather
conditions. Rolling material is also common in these steep areas and can
result in significant fire growth, in holding problems and jeopardize
fire fighter safety.
Firefighter safety is a significant concern in this Unit as a result
of the influences topography has on the way fires burn. Managers should
consider safety as it relates to this topography when sizing up fires
for suppression actions. Midslope fires are of particular concern and
should be carefully evaluated to assure that firefighters safety is not
compromised by fire below fire suppression personnel. Caution should also
be taken with down hill line construction with close attention given to
the required safety measures prescribed in the downhill guides.
Values to be protected in this Fire Management Unit include structures,
infrastructure, improvements, T and E species, wildlife habitat, commercial
timber, range values, recreation areas, cultural resources and public
safety. The objective for fire management within the Unit emphasizes suppression.
Wildland fire use is not authorized and will not be used as a fire management
strategy. Fires will receive aggressive initial attack, a Wildland Fire
Situation Analysis (WFSA) will be prepared is initial action is unsuccessful
in suppressing the fire.
Section IV:Wildland Fire Management Program Components
B. Wildland Fire Suppression
3. Initial Attack
Initial attack is an aggressive suppression action consistent with firefighter
and public safety and with values to be protected. The Central Idaho Coordination
Center uses WildCAD Run Cards to dispatch resources based on the current
response level across the forest.
d. Response times
Responses in the Suppression non-WUI can be expected in the 20 to 45
minute range depending on the specific location of the fire. These locations
are by nature more likely to be in remote locations accessible best by
helicopter, or via backcountry road.
4. Extended Attack and Large Fire Suppression
A wildfire is considered to be in extended attack status when:
• Suppression efforts have not succeeded or are not expected to
reach containment within 24 hours.
• The initial attack incident commander (ICT 4 or ICT5) requests
additional resources that result in fire complexity attaining Type III
status within or following the first 24 hours following the arrival of
the first suppression resources.
b. Implementation Plan Requirements—WFSA development
Type III incident management.
A Type III incident commander (IC) will manage incidents that reach a
Type III complexity level. This will be a full time dedicated IC with
no collateral duties.The forest has assembled a Type III team to manage
these incidents through to completion or until transition to a Type I
or II incident management team.
7. Other Fire Suppression Considerations
Safety
Safety is the number-one priority for all personnel engaged
in or supporting fire management activities on the forest.
Fire management work is one of the most hazardous jobs encountered
by Forest Service personnel.The incident commander and all supervisors
will always put the safety of his/her personnel first. There is no fire
situation so serious that the life of anyone should be risked in order
to get to the fire sooner, get the fire out quicker, or to keep the burned
areas smaller.
All employees will abide by the Safety First policy. Each employee
has a responsibility for his/her personal safety and that of fellow employees.
It is also everyone’s responsibility to call attention to any unsafe
practice that is observed.
1. All fire personnel will follow the Ten Standard Firefighting Orders
and the 18 Watch Out Situations and shall practice the principles
of Lookouts, Communications, Escape Routes, and Safety Zones (LCES).
These basics of fire fighting survival will be utilized as a checklist
for supervisory personnel on the fire, and as a source for other fire
line personnel to pose questions to supervisory personnel whenever they
have concerns about their personal safety. All firefighters will carry
and utilize their Incident Response Pocket Guide.
2. All Type III and more complex incidents will be staffed with a qualified
safety officer.
Ten Standard Firefighting Orders
All Ten Standard Firefighting Orders were violated or compromised.
1. Keep informed on fire weather conditions and forecasts.
Spot weather forecasts were not requested for July 22. Few weather observations
were taken on the line during the entire fire. Fire personnel relied heavily
on weather observations from Long Tom Lookout that did not represent the
Cramer Fire site (IC Type III and Cramer Fire personnel).
2. Know what your fire is doing at all times.
Due to the steep terrain and multiple aspects, lookouts were not in vantage
points to view the entire fire.The visibility at H-2 was limited due to
terrain and vegetation. On July 22, the IC’s view of the fire came
from two reconnaissance flights.The restof the day he was at the Cove
Creek helibase, 13 miles from the Cramer Fire (IC Type III and Cramer
Fire personnel).
3. Base all actions on current and expected behavior of the fire.
Actions were based more on the observed fire behavior in the
morning than what was predicted to occur based on the seasonal severity,
weather forecast, and previous days’ fire behavior (IC Type III
and Cramer Fire personnel).
4. Identify escape routes/safety zones and make them known.
Three of the four safety zones identified by the IC and two crew bosses
were not safety zones on the afternoon of July 22, during conditions of
extreme fire behavior. Hear H-1, the black was a safety zone, but the
unburned sagebrush field was a survival zone. Near H-2, the black on the
east side of the ridge during the uphill fire run was a survival zone,
but the old burn/ ceanothus brush field was neither a safety zone nor
a survival zone (IC Type III, Central Oregon Regulars crew boss, Indianola
assistant helitack foreman).
5. Post lookouts when there is possible danger.
The IC’s plan for placement of lookouts was not clearly communicated
to personnel assigned to the fire. No lookout with a view of H-2 or the
Cache Bar drainage was posted on July 22 to monitor fire in the Cache
Bar drainage and to communicate critical weather and fire behavior information
to the rappellers. Aviation resources over the fire could not function
full time as lookouts for ground crews given their other duties and responsibilities
(IC Type III).
6. Be alert. Keep calm. Think clearly. Act decisively.
On July 22, when the IC made his decision to retrieve the rappellers from
H-2, he did not act decisively by immediately removing the rappellers
from H-2. During the critical period prior to, and after contact was lost
with the rappellers, the IC was functioning as the district FMO/ AFMO,
performing multiple collateral duties on the radio (IC Type III).
7. Maintain prompt communications with your forces, your supervisor,
and adjoining forces.
On July 22, critical observations of fire activity in the Cache Bar drainage
were not communicated to the IC and the rappellers at H-2. The IC did
not update the rappellers on H-2 about revised strategy and tactics. More
than 30 minutes elapsed after loosing contact with the rappellers at H-2
before the IC became engaged in the search and rescue operation (IC Type
III, air attack, lead plane 41).
8. Give clear instructions and ensure they are understood.
On July 22, the IC’s instructions regarding the locations of lookouts
were not well understood.The IC dropped off a helicopter crew person east
of H-1 without a plan, a briefing, or a designated safety zone (IC Type
III).
9. Maintain control of your forces at all times.
On July 22, the IC was not in control of his forces on the fireline, deferring
operations to his strike team leader. He did not supervise and adequately
contact, monitor, or coordinate with the H-2 operation (IC Type III).
10. Fight fire aggressively, having provided for safety first.
Initial attack suppression efforts on the Cramer Fire were inadequate
on July 20 and 21, causing the fire to grow in size and complexity under
extreme burning conditions. Midslope suppression tactics were used on
July 21 and 22 during extreme burning conditions.There were significant
safety lapses prior to the fatalities. The safety of the rappellers was
compromised by focus on fire activity in the Cramer Creek drainage and
the eventual burnover of H-1 (North Fork/Middle Fork district ranger,
forest FMO, zone duty officer, IC Type III).
18 Watch Out Situations
Nine of the 18 Watch Out Situations were present and not mitigated.
1. Fire not scouted and sized up (NA).
2. In country not seen in daylight (NA).
3. Safety zones and escape routes not identified (NA).
4. Unfamiliar with weather and local factors influencing fire
behavior (NA).
5. Uninformed on strategy, tactics, and hazards (NA).
6. Instructions and assignments not clear.
On July 22, the IC’s instructions regarding the locations of lookouts
were not well understood.The IC dropped off a helicopter crew person east
of H-1 without a plan, a briefing, or a designated safety zone (IC Type
III).
7. No communication link with crew members/supervisor.
The IC did not supervise and adequately contact, monitor, or
coordinate with the H-2 operation (IC Type III).
8. Constructing fireline without safe anchor point.
Anchor points were not established (IC Type III, strike team leader).
9. Building fireline downhill with fire below.
The tactics for the west side of the fire were for a crew to build downhill
fireline from H-2 (IC Type III).
10. Attempting frontal assault on fire (NA).
11. Unburned fuel between you and the fire.
The rappellers at H-2 had two drainages of unburned fuel (Cramer
Creek and Cache Bar) below them (IC Type III).
12. Cannot see main fire, not in contact with anyone who can.
The visibility at H-2 was limited due to terrain and vegetation. No lookout
with a view of H-2 or the Cache Bar drainage was posted on July 22 to
monitor fire in the Cache Bar drainage and to communicate critical weather
and fire behavior information to the rappellers (IC Type III).
13. On a hillside where rolling material can ignite fuel below.
Rollouts were a common occurrence during all phases of the Cramer Fire.
A combination of backing and rolling allowed fire to establish itself
in the Cache Bar and Cramer Creek drainages. (IC Type III).
14.Weather is getting hotter and drier.
Fire activity on the SCNF increased dramatically through June and into
July from hot, dry weather and multiple lightning starts, indicating the
potential for new starts. Conditions had been getting progressively hotter
and drier during the Cramer Fire (IC Type III, Cramer Fire personnel,
North Fork/Middle Fork district ranger, forest FMO).
15.Wind increases and/or changes direction.
Wind gusts on the Cramer Fire increased markedly during the afternoon
of July 22 and changed direction. Personnel on the fire did not account
for the predicted changes in windspeed and direction for the afternoon
(IC Type III and Cramer Fire personnel).
16. Getting frequent spot fires across line (NA).
17. Terrain and fuels make escape to safety zones difficult
(NA).
18. Taking a nap near fireline (NA).
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