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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 OSHA Cramer Fire inspection file, among about 50 pages of note-taking sheets used during the interview process. The author is unknown, but presumably these "lessons learned" were written by someone within the USFS and familiar with the Salmon-Challis National Forest and Cramer Fire.

Type 3 Incidents:

Given that the last four burnover fatalities I know of (Cramer, Kate's Basin, 30 Mile, and South Canyon) were on Type 3 incidents of one flavor or another, this seems like a good place to start, and based on what we found with Cramer, you no doubt know why.

  1. Top to bottom review of the Type 3 level of organization nationally. Training, personnel being placed into Type 3 IC positions, the sorts of incidents being run under a Type 3 organization, the works. Maybe even go as far as setting up a national working group to address this. Things to possibly include - mission and intent of the Type 3 level of organization nationally, training and experience required and adequacy, the increasing reliance on Type 3 "teams" to take on increasingly complex incidents, and the inconsistent use of "after-action reviews" (or close-outs, if you will).
  1. Come up with some sort of measure of Type 3 IC competency as a final part of the final certification process. In fire depts., we do "assessment centers" for Company Officer and Battalion Chief promotional processes; why not something like that for the Type 3 IC? OJT and Task Books were a good step in this direction, but they're still subject to "pencil-whipping" and other inconsistencies. Some sort of standardized assessment might help bring some problems to the surface.

    My thinking is that with Type 4 or 5, the incident is small enough that it's not a huge deal to identify problem people and deal with them immediately. And with Type 2 or 1, the IC is further removed from line operations, and a questionable IC will not normally be in a position where he could jeopardize people's safety on the line. In the case of a Type 3 IC, the incidents tend to be larger, more complex, and the IC juggling a lot, especially if few of the supporting positions are filled. It's the most complex organizational level where the IC is still directly supervising line operations.

  2. Review of the Task Book system. It's been ten years since implementation; is it working or is it not? Where are the weaknesses, what needs to be changed?
  1. Renewed emphasis on the fundamentals from 130/190 on up. Situational awareness, accountability (including for self), trigger points, mission-creep, etc.
  1. Timely and consistent fire weather and behavior information on all Type 3 incidents. This doesn't necessarily have to be a fully-qualified FBAN, just someone who can fill this role at some minimum level of competency.
  1. No more checklists!! There are too many as it is, and if four basic things — LCES — were not covered on the Cramer Fire, the problem is more fundamental.

Maintaining an Experienced Workforce

  1. Ensure adequate, if not prolific, training opportunities for people taking on supervisory roles on fires, regardless of seasonal/permanent status. If they're responsible for people's safety, they should get top priority! And fire personnel should get priority for fire training courses.
  1. End the "Golden Carrot" system. I know of too many people who held on for years as a seasonal (so far 18 years is the record), hoping for a permanent, full-time appointment, grasping at periodic "glimmers of hope." Many others moved on, especially the better ones. There needs to be some way to identify good people, foster their career development, and give them real, true opportunities. We need to provide encouragement and tangible opportunities to the "Heath Hands" of the world, and continue to build their experience and knowledge base and draw on their abilities.
  1. Find some way to ensure consistent, adequate funding for the agencies. Some sort of "buffer" against the wild swings in funding for fire programs from year to year. I can understand that in tough times, there's going to be some belt-tightening. However, Congress itself was the impetus for developing NFMAS, and to fund a heavy fire-load forest at 50% MEL is insane and irresponsible. Even if this was increased later, it's impossible to plan for a fire program that way, and it's not a good way to retain a consistent, reliable, and competent workforce. If the position was identified as needed, fill it! And if cuts are to be made, don't make all cuts on the backs of the seasonal workforce - the ones who actually fight the fires.

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