Colorado Firecamp - wildfire training wildland firefighter training Wildfire Blog Engine Boss Apprenticeship Location and Facility About Colorado Firecamp Frequently Asked Questions
Colorado Firecamp - wildland firefighter training

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.


News Release

U.S. Department of Labor
Office of Public Affairs
Seattle, Washington
For Immediate Release
April 1, 2004
Contact: Jeannine Lupton
Phone: (206) 553-7620

OSHA Finds Safety Violations at Wildfire Site In Idaho
Notices Issued to U.S. Forest Service

SEATTLE - The U.S. Labor Department's Occupational Safety and Health Administration (OSHA) has given its findings to the U.S. Department of Agriculture Forest Service following the investigation of last summer’s Cramer Fire near Salmon, Idaho. Two U.S. Forest Service (USFS) helitack crew personnel died at the site on July 22, 2003.

OSHA issued notices to the USFS for alleged serious, repeat and willful violations of safety standards. The willful notice listed violations of all 10 “standard fire orders” and 14 of 18 “watch out situations” listed in the Interagency Standards for Fire and Fire Aviation Operations.

The notice for serious violations included:

-- Failure to conduct fire complexity analysis;
-- Failure to provide additional supervisory and suppression support;
-- Failure to maintain and calibrate automated weather stations; and
-- Failure to conduct inspections of fire operations for safety and health hazards.

OSHA also noted that the USFS delegated inadequately trained employees to identify, evaluate and correct hazards related to complex wild land fire safety.

The notice of an alleged “repeat” violation was issued because OSHA found that the USFS did not include elements related to safety and health program performance in evaluations for fire supervisors, fire program management officials and line officers. OSHA previously had cited the USFS for this violation on Feb. 8, 2002.

OSHA found the violations during its fatality investigation at the Cramer Fire site near Cache Bar on the north side of the Salmon River, approximately 50 miles northwest of Salmon, Idaho. The USFS may meet informally with OSHA to discuss the violation notices, including methods of correction and length of abatement periods.

The Occupational Safety and Health Act defines a willful violation as one committed with an intentional disregard of, or plain indifference to, the requirements of the OSH Act and regulations. A serious violation is one in which there is substantial probability that death or serious physical harm could result and the employer knew, or should have known, of the hazard. A repeat violation is an additional occurrence of a violation for which the employer previously had been cited.

OSHA is dedicated to saving lives, preventing injuries and illnesses, and protecting the health and safety of America’s workers. In fiscal year (FY) 2002, the most recent year for which data have been published, there was a 6.6 percent decline in work related fatalities in the U.S. In FY 2003, OSHA conducted almost 40,000 inspections, and more than half focused on high-hazard industries. For more information visit


U.S. Labor Department releases are accessible on the Internet at The information in this news release will be made available in alternate format upon request (large print, Braille, audio tape or disc) from the COAST office. Please specify which news release when placing your request at (202) 693-7765 or TTY (202) 693-7755.

<<< continue reading—OSHA, Citation 1>>>

©2004-2006 Colorado Firecamp, Inc. home scheduleblogENGBfacilityabout usFAQ's