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
Training and Experience
Pre Incident
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The Novato Fire District and the Novato Professional Firefighter’s
Association have collaborated on the development and implementation
of an extensive Career Development Program. The Career Development
Program models both the National Wildfire Coordinating Group (NWCG)
and the California State Fire Marshal Training Guidelines (CFSTES)
for all Safety Positions within the Organization. Personnel must meet
the Career Development requirements prior to testing for a specific
position.
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In addition to Career Development guidelines, the District has developed
Standard Company Evolutions and proficiency standards for wildland
operations. Standards are used to evaluate a company’s performance
and competency.
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According to District policy all engines are staffed with a minimum
of a Company Officer (Captain), Engineer (Apparatus Driver/Pump Operator)
and a Firefighter or Firefighter/Paramedic.
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Crews received field training in shelter deployment but not in re-locating
to a safety zone or entering an engine in a crisis situation.
- Career Development minimum requirements specific to wildland firefighting
include:
Captain
S-130, Firefighter Training
S-131, Advanced Firefighter Training
S-190, Introduction to Wildland Fire Behavior
ICS 200, Introduction to ICS
S-205 (S-215), Fire Operations in the Urban Interface
S-234, Ignition Operations
S-270, Basic Air Operations
S-290, Intermediate Fire Behavior
ICS 300, Intermediate ICS
S-212, Wildfire Power Saws
Engineer, Firefighter and Firefighter/Paramedic
S-130, Firefighter Training
S-131, Advanced Firefighter Training
S-190, Introduction to Wildland Fire Behavior
ICS 200, Introduction to ICS
S-212, Wildfire Power Saws
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In preparation for the advent of CICCS (the California adopted version
of NWCG 310-1, Wildland Fire and Prescribed Fire Qualifications System
Guide) the District has continued to add requirements, specific to
wildland firefighting, to its Career Development Program.
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All four members of Engine 6162 exceeded the wildland specific training
and experience requirements, for their respective positions, according
to the Districts Career Development Guide.
-
All four members of Engine 6162 also met or exceeded the education
requirements of NWCG 310-1 for their respective positions.
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District personnel respond to several wildland fire incidents each
year within the 71 square miles of the District. The District is located
within six miles of the California coast, slightly north of the San
Francisco Bay waters and over 40 square miles of the District is considered
urban interface area.
-
The typical weather pattern of the District includes a light morning
sea breeze transitioning to a stronger afternoon westerly wind that
surfaces at approximately 1400 hours. The rare north or east wind
events produce high temperatures, low relative humidity but generally
little surface-level wind. Interestingly, few fires have occurred
in this period. The District has long believed that the recurrence
of the typical weather pattern in the days immediately following a
north/east wind event yield conditions that are most likely to result
in a large-loss/acreage fire. Typical relative humidity in the summer
months ranges in mid-thirties and temperatures from the mid-seventies
to eighties.
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Fires occur predominantly in the urban interface area. Fires typically
occur in fuel models of annual grass and Oak woodland. An occasional
fire becomes established in heavier fuels such as brush (e.g., Manzanita).
Because fires typically occur in the District interface (recent fire
history has included fires of significant magnitude that caused loss
of structures), personnel are extremely familiar with structure protection
operations in this environment.
Incident
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The crew of Engine 6162 used their training and experience in the
specific
operations that were conducted at 920 Orchard Lane to:
- Initiate a standard structure protection evolution in accordance
with the Districts Standard Evolution Manual and guidelines outlined
in S-205 with the following exceptions:
- Entry was not made into the house therefore no interior preparation
was completed.
- The residential propane tank, located behind the house, was
not shut off at the tank.
- A secondary water supply was not available because the power
needed to operate the pump on the well was out in the area.
-
Remove light grass fuels, using drip torches and fusees, to create
a defensible space below the structure using principles outlined in
S-234.
-
Identify an Escape Route and Safety Zone using the principles outlined
in situational awareness training with LCES (Lookouts, Communications,
Escape Routes and Safety Zones). Engineer Rucker was given the assignment
of being the Lookout by Captain McDonald. All members did have a view
of the surrounding area with the exception of the area to the south/southwest.
Communications was confirmed and maintained with the Strike Team Leader.
-
Remove brush and other similar fuels, with a chainsaw, from the driveway
and adjacent areas as outlined in S-212 and S-205.
-
Wear protective clothing and equipment in accordance with District
policy, industry standards and S-130.
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Communicate amongst other Strike Team Resources and the Strike Team
Leader as outlined in ICS-200 and 300.
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To identify specific triggers when the crew would access the escape
route and safety zone. The collective experience and training of the
crew prevented further injury or fatalities.
-
Personnel are taught to discard non-essential tools and equipment
when seeking access to a Safety Zone or Last Resort Survival Options.
However, these behaviors have not been consistently reinforced by
the District during training activities. If, in fact, Engineer Rucker
was wearing a hose pack as indicated in the CDF
“Green Sheet” it is unknown why he did not
discard that pack. None of the other crew members can recall Engineer
Rucker having a hose pack on his back during the operations at 920
Orchard Lane.
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Although personnel were several hundred miles from home, they were
somewhat experienced with the fuel, weather and interface conditions
presented on Orchard Lane. However, it should be noted they were unfamiliar
and not briefed on the burning characteristics, fire history, micro-climactic
and drought-stressed conditions or made aware of a “Fire Weather
Watch” that had been posted on October 29, 2003 at 0900 hours.
Post Incident Considerations
-
Once the decision had been made to commit to protect the structure
at 920 Orchard Lane it is evident that the crew’s training,
experience and use of LCES saved the lives of three crew members when
the fire unexpectedly blew up.
-
Accurate and easily accessible training records proved to be a necessity
in the Post Incident Evaluation of the crew’s educational background
including the OSHA review. These records also allow the District to
periodically assess the currency of training for all members.
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Wildland safety and survival techniques should be incorporated into
drill scenarios so that crews gain experience and are evaluated on
their ability to Establish Lookouts, Establish Communication Procedures,
identify and utilize Escape Routes, Safety Zones and Last Resort Survival
Options.
-
No plan to protect a structure should be based on
the anticipated need to seek refuge in the engine, structure, or in
a fire shelter when the flame front passes. On the other hand even
the best managed events can change for the worse. In these cases last
resort survival options such as entering the engine, structure, shelter
deployment or any combination of these options should be identified
early, reassessed regularly and shared with all crew members. Time
and the ability to select a combination of Last Resort Survival Options
are the critical components to survival in the event of an interface
burnover.
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The training received in S-205 (S-215) drove District philosophy
regarding structure protection operations. In this case, the training
received in S-205 and similar courses focus upon the ability to save
the structure as opposed to the safety and survivability of the crew
and the engine.
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A goal of future policy development and training is that an assessment
of structure protection options should be primarily based upon the
safety and survivability of the crew and engine with the structure
as a secondary concern.
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A review of “Situational Awareness” is a key component
in the assessment of any wildland firefighting scenario. “Situational
Awareness” is the identification and mitigation options of the
incident environment, resources and existing operations that affect
the safety and survivability of the crew. The key to “Situational
Awareness” is to continue to communicate safety concerns to
all crew members and to ask questions regardless of position or rank.
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It is also crucial that departmental training is based on strong
organizational philosophy with supporting policies that provide members
with mitigation options that are irrefutable up to and including refusal
of assignments.
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It is critical that there be mutually agreed philosophy and supporting
policy between federal, state and local agencies regarding wildland
firefighting operations. Philosophy and supporting policy drive training
and the formation of training curriculum. Training should not drive
philosophy and policy.
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External training can inadvertently drive internal organizational
philosophy. It is important that organizations evaluate the content
of external training to determine if it meets their internal philosophy
and policy.
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Experience and education based guidelines should be in place before
allowing any member to accept an out of county assignment
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