NIOSH Cedar Fire Report
CDF Cedar Fire Report
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
Personal Protective Equipment
Pre Incident
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The Novato Fire District issues all personnel a full complement
of Personal Protective Equipment (PPE) including fire shelters and
gloves. Personnel are required to purchase their own wildland boots.
All PPE must meet the current CAL OSHA regulations,
NFPA standards, and Novato Fire Protection District policy 1-V-12.
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Wildland PPE:
-
Undergarments:
- Nomex IIIA station uniform pants
- Long sleeve 100% cotton T-shirt, gray in color, with District
approved logo on front only
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Outerwear:
- Wildland helmet with front brim, and adjustable leather/nylon
chin strap
- Goggles, with protective nose shield with ¾” elastic
strap or 1/16” elastic cord retainer
- Helmet shroud, attached to helmet with Velcro, and closed in front
facial midline with Velcro
- Protective structure hood (fire resistive) Nomex IIIA
- Wildland jacket with single layer sleeves, Nomex IIIA with 6”x10”
Nomex “Novato Fire Dist” patch on back
- Wildland pants, single layer, Nomex IIIA
- Structure or wildland leather gloves with wristlet
- Protective full leather upper boots with lug soles
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Accessories
- Current generation nylon FSS web belt with shoulder harness and
pouches made of Cordura duck nylon cloth with polyurethane coating
- Pouch with current generation nylon FSS fire shelter, GSA issue,
California OES modification compliant
- Pouch with Timberline hose clamp
- Pouch with 2 plastic 500 ml commercially bottled waters
- Pouch with hose fittings, such as 1.5” x 1.5” gated
wye, 1.5” 20/60 KK forestry wildland nozzle, 1.5” spanner
- Pouch with fusees (stored on apparatus) may be attached to web
belt as needed
- Portable radio Cordura nylon chest harness with Cordura nylon
straps and heat resistant plastic buckles
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Exact brands may vary, however, all Wildland PPE must meet above
stated standards.
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All personnel are provided with ongoing training in the donning of
PPE, shelter deployment and PPE inspection practices consistent with
NFD Basic Competencies, “Wildland PPE” and policies. (Appendix
I).
Incident
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At the time the crew of Engine 6162 was operating at 920 Orchard
Lane, all personnel were wearing the full complement of Wildland PPE
as stated above, and in accordance with District standards.
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Captain McDonald and Engineer Rucker wore Nomex facial protection
style masks. FF/PM Smith and Engineer Kreps had their structure hoods
pulled up an in place. Captain McDonald’s structure hood was
pulled down around his neck. It is unknown if Engineer Rucker structure
hood was pulled up and in place or down around his neck. Bandannas
were worn by crew members, but not as facial protection.
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As a result of the burnover, the following observations on PPE and
Equipment were noted:
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All undergarments performed to specifications and expectations
based on the specific conditions encountered, except: Captain
McDonald’s long sleeve T- shirt showed incipient signs of
thermal degradation above the belt line on the back.
-
All outer garments performed to specifications and expectations
based on the specific conditions encountered, except: Captain McDonald’s
1/16” goggle restraint (round cord) failed due to intense
heat.
-
Captain McDonald and Engineer Kreps received facial burns in the
area expected to be protected by their Nomex helmet shrouds and
the nose shields on their goggles.
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FF/PM Smith received circumferential first degree burns around
his eyes even though he was wearing his goggles.
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Captain McDonald’s wildland jacket was substantially thermally
degraded on the back. Specifically, Captain McDonald sustained 2nd
degree burns on his mid back in the pattern of the cross strap of
the shoulder harness portion of the web belt.
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Engineer Kreps sustained small 1st and 2nd degree burns on either
side of his spine in the area of the cross strap of the shoulder
harness portion of the web belt.
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Captain McDonald’s wildland pants were substantially thermally
degraded on the back and the front at the knee level.
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Captain McDonald’s was wearing single layer wildland gloves
with wristlets. He sustained 2nd and 3rd degree burns to both hands.
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Captain McDonald’s Cordura nylon radio chest harness and
buckles were thermally degraded.
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Captain McDonald’s web belt and shoulder harness burned while
being worn due entirely to the high ambient heat. This resulted
in the loss of all of his web belt equipment and transfer burns
to his body.
Post Incident Considerations
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When considering any changes to wildland PPE it is important to
remember that the Cedar incident was, in fact, a firestorm and not
a normal typical wildland incident. During normal wildland operations
the PPE required by OSHA, if worn as intended will work as it is designed
to. This equipment is not necessarily designed to endure a firestorm
where ambient temperatures can become extreme but survivable. A balance
needs to be obtained between all gear for the “normal”
and “catastrophic” situations that a firefighter may face.
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Web belts are an essential part of the PPE ensemble, allowing personnel
to carry fire shelters, water, and other essential firefighting equipment.
The typical web belt is constructed of nylon, an inherently combustible
material, and plastic buckles likely to cause convective heat transfer
to the wearer.
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Another inherent problem with web belts is that the shoulder straps
compress the air space between the protective Nomex of the wildland
jacket and the skin of the wearer. When this air space is compressed
heat will more readily transfer through almost any protective material
to the wearer. A reduction in the weight of the loaded web belt may
reduce the compression situation or possibly allow the shoulder straps
to be eliminated.
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This is an example of achieving a balance between normal and catastrophic
operations. Heavy Nylon web belts work fine during normal operations
but can exacerbate injuries and burns during catastrophic operations.
Decisions to change construction materials should be based on seeking
a balance somewhere in the middle between adequate protection and
overprotection, cost vs. benefit.
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General wildland survival philosophy states that when using an escape
route, to seek refuge to a safety zone, in a burn over situation firefighters
should quickly shed all non-essential equipment including web belts.
This procedure should be done while retaining portable radios and
fire shelters. Based on the rapid sequence of events that occurred
at the Cedar Incident this procedure does not seem to be a realistic
expectation. Further research should be conducted in an effort to
reduce the weight and composition of the web gear so that it does
not impair progress or cause burns to the wearer, so that it does
not have to be removed in an emergency.
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Undergarments performed appropriately to provide a second layer of
protection and minimized thermal skin burns. Captain McDonald suffered
burns through his wildland jacket and T-shirt due to the ambient heat
conditions and the burning web belt. Captain McDonald received burns
through his wildland pants and Nomex station uniform pants in areas
where his skin was in direct contact with the material and where the
air space between the fabric layers was compressed. The burns on Captain
McDonald’s legs stopped at his lower underwear line. The triple
layer of Nomex wildland pants, Nomex work pants and cotton underwear
eliminated any burns in the groin area. It is likely that nylon or
other synthetic undergarments would have caused the same burns as
those that resulted from the combustibility of the web belt material.
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The 1/16” goggle restraint cord worn by Captain McDonald was
not of sufficient dimension to withstand the ambient heat conditions.
The ¾” goggle strap worn by other personnel did not fail.
The District has seen a reduction in thermal injuries to the nose
since personnel began wearing goggles equipped with nose shield.
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When helmet shrouds were worn in conjunction with structure hoods
facial burns were negated.
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Nylon chin straps should be replaced with non combustible versions.
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While not causal to the injuries sustained at the Cedar Incident
it should be understood that shrouds which seal along the midline
of the face and are attached to the helmet with Velcro may not provide
the most optimal protection currently available.
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Current District practice regarding the wearing of structure hoods,
as a second layer of facial protection, on wildland fires allows for
personal judgment. Captain McDonald had his Nomex face shield on at
the time of maximum heat exposure. In this case the practice of allowing
personal judgment may have resulted in some facial burns to Captain
McDonald; however, his use of a personal Nomex facial protection style
mask may have prevented more significant inhalation burns.
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Additional research needs to be conducted with a focus on protecting
the wildland firefighter’s airway in high ambient temperature
situations. Captain McDonald, as did other civilian burn victims,
incurred a lung infection due to exposure of organic spores that were
present in the smoke. Apparently the filtering system in the personal
Nomex facial protection mask he was wearing was not able to eliminate
the exposure to these spores.
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While exposed to extreme heat the protection provided by the double
layering of undergarments and Nomex outer garments did not fail. They
provided the expected level of protection even though the Nomex outer
garments degraded to varying degrees.
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The wildland leather gloves did not provide protection against thermal
burns when exposed high ambient temperatures resulting in 2nd and
3rd degree burns to Captain McDonald’s hands. The burn demarcation
line on Captain McDonald’s hands occurred at the wrist line
in the area in which double layering of the undergarments and the
glove wristlets was maintained. In addition Engineer Kreps sustained
first degree burns to his knuckles while using the same issued wildland
gloves. It was not the material of the glove that caused the burns
but rather its single layer construction and relatively tight fight
that caused the burns. A second layer such as a non-combustible liner
may provide the protection necessary to prevent similar injuries.
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Protective full leather upper boots with lug soles performed as expected.
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The current generation nylon and Cordura duck nylon cloth with polyurethane
coating FSS web belt, pouches and shoulder straps worn by Captain
McDonald burned and failed. The failure was due to its materials being
inherently combustible with failure occurring at approximately 350
degrees F according to non-scientific studies. The burning web belt
and components added to the degradation of the outer garments resulting
in 2nd degree burns to Captain McDonald’s back. These failures
could cause the loss of vital safety, survival and
communications equipment.
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Firefighters should never wear essential equipment made of inherently
combustible materials while engaged in fire suppression activities
nor should they wear any non-essential inherently combustible materials
that can not be quickly and safely discarded in the event of an emergency.
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