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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.

 

United States
Department of
Agriculture
Forest
Service
Washington Office 14th & Independence SW
P.O. Box 96090
Washington, DC 20090-6090
                                         File Code: 6700
Date: May 4, 2004

Mr. Jerrold R. Hockett
Area Director
Occupational Safety and Health Administration
Suite 20101
1150 North Curtis Road
Boise, ID 83706

Dear Mr. Hockett

This letter serves as our Notification of Corrective Action taken as a result of Inspection Number 117886150. The abatement items for all of the citations that address the actions of the Type 3 Incident Commanders are included in the simulation and evaluation process designed and implemented to determine the incumbent’s ability and test his/her knowledge on each item. The specific evaluation factors are listed under the abatement action for each specific item.

Actions taken are as follows:

Citation 1 Item 1 ABATED

1.1.a.

Region 4 Abatement Action
All Type 3 Incident Commanders (ICT3) in the Intermountain Region have been required to go through a time-pressure simulation evaluation process designed and implemented to determine the incumbent’s ability to make time-critical decisions on fires of increasing complexity, and test his/her knowledge and application of policy and safe operating practices. All ICT3’s must successfully complete this evaluation, within two attempts, to perform ICT3 duties. (Encl 1 & 2)

Other Planned Action
All ICT3s throughout the country must complete this evaluation, within two attempts, before performing ICT3 duties.

1.1.b.

Region 4 Abatement Action
A comprehensive analysis of fire workload, risks, and organizational resource alternatives was conducted to evaluate the existing fire organization on the forest. As a result, the Forest has reorganized into a two-zone fire organization, which will best meet the current and future needs. This organization will increase efficiency and flexibility, especially during high fire emergency situations. The organization will increase the Forest’s ability to provide for adequate backup, and provide effective forest wide duty officer coverage.

An external review of the Dispatch Office organization and operational protocols was completed and has resulted in significant changes designed to improve quality, efficiency, and ultimately the safety of the Forest operation. To reduce the amount of stress and fatigue associated with working extended shifts, two additional Dispatch Office positions are in the process of being advertised and filled by the personnel office. These new positions will focus on coordination of aviation activities, intelligence gathering, coordination, and dissemination, thereby allowing dispatchers to focus on initial attack dispatching and coordination. The Forest is implementing preplanned dispatch, including pre-approved responses to better facilitate initial attack and extended attack response.

1.1.c.

Region 4 Abatement Action
The Salmon-Challis National Forest completed inspection, calibration, and maintenance of the Skull Gulch RAWS station utilized to support fire suppression activities. (Encl 3)

Citation 1 Item 2 ABATED

Region 4 Abatement Action
All Type 3 Incident Commanders (ICT3) in the Intermountain Region have been required to go through a time-pressure simulation evaluation process designed and implemented to determine the incumbent’s ability to make time-critical decisions, and test his/her knowledge and application of policy and safe operating practices. This evaluation included an assessment of the procedures for ensuring compliance with Lookouts, Communication, Escape Routes, Safety Zones (LCES), the Ten Standard Firefighting Orders and the Eighteen Situations That Shout Watch Out. All ICT3’s must successfully complete this evaluation within two attempts to perform ICT3 duties. (Encl 1 & 2)

Other Planned Action
All ICT3s throughout the country must successfully complete this evaluation within two attempts before performing ICT3 duties.

Citation 1 Item 3 ABATED

Region 4 Abatement Action
The Regional Forester has directed that Intermountain Region District Rangers who conduct supplemental safety and health inspections on Type 3, 4, and 5 wildland fires will have sufficient Incident Command System training to conduct these inspections or will be accompanied by someone with these qualifications. (Encl 4)

Other Planned Action
The Forest Service will, through national policy or interim directive specify the minimum Incident Command System qualifications for Forest Supervisors and District Rangers to perform supplemental safety inspection or that must be present in person(s) with them during the inspection.

Citation 2 Item 1 ABATED

Region 4 Abatement Action
All Type 3 Incident Commanders (ICT3) in the Intermountain Region have been required to go through a time-pressure simulation evaluation process designed and implemented to determine the incumbent’s ability to make time-critical decisions, and test his/her knowledge and application of policy and safe operating practices. This included training on recognition and mitigation of hazards represented in the Ten Standard Firefighting Orders and the 18 Situations That Shout Watch Out. All ICT3’s must successfully complete this evaluation within two attempts to perform ICT3 duties. (Encl 1 & 2)

All supervisory personnel associated with the Cramer Fire fatality have received letters withholding their “Red Card” certification until completion of ongoing administrative reviews.

Other Planned Action
All ICT3s throughout the country must complete this evaluation before performing ICT3 duties.

Citation 3 Item 1 ABATED

Region 4 Abatement Action
Direction requiring inclusion of additional safety performance standards for Forest Supervisors and District Rangers (part of the Thirtymile fire fatality abatement plan) was promulgated in a letter of Direction, July 3, 2003, signed by the Chief. (Encl 5) The Regional Forester, Intermountain Region, has ensured that all Forests within the Region comply with this direction. (Encl 4)

Other Planned Action
A new letter to senior Forest Service leaders restating this requirement and requiring written assurance of compliance will be sent.

We will keep you informed of our progress completing the Other Planned Actions.
If you have any questions, or require further documentation, please contact Mr. Dick King, Director, Safety and Occupational Health at (202) 401-4470.

Sincerely,

/s/ Christopher L. Pyron for

DALE N. BOSWORTH
Chief


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