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Cramer Fire
Dedication


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

Addendum


Factual Report

Executive Summary

Narrative
   Background
   (facts 1 - 57)
   Preaccident
   (facts 58 - 201)
   Accident
   (fact 202)
   Postaccident
   (facts 203 - 237)

Findings

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

OSHA FOIA Letter


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.

 

U.S. Department of Labor
Occupational Safety and Health Administration

Inspection Number: 117886150
Inspection Dates: 07/23/2003-08/07/2003
Issuance Date: 03/26/2004

Notice of Unsafe or Unhealthful Working Conditions

Company Name: U.S. Forest Service, Intermountain Region 4
Inspection Site: Cramer Fire, T23N, R15E, Section 20, North Fork, ID 83466


Citation 1 Item 1         Type of Violation: Serious

29 CFR 1960.8(a): The agency did not furnish employees employment and a place of employment free from recognized hazards that were causing or likely to cause death or serious physical harm, in that employees were exposed to the hazards of burns, smoke inhalation, and death from fire-related causes:

  1. Cramer Fire: On or about July 21 and 22, 2003, as the fire increased in size and complexity, shifted to extended attack, and the suppression strategies and tactics were not successful, an appropriate complexity analysis was not conducted and reviewed. The agency did not ensure that hazardous fires increasing in complexity are quickly identified and a safe transition occurs to the appropriate level incident response.

Among other methods, one feasible and acceptable abatement method to correct this hazard includes ensuring that national fire policy is implemented all the way down to the incident level and that district or forest level fire managers use and review the complexity analysis to ensure that the level of incident command is commensurate with the complexity of the fire.

  1. Cramer Fire: On or about July 21 and 22, 2003, when fire behavior thresholds at which large fires typically occur were exceeded, fire program managers did not provide additional supervisory and suppression support.

Among other methods, one feasible and acceptable abatement method to correct this hazard includes ensuring that fire behavior thresholds for large fires are recognized by district and/or forest level fire managers and additional supervision is provided and suppression support is requested as needed.

  1. Salmon-Challis National Forest: The remote automated weather stations (RAWS) near the fire had not received maintenance and calibration before the start of the fire season. The temperature and relative humidity sensor was reporting incorrect information from the Skull Gulch RAWS, closest to the Cramer Fire.

Among other methods, one feasible and acceptable abatement method to correct this hazard is to ensure that all RAWS are calibrated and maintained prior to the start of the fire season. Periodically monitor throughout the season to ensure the RAWS are functioning properly.

Note: Abatement certification and supporting documentation are required for this item.

Date By Which Violation Must be Abated: 04/21/2004

Citation 1 Item 2         Type of Violation: Serious

29 CFR 1960.25(c): All areas and operations of each workplace did not receive sufficient unannounced safety and health inspections at least annually, and more frequently where there is an increased risk of accident, injury or illness due to the nature or the work performed:

  1. Cramer Fire: On or about July 21 and 22, 2003, inspections of the fire operations were not conducted for safety and health hazards on the fire to determine compliance with LCES (Lookouts, Communications, Escape Routes, and Safety Zones), the Ten Standard Firefighting Orders, and Eighteen Situations that Shout Watch Out.

Note: Abatement certification and supporting documentation are required for this item.
Date By Which Violation Must be Abated: 04/21/2004

Citation 1 Item 3         Type of Violation: Serious

29 CFR 1960.57: The Agency did not provide training to safety and health inspectors with respect to identifying and evaluating hazards and suggesting general abatement procedures:

  1. Training provided to District Rangers who conduct supplemental safety and health inspection on the type 3, 4, and 5 wildland fires was not sufficient to enable them to adequately identify, evaluate, and suggest general abatement procedures related to complex wildland fire safety.

ABATEMENT NOTE: Among other methods, one feasible and acceptable abatement method to correct this hazard is to ensure inspectors receive specialized safety training commensurate with the level of incident complexity, such as the qualifications necessary for a Safety Officer Type 1, 2, or 3. Also, ensure that these inspectors are thoroughly evaluated to ensure maximum competency.

Note: Abatement certification and supporting documentation are required for this item.

Date By Which Violation Must be Abated: 04/21/2004

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