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
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
Adobe PDF and Microsoft Word versions of documents related to
the Cramer Fire can be downloaded from the U.S.
Forest Service website.
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U.S. Department
of Labor
Occupational Safety and Health Administration
Inspection Number: 117886150
Inspection Dates: 07/23/2003-08/07/2003
Issuance Date: 03/26/2004
Notice of Unsafe or Unhealthful Working Conditions
Company Name: U.S. Forest Service, Intermountain
Region 4
Inspection Site: Cramer Fire, T23N, R15E, Section 20,
North Fork, ID 83466
Citation
1 Item 1 Type of
Violation: Serious
29 CFR 1960.8(a): The agency did not furnish employees employment and
a place of employment free from recognized hazards that were causing or
likely to cause death or serious physical harm, in that employees were
exposed to the hazards of burns, smoke inhalation, and death from fire-related
causes:
- Cramer Fire: On or about July 21 and 22, 2003,
as the fire increased in size and complexity, shifted to extended attack,
and the suppression strategies and tactics were not successful, an appropriate
complexity analysis was not conducted and reviewed. The agency did not
ensure that hazardous fires increasing in complexity are quickly identified
and a safe transition occurs to the appropriate level incident response.
Among other methods, one feasible and acceptable abatement method to
correct this hazard includes ensuring that national fire policy is implemented
all the way down to the incident level and that district or forest level
fire managers use and review the complexity analysis to ensure that the
level of incident command is commensurate with the complexity of the fire.
- Cramer Fire: On or about July 21 and 22, 2003,
when fire behavior thresholds at which large fires typically occur were
exceeded, fire program managers did not provide additional supervisory
and suppression support.
Among other methods, one feasible and acceptable abatement method to
correct this hazard includes ensuring that fire behavior thresholds for
large fires are recognized by district and/or forest level fire managers
and additional supervision is provided and suppression support is requested
as needed.
- Salmon-Challis National Forest: The remote automated
weather stations (RAWS) near the fire had not received maintenance and
calibration before the start of the fire season. The temperature and
relative humidity sensor was reporting incorrect information from the
Skull Gulch RAWS, closest to the Cramer Fire.
Among other methods, one feasible and acceptable abatement method to
correct this hazard is to ensure that all RAWS are calibrated and maintained
prior to the start of the fire season. Periodically monitor throughout
the season to ensure the RAWS are functioning properly.
Note: Abatement certification and supporting documentation are required
for this item.
Date By Which Violation Must be Abated: 04/21/2004
Citation 1 Item 2 Type
of Violation: Serious
29 CFR 1960.25(c): All areas and operations of each workplace did not
receive sufficient unannounced safety and health inspections at least
annually, and more frequently where there is an increased risk of accident,
injury or illness due to the nature or the work performed:
- Cramer Fire: On or about July 21 and 22, 2003, inspections of the
fire operations were not conducted for safety and health hazards on
the fire to determine compliance with LCES (Lookouts, Communications,
Escape Routes, and Safety Zones), the Ten Standard Firefighting Orders,
and Eighteen Situations that Shout Watch Out.
Note: Abatement certification and supporting documentation are required
for this item.
Date By Which Violation Must be Abated: 04/21/2004
Citation 1 Item 3 Type
of Violation: Serious
29 CFR 1960.57: The Agency did not provide training to safety and health
inspectors with respect to identifying and evaluating hazards and suggesting
general abatement procedures:
- Training provided to District Rangers who conduct supplemental safety
and health inspection on the type 3, 4, and 5 wildland fires was not
sufficient to enable them to adequately identify, evaluate, and suggest
general abatement procedures related to complex wildland fire safety.
ABATEMENT NOTE: Among other methods, one feasible and acceptable abatement
method to correct this hazard is to ensure inspectors receive specialized
safety training commensurate with the level of incident complexity, such
as the qualifications necessary for a Safety Officer Type 1, 2, or 3.
Also, ensure that these inspectors are thoroughly evaluated to ensure
maximum competency.
Note: Abatement certification and supporting documentation are required
for this item.
Date By Which Violation Must be Abated: 04/21/2004
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