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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.


Note: This document was released as part of the Cramer Fire inspection file as a copy of a fax sent from the OSHA Denver Office on July 12, 2001 - presumably to assist the Thirtymile Fire investigation.

Guidelines for a Team Investigation of a Catastrophic Incident

In July, 1994, fourteen firefighters died in the South Canyon fire near Glenwood Springs, CO. The Denver Area Office was charged with the investigation of the incident —an investigation that would result in a Notice of Unsafe or Unhealthful Working Conditions to the U.S. Department of Agriculture/Forest Service and the U.S. Department of Interior/Bureau of Land Management. Each agency received two items in the citation, one Willful and one Serious.

A "Fire team" was formed comprised of the Area Director, Assistant Area Director, One Safety Specialist and one Industrial Hygienist. In addition the team was augmented by the Deputy Regional Administrator and other regional staff including representatives from Federal State Operations, TEC/FAP, and Technical Support.

This report is designed to assist Region VIII teams in the investigation of any future occurrences or catastrophes.

The Fire Team provided input which has been divided into four categories — Communications, Equipment/Workspace, Team Builders, and Team Support — and then subdivided into What We Did Right and What We Can Do Better.

The Fire Team believes that through their investigation they have established a successful protocol for future investigations of catastrophic events.



Good communications are necessary within the group, especially between Management and Compliance Officers. It works best to have a local management contact and also one at the National level.

Requested and received information from the local District Office of the investigated agency/employer.

Everyone on the team (Area Office and Regional Office staff) got a copy of everything.

Be sensitive to the possible resentment from others within the office who feel the “team” is being treated differently. If internal dissatisfaction is noted, curtail it immediately to avoid detrimental side effects within the organization.

Communicate with the families of the deceased. All Area Office staff were aware that calls from those family members were to be answered by a team member or staff member familiar with the case. The family member should always reach someone to talk to.

Several letters were sent from OSHA to the families of the deceased with an 800 # and information on the investigation. This was done early in the investigation as a proactive initiative.

The media was always handled by management.

A list of questions and answers were developed for the media.

The media was controlled from one location — the Area Office.

The Area Office worked as one when the press releases were issued. Packets of information were prepared in advance for the anticipated onslaught of requests from the public. This foresight proved to be good planning.

From the beginning and throughout the investigation, OSHA’s credibility was reinforced with the investigated agencies with an up-front approach. Nothing was released to the media without the knowledge of the investigated agency.

OSHA admitted up-front that they were not experts.

OSHA management and investigators reached agreement on the questions for interviews with others.


Be sensitive to each other’s needs. Assuming there is not immediacy to a request could be detrimental to the investigation efforts. Upper management needs to be notified if a request has not been promptly fulfilled.

Recognize the importance and significance of the incident early in the process. If need be, push the issue of importance.

Get commitment from management for personnel resources to conduct the project. Keep talking among team members and with the agency to avoid wrong impressions or expectations.

Topography maps as audiovisuals detracted from the verbal presentation at the National Office.



Be prepared with laptops, modems, printers, cellular telephones, etc. The types of equipment needed will depend on the circumstances and location of the incident.

Computerizing the citations and reports helped in making last minute changes.

A separate office space was set aside for the sole use of the investigating team.


Assure that sufficient types and quantities of equipment are available. For this investigation, additional cellular telephones, one for each team member, would have provided an easier and time-saving avenue of communications from remote locations.



A lot of emphasis was put on the composition of the team. It is recommended that all candidates considered be asked for their input.

Team members were selected based on availability, background, expertise, and how well they complemented each other. Diversity can make a significant contribution to the team.

Adjustments were made as necessary in the number of team members and in the assistance they needed to do the work. The teams perceptions of needed personnel and or staff assistance are probably correct and their suggestions should be trusted.

it is important that the team members have trust and confidence in each other and that the roles of all team members are recognized.

The team was Unified, both management and investigators.

The team members agreed that one couldn’t make promises and not deliver.

The team assumed ownership of the case. Managing the process was left to the investigators and presented to management for their approval. CSHO’s were given the authority and flexibility with limited control and/or monitoring.

The group held many meetings and concentrated on long-term outlook.

The decision-making process was flexible based on CSHO input and their strong belief. No decisions were made in a vacuum, i.e., enough information was available so that the right decisions could be determined by management. Once a local decision was made, it was transmitted to the National Office.

The team recognized the magnitude of the case and dealt with a plethora of people — government agencies, local authorities, national office staff, and congressional leaders — and emotions — grief, anger, and power.

The case was well-prepared and presented by investigators, not management.

Practice sessions of the presentation, complete with audiovisual aids, were conducted. The presenters were flexible in changing their tactics during practice. The team planned for the defense of their position in preparation to counter possible rebuttals from the National Office.

The was a common goal for both the Area Office and the Regional Office and the specific roles were all in tune with the projected outcome.

The closing conference was totally controlled and handled by the team.

The team followed through after the citation/abatement assistance to assure continuity of OSHA’s intent.


The team needs to be comfortable with each other’s basic philosophy and level of commitment. In this investigation the Area Director assumed a larger role on the team, substituting himself for another member. All team members must totally believe in their work and remain committed to it.

Use a timeline and establish a review process of the proposed violations/citations. Determine who will review and how many reviewers are necessary.



The team discovered that “Fear of Failing” is a factor, but with management’s support and total commitment the team was able to discourage the “what if” scenarios. This commitment and support motivated the team members.

Additional funding was anticipated and made available by the Agency for the team to make countless trips to the worksite as well as travel to visit the families of the deceased and to the National Office.
Management empowered the team with as much time as they needed to focus on the incident and to process a well-prepared Willful and Serious case. The process from start to finish is estimated at a staggering 1,000 hours per CSHO and travel costs totally over $11,000.

The Regional Office provided guidance rather than directing or mandating orders to the team

The Regional Office ran interference with any opposition and acted as the conduit to the National Office. Feedback from the field was available on a daily basis.

The Regional Administrator played a major role in communicating with the National Office and assuring that the investigation continued.

In this investigation of Federal Agencies, the lack of Solicitor involvement worked our advantage.

OSHA hired an expert about ¾ of the way though the investigation. It worked on this case, but it may or may not work depending on the incident. Know what you want the expert to do. Be prepared to clearly identify the amount of work you want the expert to perform; it will cost less.

Just as the Area Director needed to assert himself as a team member, it was also necessary for the Deputy Regional Administrator to provide his services from the regional Office for the team. He was successful in using his influence to attain information and establish important contacts.


The team initially did not receive information or full cooperation from other agencies or National Office personnel. This was an organizational issue as well as a political issue. The team fells that having a contact person with clout will make the difference. In this investigation the “clout” was the Regional Office, specifically, the Regional Administrator and Deputy Regional Administrator.


1. The team should decide early in the process if the final product is expected to be a citation, a report, or a combination of the two.

2. Sometime during the investigation, the team should decide if it will be a coordinated final product.

3. The team should discuss the need for legal support.

4. For reference purposes and as a statistical measure, track the time spent by each team member as well as the travel funds expended.


1. The success of OSHA’s investigation and the results of significant findings from the South Canyon Fire can be attributed to a remarkable team of individuals—

2. Good communications are essential throughout the process with everyone— team members, office staff (Area, Regional, and National), other agency/company representatives, family members of deceased, public, and media.

3. The Agency’s support in committing personnel, allocating equipment and funds, and allowing the time to do the job well, contributed to the team’s success.

4. A successful team is the result of:

a. good planning
b. a strong belief in the purpose and goal, and
c. the versatility to make adjustments when necessary.

5. A workable team should consist of a diverse group of individuals. Each member of the team should have the opportunity to make a significant contribution.


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