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

TABLE OF CONTENTS

Prologue

CDF Green Sheet

Overview

Summary
Report Procedures
The Novato Fire District
The Cedar Fire
NFD Resource Commitments to Southern California
Engine 6162 - Dispatch and Travel to the Incident
Engine 6162 – October 28, 2003 Assignments
Engine 6162 – October 29, 2003 Assignments
Engine 6162 – Burnover
Engine 6162 – Post Burnover Actions

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
Refusal of Risk
Wildland Firing Operations

Inaja Fire Tragedy

Acknowledgements