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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.


Freedom of Information Act request, re: Cramer Fire

December 19, 2005

Kent Maxwell
Colorado Firecamp, Inc.
9008 County Road 240
Salida, CO 81201

Mrs. Rita Morgan
USDA Forest Service, FOIA
1400 Independence Avenue, SW
Mail Stop: 1143
Washington, DC 20250-1143

Dear Mrs. Morgan:

On behalf of Colorado Firecamp under the Freedom of Information Act, I am requesting access to all

1. audio recordings,
2. transcripts,
3. Central Idaho Dispatch logbook entries,
4. Cove Creek Helibase logbook entries,
5. Indianola Helitack Base logbook entries, and
6. any subsequent timelines or summaries

of the radio transmissions (including Forest Net, air-to-air, and air-to-ground) concerning the Cramer Fire near North Fork, Idaho on the Salmon-Challis National Forest from July 20, 2003 at 1630 hours when the fire was first reported by the Long Tom Lookout, through July 23, 2003 at 1800 hours when the Cramer Fire accident investigation team arrived in Salmon, Idaho.

The substantial public interest in disclosure of the audio recordings outweighs the privacy interest in non-disclosure. The release will "expose to public scrutiny official information that sheds light on an agency's performance of its statutory duties." Specifically, the words and voice inflections on the audio recordings will shed light on the decisions and actions of United States Forest Service (USFS) employees and contractors with regard to firefighter safety, situational awareness, direct supervision, and management oversight while suppressing a wildland fire on public lands. Disclosure of transcripts will assist in public understanding of the audio recordings, in addition to evaluating the accuracy of the quotes and characterizations of voice inflections released in the Cramer Fire fatality accident investigation report. Disclosure of logbook entries and timelines/summaries will increase public understanding of the documentation of official communications by USFS personnel.

The larger public interest will be served by learning lessons from the events that led to the deaths of USFS firefighters Jeff Allen and Shane Heath. Communication failures, such as occurred on the Cramer Fire, are cited in almost every wildland fatality entrapment investigation and need to be studied.

Colorado Firecamp is a 501(c)(3) non-profit, wildland firefighter school. For the purposes of fee determination, I request classification as an educational institution. If there are any fees charged for searching or copying the records, please supply the records without informing me of the cost if the fees do not exceed $250, which I agree to pay.

I request a fee waiver in consideration of the following 6 factors:

(1) The audio recordings, transcripts, dispatch logs and timelines/summaries concern "the operations or activities of the government" as records of official communication between individuals engaged in wildfire suppression duties while employed or contracted by the United States Government;

(2) The disclosure is "likely to contribute" to an understanding of government operations or activities. The disclosure will shed light on decision-making and risk management related to USFS command and control of incident operations during initial attack, extended attack and transition wildland fires.

(3) Disclosure of these materials will contribute to an understanding of the subject by the general public likely to result from disclosure. Colorado Firecamp has demonstrated an ability to disseminate information to the general public, particularly with regard to firefighter safety and entrapment fatality investigations. Previous FOIA requests to the Occupational Safety and Health Administration (OSHA) and Bureau of Land Management (BLM) resulted in disclosure of investigation reports related to the Cramer Fire and the 1995 Point Fire. By means of a simple request to the California Department of Forestry and Fire Protection (CDF), Colorado Firecamp prompted the release of the full, un-redacted investigation report of the 2004 Tuolumne Fire. Colorado Firecamp has assembled the most complete and accessible internet collection of investigation reports related to the entrapment fatality on the 2003 Cedar Fire. Please see:

During 2005, Colorado Firecamp adapted a case study of the Point Fire tragedy and mailed the instructor guide, student handout and video to 294 fire departments in Colorado. In addition, the print documents with video ordering information received national distribution by posting on the Wildland Fire Lessons Learned Center website.

Colorado Firecamp will incorporate the requested disclosure in a case study of the Cramer Fire, to be made freely available to the wildfire community. Review of entrapment incidents is required for the Wildland Fire Safety Training Annual Refresher (WFSTAR). Colorado Firecamp has planned a training exercise, "Wildfire Safety Drill: Mobilizing Lessons Learned" scheduled for the weekend of April 28-30, 2006. This will be an annual 2-day exercise dedicated to improving firefighter safety at initial attack and transition fires. The Wildfire Safety Drill will serve as a showcase for the best practices of the annual fireline safety refresher class.

In support of our theme of "mobilizing lessons learned," the Drill will include evening presentations about fatality entrapments. We have a commitment from Fire Chief Jeff Meston for a presentation by the Novato Fire Protection District about the Cedar Fire tragedy. Our other keynote presentation will feature the Cramer Fire, to include portions of the requested disclosure.

In early 2006, we anticipate approval of a $147,000 grant request to the Department of Homeland Security to improve wildland firefighter safety. The centerpiece of our "Fire Origins" project will be the creation of a digital archive of 50 wildland entrapment fatality reports to be hosted by the Wildland Fire Lessons Learned Center in Tucson, Arizona. Additionally, we will revise the National Wildfire Coordinating Group (NWCG) PMS-490 curriculum, "Lessons Learned: Fatality Fire Case Studies." We will create a more in-depth case study of the Cramer Fire for inclusion in the PMS-490 revised curriculum. Portion of the requested audio recordings and transcripts would be included to stimulate discussion and understanding of the 5-step risk management process.

(4) The disclosure is likely to contribute "significantly" to public understanding of government operations or activities. Specifically, public understanding will increase with regard to the use and effectiveness of radio communications within the context of command and control of USFS fire suppression operations. These operations include: on the evening of July 20th when a type 3 IC had been assigned but failed to assume command of the Cramer Fire; on the morning of July 21st when available helicopter resources were not utilized by the type 4 IC; on the afternoon of July 21st when the forest aviation officer became concerned about command and control under a second type 3 IC; on the morning of July 22nd while construction of Helispot 2 was proceeding; on the afternoon of July 22nd as the various the other crews continued working the fire's east flank near Helispot 1, a lookout was inserted and extracted by helicopter, and the IC dealt with the need to reassign aerial resources to other fires; the critical half hour prior to the burnover of H-2; and the rescue/recovery efforts following as the first type 3 IC assumed command of the incident.

The disclosure also relates to a 1999 report prepared by the RAND Corporation's National Defense Research Institute, “Command Concepts: A Theory Derived from the Practice of Command and Control.”

In recent years, the fire service has learned from military operations and research, just as the military has studied the fire service. The Command Concepts theory “centers on the idea of a command concept, a commander's vision of a military operation that informs the making of command decisions during that operation. The theory suggests that the essential communications up and down the chain of command can (and should) be limited to disseminating, verifying, or modifying command concepts. The theory also suggests, as an extreme case, that an ideal command concept is one that is so prescient, sound, and fully conveyed to subordinates that it would allow the commander to leave the battlefield before the battle commences, with no adverse effect upon the out-come.” (Builder, et al.)

The events of the Cramer Fire, as illuminated by the requested disclosure, will shed light on government activities as they relate to the command concept: 1) about the enemy (wildfire) and his plans (expected fire behavior,) 2) about our (USFS) force dispositions and plans, and 3) about contingencies.

(5) No commercial interest exists for Colorado Firecamp with respect to the materials requested for disclosure. As a 501(c)(3) non-profit, Colorado Firecamp is clearly not seeking financial gain from this disclosure.

(6) Because the primary interest in disclosure is to improve firefighter safety and we have no commercial interest in the requested information, clearly, the public interest is of greater magnitude than any commercial interest.

If you deny any part of this request, please cite each specific reason that you think justifies your refusal to release the information.

Please notify me of appeal procedures available under the law. If you have any questions processing this request, you may contact me at the following telephone number: (719) 539-9329.


Kent Maxwell
Kent Maxwell, coordinator
Colorado Firecamp, Inc.
"keeping quality in qualification"

(719) 539-9329 (work)
(719) 539-2730 (fax)

9008 County Road 240
Salida, CO 81201

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