NIOSH Cedar Fire Report

Summary

Introduction

Investigation & Medical Findings

Recommendations / Discussions

References

Glossary of Terms

Maps and Photographs

CDF Cedar Fire Report

Table of Contents

Review Team Process

Overview of Accident

Summary of Events

Sequence of Events

Findings

Causal Factors

Contributory Factors

Circumstances

Site Conditions

Graphics – List of Illustrations Table

Description of Supporting Data and Supplementary Information

Novato FPD Investigation Analysis

Table of Contents

Prologue

CDF Green Sheet

Overview

Lessons Learned

• ALS Equipment
• Apparatus
• Communications
• Equipment
• Fire Behavior
• Personal Protective Equipment
• Training and Experience
• Policy and Tactics
• Human Factors

Draft Standard Operating Procedures

• Wildland Structure Protection SOP
• Refusal of Risk SOP
• Wildland Firing Operations SOP

Inaja Fire Tragedy

• Introduction
• Sequence of Events
• Conclusion

Acknowledgements

California Department of Forestry and Fire Protection
Review Report of Serious CDF Injuries, Illnesses, Accidents and Near-Miss Incidents

Engine Crew Entrapment, Fatality, and Burn Injuries
October 29, 2003
Cedar Fire
CACNF-003056
CACSR-000132
Southern Region

TABLE OF CONTENTS

Review Team Process..................................................3

Overview of Accident..................................................6

Summary of Events.....................................................7

Sequence of Events....................................................15

Findings.....................................................................57

Causal Factors...........................................................64

Contributory Factors.................................................65

Circumstances............................................................67

Site Conditions..........................................................70

Graphics – List of Illustrations Table.........................80

Description of Supporting Data and
Supplementary Information.......................................81

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