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
Suppression Equipment

Pre Incident

• 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 addition to the FIRESCOPE requirements, all Novato Fire District Type III engines carry the following equipment pertinent to this incident and not covered in other sections of this report.

• Hose Bed

  • Single bed, 600’ flat load with 3” double jacket, synthetic supply hose in 50’ lengths with 2.5” NS couplings. The supply line is terminated with a 2.5” x 2.5” clappered Siamese.

• Livelines

  • One wyed bumper discharge with one 1.5” Nitrile single jacket hose line, 30’ in length with a 20/60 gpm wildland fog nozzle and one 1.5” Nitrile single jacket hose line, 30’ in length with a 30/50 gpm stacked smooth bore wildland nozzle. Both nozzles are equipped with removable bales.

  • Two liveline crosslays, 1.5”, synthetic, double jacket, 150’ in length with combination 30-200 gpm fog nozzles. Both nozzles are equipped with removable bales.

  • One rear wildland liveline, 1.5” cotton single jacket, 150’ in length with a 20/60 gpm wildland fog nozzle and removable bale. A Siamese is inserted at end of the first 50’ length to facilitate another engine taking over the supply of the line.

• Wildland Hose Packs

  • 8 hose packs carrying two 100’ sections of 1.5” single jacket, cotton wildland hose each (for a total of 1600’). The packs are made of a nylon type material and are capable of deploying individual lengths of hose without pack removal. One length of hose in each pack is equipped with a 1.5” x 1” tee. Each pack weighs 46.5 pounds. Four of the packs are carried in the left rear compartment and four are carried in the front left of the supply hose bed.

• Mop Up Kits

  • 4 hose packs carrying two 100’ sections of 1” single jacket, cotton wildland hose each (for a total of 800’). The packs are made of a Cordura nylon material. Each pack carries a 1.5” x 1” tee, Forester style hose clamp, 10/24 gpm wildland fog nozzle without bale. *1” wildland hose is only used for mop
    up purposes.

• Engine Protection Line

  • One 50’ length of 1.5” double jacket cotton hose with a 20/60 gpm wildland fog nozzle carried in a side compartment.

• Web Gear

  • See PPE Section

• Firing Equipment

  • Two orchard style drip torches
  • One 2.5 gallon dip torch fuel can
  • One case of wildland fusees
  • 4 fusee removable pouches, made of Cordura nylon, capable of being attached to the FSS web gear and shoulder harness with 5 fusees each.



• Chainsaw

  • One 031 Stihl with XX” bar with wood cutting chain
  • One combination fuel/oil can
  • One falling kit including, chaps, hearing protection, wedges and saw repair kit



• Weather Kit

  • One Forest Service belt weather kit

• Maps

  • One state Thomas Bros. guide

• Out of County Kits

  • The District maintains several kits that are placed on engines at the time of dispatch intended to provide personal support and essential equipment. These kits contain personal hygiene items, sleeping, cooking and rations. The kits are carried in the FSS style “Red Bags”. Prior to departure a cooler is also added and filled with bottled water and sports drinks. Room is designated on each engine for this equipment. No other comfort or entertainment items are carried and no combustible items are allowed on the exterior of the engine.

• Medical , see ALS equipment section

• GPS

  • GPS units are carried on all Chief Officer vehicles but not on the Districts engines.

  • Captain McDonald took his personal GPS unit with him on this incident

Incident

• At the time the crew of Engine 6162 was operating at 920 Orchard Lane the following equipment was utilized:

  • The wyed bumper discharge 1.5” Nitrile single jacket hose line, 30’ in length with a 20/60 gpm wildland fog nozzle was deployed to control the burning operation on the existing brush piles near the engine. The brush piles were ignited by the crew to reduce the fuel load near the house. Engineer Rucker was using this line to maintain control of the intensity of the brush piles.

  • This line was left charged and placed on the front bumper of the engine as fire conditions began to intensify. As Engineer Kreps exited the house for the first time to locate Engineer Rucker, he found the line charged and intact. Engineer Kreps was able to utilize the line for approximately 15 seconds until the water supply was exhausted. Subsequently, when the crew entered the engine to depart 920 Orchard Lane the bumper line was still deployed and intact. In exiting the driveway the line was driven over and damaged.

• At the time the crew of Engine 6162 was operating at 920 Orchard Lane there were two 1.5” wildland single jacket hoselines, each 100’ in length, deployed from a gated wye attached to a rear discharge of the engine. This is a standard Novato Fire District company evolution for structure protection operations. District personnel are discouraged from using hose lines over 200’ in length for structure protection.

• One of the eight wildland hose packs was used to form the two 1.5” structure protection lines attached to the rear of the engine. These lines were deployed and charged in preparation for structure protection and fire control. These lines were not staffed until the crew took refuge behind the engine. At that time Engineer Rucker staffed one of these lines near the tailboard of the engine on the passenger side. FF/PM Smith staffed the other line near the front bumper on the passenger
  side of the engine.

• Both hose lines were substantially burned as a result of the burn over and unusable. The nozzles and gated wye remained structurally intact.

• The remnants of a second hose pack were found on the concrete patio near Engineer Rucker’s body following the burn over.

• The drip torches were used by FF/PM Smith and Engineer Kreps to conduct a low intensity burnout operation including the ignition of a existing burn pile, light down slope surface fuels and ornamental vegetation along the west facing driveway near the home. Captain McDonald threw several fusees down slope into the manzanita below the grass line. The operation using the drip torches was effective in reducing the grass and ornamental vegetation below the engine and along the driveway. The fusees had little or no effect in igniting the manzanita.

• The chainsaw was initially used to remove a few overhanging limbs and a minor amount of brush along the driveway to 920 Orchard Lane to improve access/egress. It was later placed on the patio along the escape route to the house. The chainsaw was burned beyond operability.

• The weather kit was not utilized to monitor weather conditions during the operations at 920 Orchard Lane. It should be noted that the weather conditions, obtainable by a belt weather kit, just prior to the burnover were not necessarily indicative of what was going to occur. The temperature was in the low 70s and the relative humidity was approximately 30%. Winds were estimated to be 7-10 mph.

• A falling axe from Engine 6162 was placed by the rear door of the house prior to the burn over and used to force entry into the house.

• A McLeod was placed at the rear of the engine on the passenger side, next to the rock wall.

Post Incident Considerations

• The single jacket structure protection hose lines burned through. Research should be conducted to evaluate alternate hose types that would offer improved survivability in similar conditions, e.g. the 30’ nitrile hose on the front bumper did not burn.

• Due to the combustible nature of the hose packs, consideration should be given to the materials used in there construction or to the ease that they can be removed in an emergency.

• This fire, even after several days, was understandably still being fought using initial attack and “bump and run” strategies without adequate overhead supervision. To effectively and safely operate under these conditions it is essential for the Strike Team/Task Force Leader to have the ability to quickly access key accurate situational information, such as spot weather forecasts, fire history maps, live and dead fuel moisture and fire behavior predictions.

• Consideration should be given to providing all Strike Team/Task Force Leaders or engine companies with the training and capability to quickly and continuously access current and expected weather conditions (preferably from local RAWS locations), topographical maps, street maps, aerial photos, current and predicted fire behavior and conditions, expected local weather conditions, fire weather watches and warnings, fire history and any other pertinent information that would improve situational awareness and safety. Technology in the form of wireless communications capable of linking to an incident web site may provide this information quickly and continuously to the resources that need it to operate safely.

• Regardless of the perceived weather conditions weather should be taken on a regular basis using what ever means that are available to the crews or Strike Team/Task Force Leader.

• All responding resources should be appropriately equipped for the assignment. This responsibility falls on the agency filling the assignment, the responding crew, and ultimately on the STL or TFL.

• GPS units may provide crews with information regarding local topography and geographical locations in the event of an emergency.

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