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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.


"Newsletter of the Forest Service Fire Operations Safety Council"

Cramer Fire - Lessons Learned
and Agency Actions

The lessons learned from the Cramer Fire tragedy are not new. And there are NO silver bullets available to ensure that another Cramer, Thirtymile, or South Canyon tragedy will ever happen again. No matter the policy, quality of management or the amount of oversight – when it comes to Fireline Survival – the ONLY PROVEN positive actions are those that mitigate the 18 Watch Out Situations and adhere to the 10 Standard Firefighting Orders.

In their Management Evaluation Report the Cramer Fire Investigation Team determined that the causes of the tragedy were primarily focused in two critical areas: failures in leadership, and overall failure by leaders and firefighters alike to respond to a rapidly deteriorating situation (lack of situational awareness).

Subsequently, the Cramer Fire Accident Review Board (ARB) issued the Cramer Accident Prevention Plan (APP). The Cramer APP identified five “…key actions that would… best prevent similar mishaps in the future.” These actions focused on leadership training, assuring leader qualifications, and completing the remaining few action plan items from the Thirtymile Fire, which also focused on leadership failures and faulty situational awareness. In response to the Accident Review Boards, the Deputy Chief for State and Private Forestry committed the agency to implementing a “Leadership Development Strategy.” The strategy responds to each of the APP action items, and indicates a commitment to foster and nurture a dedicated leadership development program within the interagency community. THIS IS WHERE YOU NEED TO BE ENGAGED during training and as you gain career experience.

There will not be a long list of nationwide action items resulting from the Cramer Fire, however the agency is debating some policy changes in response to weaknesses exposed by the Cramer tragedy. Proposed changes:

  1. address the lack of ICS qualifications requirements for line officers who must perform supplemental safety inspections (this also responds to OSHA’s Notice of Unsafe or Unhealthful Working Conditions),

  2. Specify RAWs station maintenance and calibration requirements so no firefighter should ever have to go without a spot weather forecast or the best available fire weather information (this also responds to OSHA),

  3. Provide “Duty Officer” definitions and qualifications,

  4. Strengthening the responsibilities and involvement of the Fire Qualifications Review Committees to insure that individuals are certified appropriately, and

  5. Clarifying that Incident Commanders on Type 3, 4, and 5 fires may delegate support and operations duties to the most qualified on-scene or immediately available, local individual(s).

For information on fireline leadership training, especially for those with ICT3, 4, and 5 responsibilities check out:

To Learn more about LCES and how it works and why it is considered essential to situational awareness, check out Paul Gleason’s original LCES proposal: (June 1991) "LCES and Other Thoughts" - Here you will learn how LCES evolved, and see how Paul’s experience and thoughts came together to form the LCES concept.

Remember, firefighter safety is our highest priority, and the responsibility for success in meeting that priority begins with YOU!

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