NIOSH Cedar Fire Report
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Novato FPD Investigation Analysis
Draft Standard Operating Procedures
Inaja Fire Tragedy
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NOVATO
FIRE PROTECTION DISTRICT
Investigation Analysis
of the
Cedar Fire Incident
Engine 6162 Crew Entrapment,
Fatality, and Burn Injuries
October 29, 2003
Cedar Fire Lessons Learned
Apparatus
Pre-Incident
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The Novato Fire District cross staffs two Type III engines, with
three to four personnel, using crews assigned to engine and truck
companies. Engine 6162 operating at 920 Orchard Lane was one of these
two engines.
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The District Type III engines meet NFPA 1901 and 1906 Standards and
exceed the FIRESCOPE ICS Primary Mobile Suppression Resources Minimum
Standards in pump size, tank size, hose compliment and equipment carried.
These engines have been designed to equal capabilities in both the
urban interface and pure wildland environment. In regard to features
they are very similar to the CDF Model 14.
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In addition to the FIRESCOPE requirements, all Novato Fire District
Type III engines are four wheel drive, equipped with 500 gpm pumps,
high band mobile and portable radios, SCBAs with spare cylinders,
stored in external compartments, drip torches, fusees, chain saws,
16’ ladder, BLS medical equipment, Class A Foam and 500 gallon
water tanks. The engines are 8.5’ wide, mirror to mirror, 9
feet 4 inches in height, 9 feet 8 inches in width, 24 feet in length
with a 160 inch wheelbase. A 50’ single jacket engine protection
line with nozzle is stored in the engineer’s compartment.
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The District uses a VHF low band radio system for day to day operations,
however, all engines are equipped with a VHF high band mobile and
portable radios for mutual aid purposes. External speakers exist for
the low band system however; the high band system is not audible through
these external speakers. When available, crews responding to “Out
of County” incidents are provided additional high band portable
radios.
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Emergency warning, electronic strobe lights exist on all four corners
of the engines.
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All District engines have diamond plate hose bed and live line covers.
The ends of all hose beds are secured with vinyl flaps and held in
place by nylon straps.
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All units are custom design built with 4 door enclosed cabs on commercial
chassis. Numbers indicating the engine unit inventory number have
been placed on the roof of all Type III engines. Unit inventory numbers
differ from the engines radio designator.
- Example: The unit inventory number for Engine 6162 is
Unit 18. U-18 is displayed on the roof of the engine, not Engine
6162.
-
As units are reassigned, the District currently changes their radio
designator number to correspond to the station that they respond from
for Computer Aided Dispatch purposes (CAD). Example: If Engine 6161
is taken out of service, the reserve unit that replaces it would assume
the radio designator Engine 6161.
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The internal configuration of the cab is standard for a 4 door commercial
chassis engine, high back bucket seats in the front, divided by a
console and a CAD Mobile Data Terminal on a pedestal. The rear of
the cab is configured with standard bench seats.
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Additional fire shelters are carried in the cab to facilitate the
ability of the crew to shelter in the engine. Hooks are provided to
provide easy access to member’s wildland FSS web belt with shoulder
harness.
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Sufficient storage space is provided so that combustible material,
such as PPE storage bags and personal gear bags are not exposed.
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The District Type I engines are equipped with spark arrestor screens
on all engine air intake ducting to prevent embers from igniting the
air filters, however the Type III engines are only equipped with non-combustible
air cleaners. Spark arrestor screens are not provided on Type III
engines because they obtain their air from under the enclosed hood.
Incident
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At the time the crew of Engine 6162 was operating at 920 Orchard
Lane there were two 1.5” wildland single jacket hose lines,
each 100’ in length, deployed from a gated wye attached to a
rear discharge of the engine. Additionally a there was one 1.5”
Nitrile single jacket hose line, 30’ in length, deployed from
the front bumper discharge.
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The engine’s pump was engaged and operating. The engine was
backed into the driveway and parked facing out.
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All windows were rolled up, spotlights were on and turned upward
and the headlights and marker lights were on. Emergency lights were
not on at the time of the incident.
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When it appeared that the situation was beginning to deteriorate
Engineer Kreps increased the rpm on the engine from the pump panel.
The pump was left engaged and the two 1.5” lines were left charged.
Up to this point minimal water had been utilized.
-
During the burn over Captain McDonald, Engineer Kreps and Firefighter/Paramedic
Smith all reported embers blowing erratically under the engine as
well as intense heat from the downhill side of the engine and extreme
heat from the rear of the engine. The tires on the engine were utilized
as a heat shield prior to seeking safety in the house.
-
As a result of the burn over the charged rear hose lines were destroyed.
The remaining water in the tank was emptied through the burned hose
lines because the pump remained in gear. The front bumper line was
not damaged due to the burn over. The engine did not stall nor did
it sustain damage that prevented it from being driven to safety.
-
The engine sustained only a few small paint blisters on the driver’s
side near the back of the engine near the top of the cabinets. The
vinyl hose bed flaps were burned off on the driver’s side and
rear of the engine. The strobe light lenses were melted on the rear,
driver’s side and passenger side (excluding the cab). The lenses
on the front of the engine showed minimal deforming and remained intact
along with those on the cab on the passenger side of the engine. The
light bar showed signs of deformation but remained intact.
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There was no other damage to Engine 6162 and it passed its annual
pump test following its return to the District.
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Several minor air leaks were found in the plastic air lines, however
it is unknown if they are related to the burn over.
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The home at 920 Orchard Lane used a well system for its water supply.
At the time of the incident the power was out to the area and there
was no water available at the house, therefore there was no effort
made to re-supply the engine water supply with a garden hose.
-
The homeowner’s ladder was used to ladder the roof of the house
in the area of the front door.
Post Incident Considerations
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Due to the combustible nature of plastic/rubber air lines, wiring
and other critical undercarriage components, these components should
be protected from thermal damage during vehicle design. Further consideration
should be given to after market modifications for those units currently
in service.
-
Care should be given to keeping the undercarriage clean of grease,
oil and other combustible products.
-
Specific attention should be given to installing high temperature
fuel lines, protecting wiring from the battery to the engine computer
system and protecting air lines so that the brakes would operate properly
in a burn over or other similar event.
-
The actions taken by Engineer Kreps to throttle up the engine most
likely prevented it from stalling during the burn over. Training should
include the awareness that abandoned hose lines may burn through and
cause the depletion of water supply if discharge valves are left open
when the pump is engaged. In this case the pump was left engaged and
valves open because the hose lines were needed. When the conditions
changed quickly there was no time, nor was it safe to disengage the
pump or close the valves.
-
The diamond plate hose bed covers performed appropriately to provide
a barrier between the combustible hose bed and the burn over environment.
No undeployed hose was damaged in the burn over. However, the vinyl
flaps and nylon straps securing the hose beds were destroyed. Hose
beds and securing systems, should be fully protected using non-combustible
material.
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There have been several internal debates as to which number should
be on the roof of the engines as well as if numbers should be used
at all. There was no issue with roof numbering during the burn over
of Engine 6162. Concern exists however, that if contact from the air
utilizing the U-18 designator was attempted, the crew or the Task
Force Leader may not have realized that it was their unit because
unit inventory numbers and radio designators are different. A method
to clearly identify the District apparatus from the air needs to be
developed.
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The crew of Engine 6162 was able to enter the engine from both sides
following the burn over. However, if the entire crew had been forced
to enter the cab from the passenger side or rear, the center console
and MDT may have prevented the engineer from quickly accessing the
driver’s seat, slowing the escape of the crew.
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The enclosed cab environment maintained the interior cab integrity
of Engine 6162 and aided in the survivability of the crew during their
escape. While smoke within the cab was not a factor and SCBA cylinders
were not placed in the cab, consideration should be given to using
SCBA cylinders to pressurize the interior of the cab. However, in
this situation the cab remained clear.
-
In 1996 the Missoula Technology and Development Center studies in
Los
Angeles County determined that the materials inherent
in fire engine cab construction caused smoke from gases released from
the plastic and vinyl interior components to fill the cab in burn
over situations. Additionally it was determined that the engine cab
could only be a survivable environment during short duration, low-to
moderate-intensity fires. Until recently very little effort has been
made to protect the crew inside of the cab of the engine in a burn
over situation.
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There are other methods of protecting the crew currently available
and some of which have come from studies of engine burnovers in
Australia.
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Australia has been using an external mounted sprinkler system
for some years that has proven to be effective when there is a
sufficient on board water supply. Other methods include permanently
mounted fire curtains, similar technology to fire shelters, inside
the cab of the engine that can be quickly deployed to protect
the crew. In addition one engine manufacturing company is building
a wildland or wildland interface engine with a track-mounted fire
curtain window protection system that includes double-panel thermal
windshield glass and high temperature-tempered side windows. The
Track system allows for rapid deployment to minimize setup time
during emergencies. There are also high-temperature door gasket
materials, a fully insulated cab interior and an all aluminum
cab for maximum heat dissipation.
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Engine 6162 experienced difficulty leaving 920 Orchard Lane due to
the narrow winding driveway which was obscured by smoke. Research
indicates some automobile companies offer nighttime vision aids by
projecting near-infrared beams from two lamps in the front bumper.
The near-infrared light reflects from objects ahead back to a Charged
Coupled Device (CCD) camera mounted inside the vehicle at the top
of the windshield.
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A dedicated computer processes the resulting natural-looking
images, which are then projected onto the lower section of the
windshield within the driver's field of vision. This results in
a picture similar to that on a black and white television. This
system delivers clear illuminated images of what is ahead out
to a distance of nearly 500 feet. In the event that is necessary
to operate the vehicle in a zero visibility situation this system
may allow for the safe and quick escape of the crew. Current versions
of this system have a field of vision of 1500 feet and cost approximately
$10,000.00.
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Engines carrying Thermal Image Cameras may find them useful in
situations when visibility is obscured by smoke.
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A standard should be developed or refined, such as NFPA 1901 and
1906, for the design and construction of wildland and wildland interface
engines with a focus on crew safety and survivability, since the technology
appears to currently exist to meet these standards.
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