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

In Memory Of
Engineer Steven Rucker
and dedicated to the surviving crewmembers of Engine 6162
and to all firefighters who risk their lives for those they serve.

The Novato Fire District produced this report with hope that the reader will find within it information worthy of consideration in the ongoing effort to improve firefighter safety and survival in the wildland interface environment.

The contents of this report relate solely to the operations of Novato Fire District Engine 6162 from the time of dispatch on October 27, 2003 until the burn over occurred on the Cedar Fire on October 29, 2003. A careful review of the District equipment, training procedures and policies that may have played a role in this event was conducted. The results are included in this report.

The reader is cautioned about forming opinions or coming to conclusions regarding the contributing factors leading to the burn over of Novato Engine 6162 on the Cedar incident, based on this report alone. This report is inconclusive in the sense that only the immediate factors known to the crew of Engine 6162 have been presented and evaluated.

There are clearly other verifiable and documented contributing factors, external to the operations of the crew of Engine 6162 , that played a significant role in the Cedar burn over. Please refer to the California Department of Forestry and Fire Protection Cedar Fire – Engine Crew Entrapment, Fatality, and Burn Injuries report when it is published for this information.

Every firefighter deserves a round trip,
and to that end we must constantly remind ourselves
that the life of a firefighter is far more valuable
than any forest or structure they may be asked to protect.