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

Cedar Fire Lessons Learned
Communications Equipment

Pre Incident

• During the day to day operations, the Novato Fire Protection District equips each Type III engine with the following radios:

  • VHF High Band Mobile: One Kenwood TK-790 multi-channel, scanning radio, with external radio speaker. The radio is programmed with Marin and Sonoma County local government, CDF and NIFC frequency banks.

  • VHF Low Band Mobile: One Motorola MaraTrac multi-channel, scanning radio with external radio speaker. The radio is programmed with Marin County local government frequencies.

  • VHF High Band Portable: One Bendix King EPH/EPI Series multichannel, scanning radio with onboard charger and backup “clam shell” with AA batteries. The radio is programmed with all Marin and Sonoma County local government, CDF, USFS and NIFC frequency banks. 2 of the 15 available frequency banks are left blank for incident cloning.

  • VHF Low Band Portable: One Motorola MT-1000 multi-channel, scanning radio with onboard charger. The radio is programmed with Marin County local government frequencies.



• Day-to-day Fire District operations are dispatched and conducted on low band frequencies.

• The Novato Fire Protection District also maintains a cache of high band and low
  band portable radios for use during greater alarm incidents and mutual aid responses.

• At the time of the Cedar Incident the availability of spare high band portable radios from the radio cache had been diminished due to the fact that 2 other Novato Fire Protection District engines were committed the mutual aid assignments in Southern California.

• When Engine 6162 responded to the Cedar Incident, the crew was equipped with two Bendix King high band portable radios.

• Individual crew members responded with their personal cellular telephones. No Fire District cellular phone was installed in Engine 6162 . The one extra Fire District cellular phone assigned to operations had been used by the crew responding on OES E235 two days prior to Engine 6162 responding to the Cedar Fire.

Incident

• The Task Force Leader of XAL2005A directed the engines to utilize White 2, a State of California high band channel, as their inter-crew travel channel to San Diego.

• When the Task Force arrived at the Cedar Incident Base on October 28, 2003, the crew had their Bendix King portable radios cloned with the incident frequency load by the Communications Unit. The incident frequency load was cloned onto one of the two blank frequency banks.

• The crew of Engine 6162 received a briefing on the Communications Plan from the Communications Unit while the high band Bendix King radios were cloned with the incident frequencies on the afternoon of October 28.

• On October 28, the crew of Engine 6162 loaned one of their Bendix King radios to the Task Force Leader. The radio was loaned because the Task Force Leader did not have a high band portable. This left the crew of four on Engine 6162 with one High Band Bendix King radio.

• No other high band portable radios were available from the Communications Unit at the time.

• At the time of the burnover Engine 6162 was communicating on the appropriate Tactical and Command Channels.

• During critical periods of their operations, communications between crew members of Engine 6162 were effectively conducted by means of face-to-face. Radio communications were not a factor at this time.

• Captain McDonald’s Bendix King portable radio was dropped on the patio adjacent to the house and burned. It is apparent that the radio was dropped by Captain McDonald while attempting to rescue Engineer Rucker after making a “firefighter down” announcement.

• Mobile communications equipment on Engine 6162 remained undamaged and intact during the burn over. Captain McDonald made a mayday call on the Command Channel using the high band Kenwood mobile radio during their escape from 920 Orchard Lane.

• Once Engine 6162 made it to a safe area, subsequent radio communications were effective in coordinating their medical evacuation and apprising the Incident Command Team Command Staff of what had occurred.

Post Incident Considerations

• An external high band speaker would have enhanced the communication ability of
  Engine 6162 in the absence of high band portable radios for each crew member.

• Supplying all engine crew members with portable radios capable of transmitting and receiving on the tactical and command frequencies assigned to the incident would enhance firefighter safety and provide redundancy due to failure or loss. After giving their second portable radio to the TFL the crew of Engine 6162 had one portable remaining. This radio was with Captain McDonald and was destroyed in the burnover. If they had not been able to make it back to the engine or if the engine had been damaged, they would not have had the ability to request the assistance necessary for survival.

• Any change in the Communication Plan impacting tactical resources must be communicated to all of those resources and a confirmation received from them acknowledging the change. TF XAL2005A was aware of a change in the plan since they had their radios updated the morning of October 29.

• The ability to manually program the portable and mobile radios may be valuable when cloning services are not available.

• Having both onboard chargers and “clam shell” backup battery power with extra batteries is essential to reliable radio operations.

• The Communication Unit should be used to obtain or replace radios. Loaning radios between members of a Strike Team or Task Force should be considered as a last resort. All resources should respond to incidents with the appropriate radio equipment.

• Ideally the Communications Unit should have sufficient portable radio supplies to meet the anticipated needs on the incident. In times of extreme drawdown this will not always be possible. Responding resources should not rely on solely on the ability of the Communications Unit to provide communications equipment.

• The utilization of separate radio frequencies, other than the assigned incident tactical frequencies, for intra-crew communications, can lead to situations where resources may be unable to transmit or receive critical incident information. Strict adherence to the incident assigned frequencies should be maintained by all resources.

• Consideration should be given to installing cellular phones in all suppression apparatus.

• If assigned tactical frequencies are overloaded with radio traffic, this situation should be communicated through the chain of command for the command staff to resolve.

• Despite the life threatening conditions encountered by Engine 6162, the May-Day transmissions made by Captain McDonald were clear and concisely relayed the severity of the situation.

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