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

NOVATO
FIRE PROTECTION DISTRICT
Investigation Analysis
of the
Cedar Fire Incident

Engine 6162 Crew Entrapment,
Fatality, and Burn Injuries
October 29, 2003

Acknowledgements

The Board of Directors and members of the Novato Fire Protection District gratefully acknowledge the support received from all California Fire Agencies, the California Department of Forestry and Phoenix Fire Department, and Phoenix Fire Chief Alan Brunacini, during and after the Cedar Fire tragedy.

For coverage of Novato Fire Stations, we thank all of the Marin County Fire Agencies.

For assistance with the Memorial Service for Engineer Steven Rucker, we thank all of the Office of the Governor of California, Governor Elect Arnold Schwarzenegger in County Board of Supervisors, the Marin County Fire Department, Vallejo Fire Department, Marin County Sheriffs Office, Novato Police Department, California Highway Patrol, Marin County Department of Public Works, Marin County USAR Team, Marin County Administrators Office, Marin Center, California Office of Emergency Services, Skywalker Ranch, Golden Gate Transit, International Association of Firefighters, Keaton’s Mortuary, Marin County Firefighters Local 1775, KPIX Television, and Valley Memorial Park.

For the immeasurable support, sympathy, and concern received from the community of Novato and around the world for all of us in the Novato Fire Family, we thank you.