Cerro Grande Prescribed Fire 

Board of Inquiry 

Final Report

National Park Service 

February 26, 2001 
2/26/01 

To: Director, National Park Service 

From: Regional Director, Midwest Region 

Subject: Final Report, National Park Service Board of Inquiry, Cerro Grande 

Fire 

Through this memo I am transmitting the final report of the National Park Service 

Board of Inquiry on the Cerro Grande Prescribed Fire. While it was the charge of 

the Board of Inquiry to make written findings on corrective action regarding 

individuals, I believe that the findings of the Board warrant some observations about 

the responsibility of the National Park Service as an agency with respect to the 

Cerro Grande Fire. 

In the Board's review of the facts of the case, it found that while individuals 

adhered to the policies of the National Park Service regarding wildland fire, National 

Park Service policies in place at the time of the fire had weaknesses that helped 

contribute to the chain of events that caused the Cerro Grande Fire to escape its 

prescription. While any one of these policies as a single item, may not have been 

problematic, taken collectively they proved seriously inadequate. In addition, the 

Board found that there was a lack of an effective interagency management system 

for handling the fire. Since the fire, a host of agency and interagency activities 

have occurred that will provide remedies for these problems and strengthen the 

prescribed fire program at all levels. 

In the early days of the fire, Intermountain Regional Director Karen Wade said in a 

televised interview that the National Park Service was "responsible for what has 

occurred. The buck stops with us." The Director of the National Park Service also 

stated that the National Park Service bore the responsibility for the fire. In 

addition, following the release of the May 19, 2000, investigative report on the fire, 

Secretary of the Interior Bruce Babbitt spoke of the "unacceptable" mistakes of 

oversight committed by the National Park Service. 

All these remarks echo the feeling that the National Park Service as an institution 

bears substantial responsibility for the Cerro Grande Fire. 

At the outset, I acknowledged that the Board was directed to investigate individual 

performance and the role it played in the Cerro Grande Fire. While the Board found 

no violations of policy on the part of individuals, questionable judgment was exercised 

on several occasions. The prescribed fire program should not be judged by the 

events of the Cerro Grande Fire, the lessons learned and the subsequent changes in 

management of the program will clearly serve to make it more effective in future 

applications. What follows are the findings of the Board in this regard.

Cerro Grande Prescribed Fire Board of Inquiry Final Report i
TABLE OF CONTENTS 

 

 

TABLE OF CONTENTS ...........................................................................................I

EXECUTIVE SUMMARY ......................................................................................... II

INTRODUCTION ..................................................................................................1

BOARD OF INQUIRY PROCESS ..............................................................................4

CHRONOLOGY OF EVENTS...................................................................................7

FINDINGS AND DISCUSSION...............................................................................13

SUMMARY OF INDIVIDUAL FINDINGS .................................................................41

CONCLUSIONS ..................................................................................................45

SUMMARY.........................................................................................................46

REFERENCES .....................................................................................................47

Cerro Grande Prescribed Fire Board of Inquiry Final Report i
EXECUTIVE SUMMARY 

On May 4, 2000, Bandelier National Monument employees began the Cerro Grande 

prescribed burn. The ensuing series of events and decisions led to a subsequent 

wildland fire declaration and, three days later, pushed by strong winds, the wildland 

fire spread outside the project area threatening the Los Alamos National Laboratory 

and destroying 235 structures in and around Los Alamos, New Mexico. 

The Cerro Grande Fire quickly took on a national focus. On May 11, 2000, the 

Secretary of Interior directed an interagency investigation of the incident and, on 

May 18th, appointed an independent review board to assess the findings and 

recommendations from the investigation. The review board concluded that the 

investigation’s findings and recommendations were logical and valid—with the 

exception of those findings dealing with the National Weather Service (NWS). 

A Board of Inquiry was established to: consider the facts and circumstances of the 

incident and those that may have contributed to it; consider legal and policy 

requirements that apply to the facts of the incident and determine compliance with 

those requirements; conduct an objective critique of the actions of individuals 

directly responsible for the incident, including a review of operational procedures; 

and make written findings to the convening official for the purpose of recommending 

corrective action. In the course of its investigation and review, the Board of Inquiry 

interviewed 26 witnesses and participants, many of whom had not been interviewed 

during the initial investigation. 

The Board of Inquiry reviewed relevant documents and used the initial May 18th

Investigation Team Report as a basis for its review. The Board of Inquiry found that 

the initial investigation report was a significant accomplishment produced in a 

remarkably compressed timeframe, however, this report was not always consistent 

with the facts and in some cases, inappropriately evaluated performance. At the 

conclusion of its review, the Board of Inquiry was able to determine a clear 

understanding of the planning effort and the sequence of events that led to the 

fire’s escape in the implementation phase. The Board also made a considerable 

effort to respond to each of the findings brought forward in the Investigation 

Report. The Board’s narrative accompanying each finding is intended to frame issues 

in the context of policy requirements and reconcile differences in the evidence as it 

may affect decisions dealing with personnel actions. 

Causal factors and final impacts of this action are still being assessed. Root causes 

for the escape of the Cerro Grande prescribed fire will be debated for some time. 

It is unlikely that any individual or group will be able to determine the precise reason 

or a single cause of this incident. However, document searches and witness 

interviews have produced a clear picture of the role the park staff and cooperators 

played in both starting and subsequently suppressing the fire. 

A multitude of factors, many of which are common causes (i.e., system flaws or 

failures), as well as special causes (i.e., personal decisions and actions) interacted to 

produce a chain of events that influenced the outcome of this fire. The events 

Cerro Grande Prescribed Fire Board of Inquiry Final Report ii
beginning on May 4th, were indicative of normal prescribed fire activities. Problems 

that evolved shortly after ignition put the park staff on an irreversible pathway 

ultimately resulting in the escape of the fire. 

Cerro Grande Prescribed Fire Board of Inquiry Final Report iii
INTRODUCTION 

From February to April, 2000, staff at Bandelier National Monument in New Mexico 

prepared and approved a Prescribed Fire Plan for the Upper Frijoles 1 and 5 Burn 

Units. This burn plan covered a project area of approximately 1000 acres located in 

the northwest portion of Bandelier National Monument and adjacent to the Santa Fe 

National Forest in north-central New 

Mexico (Figure 1). 

Figure 1. General area map of the 

Cerro Grande Wildland Fire (taken 

from the United States General 

Accounting Office Report [US General 

Accounting Office 2000]).

The primary purpose of this prescribed 

fire was to reduce hazard fuels in the 

burn unit. The burn plan defined 

implementation of the full project to 

be completed in three 

sequential phases (Figure 2). 

On May 4th, Phase I of the 

prescribed fire was ignited 

and eventually escaped the 

planned boundaries. It 

ultimately spread into the 

town of Los Alamos, New 

Mexico, destroying 235 

structures and also spread 

onto lands administered or 

owned by the Santa Fe 

National Forest, the Los 

Alamos National Laboratory, 

and the San Idelfonso and 

Santa Clara Pueblos. 

Figure 2. General location of 

the Upper Frijoles Prescribed 

Fire Units (Cerro Grande 

Prescribed Fire) with 

individual phases defined 

(Figure 5A, taken from 

Investigation Team Report). 

On May 11th, Secretary of the Interior Bruce Babbitt formed an interagency 

investigation team to examine events and circumstances from the beginning of 

planning the prescribed fire until it was converted to a wildland fire with 

Cerro Grande Prescribed Fire Board of Inquiry Final Report 1
management responsibilities formally delegated to a Type I Incident Management 

Team (IMT) (May 8th). The investigation team completed its assignment and 

prepared a final report by May 18th, 2000. The report, “The Cerro Grande 

Prescribed Fire Investigation Report,” (National Park Service, Bureau of Land 

Management, U.S. Forest Service, Department of Energy, and New Mexico Energy, 

Minerals, and Natural Resources Department 2000), hereinafter referred to as the 

“Investigation Team Report,” was presented to the Secretaries of Interior and 

Agriculture and included findings and recommendations. 

Following completion of the Investigation Team Report, an Independent Review Board 

was appointed by NPS Director Stanton on May 18th. This Board was assigned to 

review the findings and recommendations presented in the Investigation Team 

Report. The Independent Board of Review submitted its final report (State of 

Florida, Bureau of Land Management, U.S. Forest Service, and White Mountain 

Apache Tribe 2000) on May 26th to the NPS Director. 

 

On June 6, 2000, National Park Service (NPS) Director Robert Stanton 

commissioned a Board of Inquiry to review the facts and circumstances surrounding 

the Cerro Grande prescribed fire and it’s escape as a wildland fire. Director Stanton 

charged the group with the following objectives: 

 Consider the facts and circumstances of the incident and those that may 

have contributed to it. 

 Consider legal and policy requirements that apply to the facts of the 

incident and determine compliance with those requirements. 

 Conduct an objective critique of the actions of individuals directly 

responsible for the incident, including a review of operational procedures. 

 Make written findings to the convening official for the purpose of 

recommending corrective action. 

The findings of the Cerro Grande Prescribed Fire Board of Inquiry (hereinafter 

called the “Board”), were developed through review of the Bandelier National 

Monument (BAND) Fire Management and Prescribed Fire Plans. In addition, the 

Board reviewed the Investigation Team Report, the Independent Review Board’s 

report (National Park Service 2000), the General Accounting Office Report on 

Lessons Learned from the Cerro Grande (Los Alamos) Fire (General Accounting 

Office 2000), received testimony from the principal government officials who 

developed those plans, and from 26 separate witnesses who participated in the 

planning and implementation of the prescribed fire and subsequent wildland fire 

suppression activities. Most interviews were conducted face-to-face but all were 

fully documented as both audio recordings and written transcriptions. Over 1,600 

pages of transcripts were developed from these interviews. The Board reviewed and 

used the Investigation Team Report as the basis for its review. Based on this, the 

Board developed findings that respond to, but are not limited to, the items 

enumerated in that report. 

Cerro Grande Prescribed Fire Board of Inquiry Final Report 2
During the course of the Board investigation, review, and deliberations, it became 

readily apparent to members that the May 18th report served as a good beginning 

point for this review. However, Board members acknowledge the fact that it was 

developed under an extremely compressed timeframe. This limitation precluded its 

authors from having the time required and ability to fully investigate all facts and 

circumstances surrounding the fire and it’s outcome. Board members further 

recognize that this timeframe made it impossible for the Investigation Team to 

interview all key personnel having first hand knowledge of prescribed fire planning 

and implementation, dispatch coordination procedures, and firefighting strategies 

and tactics and to consider these areas in relation to compliance with all applicable 

legal and policy requirements. It became apparent to the Board during the course of 

review and dialog with key witnesses, that the Investigation Team Report was not 

always consistent with the facts and, sometimes, inappropriately, measured 

performance against policy requirements believed to be consistent with the 1995 

Federal Fire Policy, but not yet adopted in agency manuals or handbook direction. 

The magnitude of loss also certainly influenced the swift reaction and call to 

accountability, as reflected in the rapid completion and release of the Investigation 

Report. 

The Board of Inquiry’s review was carried out over a span of 5 months (June – 

October 2000). This duration was necessary to fully clarify all pertinent elements of 

the original investigative report as well as other associated issues and informational 

aspects. As a result, the Board uncovered a wide array of information, including 

opposing viewpoints, differences in perception, and both corroborating and 

conflicting information. The Board used all this information to generate its findings, 

some of which directly contradict findings in the May 18th investigation team report. 

The Board’s review of the facts and circumstances surrounding the Cerro Grande 

incident focused on the prescribed fire and wildland fire activities until a Type I 

Incident Management Team assumed management responsibility. The Board’s review 

is founded on the actions of five principal individuals responsible for managing the 

prescribed fire and it’s subsequent escape. Those individuals are: Roy Weaver, 

former BAND Superintendent, now retired; Al King, BAND Fire Management Officer 

(FMO); Mike Powell, BAND Acting Assistant Fire Management Officer; Charisse 

Sydoriak, BAND Chief of Resources; and Paul Gleason, Intermountain Region Wildland 

Fire Specialist. Decisions and actions of these individuals were evaluated in the 

context of laws, policies, and guidelines in effect for the National Park Service on 

May 4th, 2000. It should be noted that findings refuting those in the May 18th

Investigation Team Report, are most often the result of that report’s use of certain 

wildland fire standards endorsed by both the Department of Interior and the 

Department of Agriculture in the Federal Wildland Fire Management Policy and 

Program Review (USDI/USDA 1995), but never fully implemented at agency levels.

This document represents the Board’s final report. It contains specific information 

regarding the chronology of events involved with this fire, the Board’s findings in 

relation to laws, procedures, and policies, and in comparison to the investigation team 

report’s findings, conclusions, and recommendations. General recommendations for 

follow-up measures presented here reflect the view of the Board based on knowledge 

of past management actions, professional assessment of actions taken in relation to 

past experiences in similar situations, and training. These measures are 

Cerro Grande Prescribed Fire Board of Inquiry Final Report 3
recommended to deciding officials as a beginning point for determining final 

accountability for this fire event. 

BOARD OF INQUIRY PROCESS 

Members of the Board of Inquiry included: 

Bill Schenk Regional Director, Midwest Region 

Len Dems Fire Management Officer, Grand Teton National Park 

Pete Hart Superintendent, New River Gorge National River 

Wally Hibbard Associate Regional Director, Operations, Southeast Region 

Mary Martin Superintendent, Mojave National Preserve 

Jerry Williams Director, Fire and Aviation Management, U. S. Forest Service, 

Northern Region 

Throughout the proceedings and deliberations of the Board of Inquiry, Janet 

Spaulding, Esq., represented the Department of the Interior, Office of the Solicitor. 

The specific employees under review included: 

Roy Weaver Superintendent, Bandelier National Monument 

Charisse Sydoriak Chief, Resources Management, Bandelier National Monument 

Al King Fire Management Officer, Bandelier National Monument 

Mike Powell (Acting) Assistant Fire Management Officer, 

Bandelier National Monument 

Paul Gleason Wildland Fire Management Specialist, National Park Service 

Intermountain Mountain Regional Office 

These employees designated the following individuals as their representative on the 

Board of Inquiry: 

Tim Sexton Fire Ecologist, National Park Service, National Interagency 

Fire Center, Boise, Idaho 

Tom Zimmerman Fire Science and Ecological Applications Program Leader, 

National Park Service, National Interagency Fire Center, 

Boise, Idaho 

Mr. Sexton and Mr. Zimmerman were active participants in the Board and it’s 

deliberations. 

Steve Botti, Fire Program Manager, with the National Park Service, National 

Interagency Fire Center in Boise, Idaho, accompanied the employees throughout the 

interview process, but did not participate in the Board’s deliberations. 

Chairman Schenk convened the Board on June 28, 2000 at 8:30 am in the Conference 

Room of the Camel Rock Suites, Santa Fe, New Mexico. Typically, the Board initiated 

Cerro Grande Prescribed Fire Board of Inquiry Final Report 4
its proceedings at 8:00-8:30 am and concluded by 5:00-5:30 pm daily. All 

proceedings were audio recorded and transcribed by a court recorder. 

In addition to the individuals mentioned above, Rick Gale, Deputy Chief Ranger for 

the National Park Service participated in some of the interviews. 

All individuals appearing before the Board of Inquiry were asked by Chairman Schenk 

to introduce themselves, give a brief description of their background, and describe 

their involvement with the Cerro Grande Fire. Board members, Janet Spaulding, and 

the five employees identified above asked additional questions. 

Individuals interviewed on June 28, 2000 included: 

Roy Weaver Superintendent, Bandelier National Monument 

Mike Powell (Acting) Assistant Fire Management Officer, 

Bandelier National Monument/Burn Boss Cerro Grande 

Prescribed Fire 

Al King Fire Management Officer, Bandelier National 

Monument/Ignition Specialist, Cerro Grande Prescribed Fire 

On June 29, 2000 the following individuals were interviewed: 

Al King Fire Management Officer, Bandelier National 

Monument/Ignition Specialist, Cerro Grande Prescribed Fire 

(continuation of interview from previous day) 

Charisse Sydoriak Chief, Resources Management, Bandelier National 

Monument/Resource Advisor and Situation Unit Leader, Cerro 

Grande Fire 

Paul Gleason Wildland Fire Management Specialist, National Park Service 

Intermountain Mountain Regional Office, Fire Observer/Relief 

Burn Boss/Incident Commander, Cerro Grande Fire 

All of the interviewed employees listed above were given, and signed, a Garrity 

warning. 

The Board reconvened on July 25, 2000 at 8:30 am in the Southwest Support Office 

of the National Park Service in Santa Fe, New Mexico. Dave Davies, Employee 

Relations Specialist, National Park Service, WASO, provided technical personnel 

expertise. Individuals interviewed on that day included: 

Holly Snider Firefighter, Bandelier National Monument 

Edward Hiatt (Acting) Assistant Fire Module Leader, Bandelier National 

Monument 

Ryan Swartz Crew Member, Bandelier National Monument 

Joseph Leon Dispatcher, Santa Fe Zone Dispatch Center (permanently 

employed with the Bureau of Land Management, Santa Fe, NM) 

John Romero Center Manager, Santa Fe Zone Dispatch Center, Santa Fe 

National Forest 

Vernon Ely and Respectively, Coordinator, Southwest Coordination Center, 

Cerro Grande Prescribed Fire Board of Inquiry Final Report 5
David Boyd U. S. Forest Service, and Coordinator, Southwest Coordination 

Center, Bureau of Land Management (joint interview) 

On July 26, 2000, the Board interviewed the following individuals: 

Kirk Smith Superintendent, Mormon Lake Hot Shots, U. S. Forest 

Service/Division Supervisor, Cerro Grande Fire 

Russ Copp Assistant Fire Management Officer, Blue Ridge and Happy 

Jack Districts of Coconino National Forest/Division 

Supervisor, Cerro Grande Fire (interview conducted by 

telephone) 

Richard Romero (Detail) Dispatcher, Santa Fe National Forest Dispatch Office 

Dick Burick Deputy Laboratory Director, Los Alamos National Laboratory 

On July 27, 2000, the Board interviewed the following individuals: 

Eugene Darling Team Leader, Emergency Management and Fire Management 

Officer, Los Alamos National Laboratory 

Thomas Lonnie Montana Deputy State Director, Bureau of Land Management, 

Fire Investigative Team Member, Cerro Grande Prescribed 

Burn 

Mike Powell (reinterview) 

Paul Gleason (reinterview) 

Kevin Joseph North Zone Fire Management Officer, Santa Fe National 

Forest 

The wildland fire situation that developed in late July and persisted at an extreme 

level through early September in the western United States precluded the Board 

from reconvening until the middle of September. 

The Board and the principals subject to review, participated in a conference call on 

August 11, 2000, to conduct an interview with representatives from the National 

Weather Service concerning its involvement in the Cerro Grande Prescribed Fire. 

The following individuals were interviewed: 

Charlie Liles Albuquerque Office of the National Weather Service (NWS) 

Tim Connor Dept. of Commerce, Legal Division- Washington, D.C.

On September 19, 2000 the Board reconvened in the National Park Service 

Southwest Support Office in Santa Fe. Chairman Bill Schenk and all Board members 

were present. Nancy Fischer, Employee Relations Specialist with the WASO National 

Park Service office joined the Board deliberations and provided technical personnel 

expertise. 

On September 19th, the Board interviewed the following individuals: 

Kathy Allred Pilot, U. S. Forest Service 

Matthew Snider (by 

conference call), 

(Acting) Fire Use Module Leader, Bandelier National 

Monument 

Dick Bahr Fuels Management Specialist, National Park Service, National 

Cerro Grande Prescribed Fire Board of Inquiry Final Report 6
Interagency Fire Center, Boise, Idaho 

On September 20, 2000, the Board interviewed: 

Joe Stutler Fire Operations Specialist, U. S. Forest Service, Pacific 

Northwest Region 

Paul Orozco Fire Staff Officer, U. S. Forest Service, Santa Fe National 

Forest 

Roy Weaver, Charisse Sydoriak, Al King, Mike Powell, Paul Gleason and Steve Botti 

then left the proceedings and the Board deliberated in executive session on 

September 20 and 21, 2000.

The final meeting of the Board of Inquiry was held from October 10 – 13th at the 

Midwest Regional Office in Omaha, NE. All board members plus Janet Spaulding and 

Nancy Fischer were present for this meeting. During this time, the Board 

deliberated over the information acquired from the previous interviews and 

developed the basis for this report. Individual writing responsibilities were assigned 

and the report was developed by Board members at their respective home units over 

the next few weeks. The report was compiled, reviewed, and finalized by Board 

members through telephone conferencing communications. This document, while not 

necessarily portraying each Board member’s exact viewpoint, does represent the 

consensus opinion of Board members. Chairman Bill Schenk then provided the final 

report to NPS agency managers. 

CHRONOLOGY OF EVENTS 

This section presents a summary of the chronology of events surrounding the Cerro 

Grande Prescribed Fire. A brief review of actions taken prior to May 4th is 

presented followed by a more detailed description of events that occurred after May 

4th. 

Planning for the Cerro Grande Prescribed Fire began in February of 2000. From 

March to April, activities associated with burn plan preparation and weather and fuel 

condition monitoring took place. In mid- to late February, Mike Powell was detailed 

into the vacant Assistant Fire Management Officer position at Bandelier National 

Monument. One of his first assignments was to prepare the Prescribed Fire Plan for 

Units 1 and 5. In preparation for this plan development, Mike contacted John 

Lissoway on March 22, 2000, the previous Fire Management Officer, now retired. 

The Prescribed Fire Plan was completed on April 19th. Live fuel moisture samples 

were collected on April 10th with dead fuel moisture samples collected from the burn 

site on April 14th. On April 18th, weather data was retrieved from the Cerro Grande 

weather station located near the southeast corner of the burn unit. From mid-March 

to mid-April, at least three snowstorms passed over the burn area; one storm 

Cerro Grande Prescribed Fire Board of Inquiry Final Report 7
deposited 16 inches of snow on the site. Verbal reports from various personnel who 

had been on-site, indicated snowbanks present in the shaded areas and duff that was 

moist or wet. Plans to burn the unit in April were not feasible due to minor dusting 

of snow, excessive wind conditions, and the lack of an agreement with the Baca 

Ranch. On April 28th, dead fuel moisture content measurements were taken on the 

burn unit. The National Weather Service was contacted on May 3rd and a weather 

forecast was obtained. 

The chronology of events that occurred on the Cerro Grande Prescribed Fire from 

Thursday, May 4, 2000, the day the prescribed burn began, until the arrival of the 

Type I Incident Management Team on Monday, May 8, 2000 is described in Table 1. 

Table 1. Cerro Grande Prescribed Fire chronology of events. 

THURSDAY, May 4th 

TIME EVENT 

Morning of May 

4th 

Mike Powell prepared the amendment to the prescribed fire 

plan, excluding the 32 acres of private land from the project. 

1300 Roy Weaver approved this amendment.

1400 Mike Powell notified Santa Fe Zone Dispatch (Zone Dispatch) of 

the intent to implement the fire plan. The dispatcher expressed 

concerns about sending mixed messages to the public by having 

Bandelier conduct a prescribed fire when the Forest Service 

had already suspended prescribed fire activities on national 

forest lands and wildland fires were currently burning. 

Mike Powell and fire program assistant made notifications to the 

various agencies and individuals on Bandelier prescribed fire 

notification list. 

1830 Al King notified Zone Dispatch of the prescribed fire. Mike 

Powell conducted the prescribed fire briefing. 

1900 Al King called the National Weather Service confirming that the 

spot weather forecast was still accurate. 

1920 The test fire was ignited near the summit of Cerro Grande. 

Twenty fire personnel (the ten person Black Mesa crew and ten 

NPS employees) were on the scene (Figure 2). 

Approx. 2000 The test fire was successfully completed, and the fire behavior 

was within expected parameters; the decision was made to 

continue the prescribed fire by Mike Powell. Crews began the 

blackline by burning down the northeast edge of the fire from 

the test fire area. Progress was slow using the ignition pattern 

outlined in the plan. They changed the ignition pattern to speed 

up the progress and the burn boss made the decision to stop 

suppressing the fire on the interior side of the ignition lines. 

Approx. 2200 Ignition was completed on the northeast edge of the fire area.

Mike Powell began walking back to the test fire areas. Upon 

reaching it, he discovered the fire had burned through the 

blackline on the northeast and was burning southwest into the 

canyon faster than anticipated. 

Cerro Grande Prescribed Fire Board of Inquiry Final Report 8
2300 The ignition crew of three and a holding crew of 12 arrived back 

at the test fire area to suppress the fire burning outside the 

test fire. Holly Snider and Ed Hiatt arrive on fire from 

assignment on Unit 40 (another prescribed fire unit completed 

earlier). 

Approx. 2315 Ignition began down the northwest edge of the unit. Crews 

reached the upper saddle and spent the next 11⁄2 hours bringing 

the fire back from the knob into the saddle, securing the line at 

0230 hours.

FRIDAY, May 5th

TIME EVENT 

Approx. 0100 Between 0100 and 0130 hours, the burn boss, Mike Powell, had 

concerns about the fatigue level of the Black Mesa Crew and 

sent them down the mountain to get some sleep. 

Five NPS personnel, Paul Gleason, and the remainder of the 

Black Mesa 10-person crew hiked down to the vehicles to get 

some sleep. 

0230 Mike Powell then left the fire, going to the office in the NPS 

housing area to order contingency resources. 

0317 Mike Powell called Santa Fe Zone Dispatch. He stated his intent 

was to order a 20-person hand crew to be on-site by morning; 

but was told to call back in the morning. The Dispatcher stated 

the burn boss called to report the fire progress and his intent 

to order a Type 3 helicopter and 20-person crew in the morning. 

 ** (FACTS IN DISPUTE). 

0600 The fire observer, Paul Gleason, woke Mike Powell and expressed 

urgency regarding the arrival time of needed resources and the 

need to contact key park staff regarding the fire situation. The 

interior fire had backed below where the blacklining operations 

had stopped. 

0630 Mike Powell stated that he attempted to contact dispatch, but 

there was no answer. Dispatch stated that they were on duty 

and received no phone call. 

** (FACTS IN DISPUTE). 

0700 Supervisory Dispatcher arrives at work and stated that he 

called the Burn Boss. ** (FACTS IN DISPUTE).

0720 Supervisory Dispatcher reported situation to Santa Fe N.F.

FMO. NPS did not want to declare a wildland fire. 

0730 Mike Powell stated that he called the Zone Dispatch, to request 

a Type 1 20-person hand crew and a Type 3 helicopter. ** 

(FACTS IN DISPUTE). The supervisory dispatcher then called 

Al King, the park FMO, and explained that the prescribed fire 

needed to be converted to a wildland fire so the requested 

resources could be obtained. Al King and the Zone Dispatcher 

reached agreement whereby resources would be ordered for a 

wildland fire currently burning on the national forest, but would 

be diverted to the prescribed fire. 

1000 Paul Gleason, Mike Powell, and Al King discussed a change in 

Cerro Grande Prescribed Fire Board of Inquiry Final Report 9
command of the prescribed fire, as Mike Powell needed sleep. 

The decision was made that Paul Gleason would now become the 

burn boss. Shortly thereafter, the holding crew on the 

northeast side reported fire slopover outside the line and they 

were having difficulty containing it. They requested water 

drops and additional firefighters. 

1030 The Type 3 helicopter (H312) arrived, dropping off two 

personnel on the northeast side of the fire and departed to the 

helibase to pick up the bucket and begin water drops. 

1100 A Type I hand crew (Santa Fe Hotshots) arrived at the fire. 

Five people went up the west line and 13 people went up the east 

line to the northeast side of the fire to assist in containing the 

slopover. A second Type I Crew (Mormon Lake Hotshots) was 

called to the Cerro Grande Prescribed Fire. 

1255 An air tanker was requested for the slopover on the northeast 

side and arrived at approximately 1600. At this point, the burn 

boss (former fire observer) made the decision to convert the 

prescribed fire to a wildland fire, which then became the Cerro 

Grande Fire. Paul Gleason then assumed responsibility for the 

fire as the Incident Commander (IC) and additional resources 

were ordered. Efforts then focused on suppressing the fire. 

Approx. 1630 A spot fire was detected one-quarter mile east of the main fire 

in Water Canyon, which the Type 1 hand crew contained. 

Another Type I hand crew arrived at the fire and started 

walking in. 

1630 Paul Gleason briefed park management on the Cerro Grande fire 

situation. 

2115 The Wildland Fire Situation Analysis (WFSA) was completed by 

Paul Gleason, Al King, and Charisse Sydoriak, and approved by 

Roy Weaver. 

2255 Zone Dispatch requested the current fire weather observations 

to send to the National Weather Service (NWS). During the 

nighttime hours, crews began burning out the east handline (the 

part of a natural or constructed fire barrier that is scraped or 

dug to mineral soil) and improved the west saw line. 

2355 NWS issued a spot weather forecast, calling for a fire weather 

watch on Saturday, May 6th. 

SATURDAY, MAY 6TH

TIME EVENT 

Between 0001 

and 0800 

One hand crew went off-shift, which left one hand crew on the 

fire to continue suppression actions. 

0230 The hand crew began blacklining operations along the east and 

west sides of the fire to stay ahead of the fire as it backed 

down the hill 

0728 The hand crew requested an air tactical group supervisor, after 

a second spot fire was observed outside the fire area to the 

east, which was successfully contained. 

1425 Roy Weaver and key fire staff met with the interagency 

cooperators (Los Alamos National Laboratory. U.S. Forest 

Cerro Grande Prescribed Fire Board of Inquiry Final Report 10
Service and Los Alamos County) to discuss the suppression 

strategy and tactics selected in the WFSA. 

1846 The crews continued firing operations to secure the handline 

along the east side of the fire. 

1900 – 2300 Handcrew burned out along west fireline.

Cerro Grande Prescribed Fire Board of Inquiry Final Report 11
SUNDAY, MAY 7th

TIME EVENT 

0730 The hand crew for the day operational period replaced the night 

crew on the east line and continued firing operations down to 

and west along State Road 4. 

0800 Air attack reported a spot fire on the park/forest boundary. 

1000 All burning operations along State Route 4 were halted due to 

down slope wind conditions. 

1150 Winds increased from the west and a spot fire occurred across 

State Route 4 into Frijoles Canyon. 

1230 The spot fire was growing rapidly and a Type I Incident 

Management Team and two Type 1 crews, two Type 2 crews, and 

one Type 3 helicopter were requested. 

1240 A decision was made by Paul Gleason to evacuate Graduation 

Flats and American Springs. 

1300 Interagency road closures and evacuation procedures were 

initiated. The Santa Fe National Forest Supervisor and forest 

FMO were notified of these actions. 

1450 Spot fires were reported along the eastside of the fire, 

increasing in intensity with the potential to threaten Los Alamos 

National Laboratory. 

1700 The spot fire to the east of the fire had grown to approximately 

100 acres with additional spotting up to one-quarter mile ahead 

of the main fire (Figure 3). 

1845 A decision was made to burn out sections along State Route 501 

and Camp May Road to protect Los Alamos. 

2100 An interagency meeting was held to develop a unified command 

delegation of authority and a revision of the WFSA. 

MONDAY, May 8th

TIME EVENT 

0100 The Type I Incident Management Team was briefed by the 

agency administrators and took over the fire operations at 0600 

hours. 

Cerro Grande Prescribed Fire Board of Inquiry Final Report 12
Figure 3. Projection of 

wind direction and fire 

spread on May 7th (Figure 

5I, taken from 

Investigation Team 

Report). 

FINDINGS AND DISCUSSION 

The following represents the full presentation of the Board of Inquiry’s findings and 

discussion of these findings. The information presented here is a complete review of 

the facts and circumstances of the incident and those that may have contributed to 

it. This section reviews legal and policy requirements of NPS employees that apply to 

the facts of the incident and evaluates responsibility and performance of the five 

employees in complying with those requirements. As part of the review of compliance 

with necessary requirements, this section presents the Board’s objective critique of 

the actions of the individuals directly involved in the incident. This entire discussion 

has been formulated by measuring findings against the findings and recommendations 

stated in the May 18th Investigation Team Report. In addition, the 12 safety 

elements listed on page 15 of the investigation team report have been addressed 

individually in terms of their contribution to safety but not in regard to their 

contribution to complexity, as was the intent of the original report. 

Table 2 lists the Cerro Grande Prescribed Fire Board of Inquiry Findings and 

Discussion. 

Cerro Grande Prescribed Fire Board of Inquiry Final Report 13
Table 2. Cerro Grande Prescribed Fire Board of Inquiry Findings and Discussion, including Investigation Team Report Findings, r

performance in terms of NPS policy, procedures, and standards.Investigation Team Finding Responsibility Board of Inquiry Findings/Performance Finding 1.A.: The complexity rating process completed for the Upper Frijoles 1 and 5 (Cerro Grande) prescribed fire plan did not follow the National Park Service rating system. The range of numeric values assigned by Bandelier (i.e, 1,2,3, did not comply with the Worksheet Numeric Rating Guide in RM-18, which has a numeric ratings range of 1,3,5 (USDI National Park Service 1998). This error in and of itself resulted in the prescribed fire being rated as low-moderate complexity (87) by Bandelier staff rather that moderate-high (137) when the correct values were used. 

Mike Powell, Burn Boss; Al King, FMO; Charisse Sydoriak, Chief of Resources; Fire Management Program Center - Boise 

The Board finds that the complexity rating proUpper Frijoles 1 and 5 prescribed fire plan did Park Service rating system. However, this waoversight by the Bandelier staff but due to thof the Wildland and Prescribed Fire Complexity Numeric Rating Guide posted on the internet at Service (NPS) Fire Management Program Centewas incorrect at the time of the Cerro Grande document created in hyper text markup languaglanguage used to create documents on the worlFMPC home page was found to present a numerincorrectly listed the guide to numeric rating vinstead of 1, 3, and 5. It is assumed that when the internet html versiofile was retyped by contractor employees and the inadvertently changed at that time or a conversiothe html file took place and as part of the convernumbering routine changed the numbers to read srather than the actual numbers of 1, 3, 5. During following completion of the website, all five federmanagement agencies had access to the internet inaccurac

y went undetected and unreported. The 

Cerro Grande Prescribed Fire Board of Inquiry Final Report 
removed from the web once the error was found 

investigation. The Board finds that the Bandelier staff comprequirement listed in RM-18, Chap. 10: SectioAssessment, “Complexity: Identification of th

the prescribed fire”, but due to circumstances 

an incorrect version of the complexity rating sy

Finding 1.B.: There are different prescribed fire complexity rating systems being used by different agencies, and within the southwest geographic area there are no standard systems among agencies. 

Wildland Fire Management Agencies 

Agency Administrators in the Southwest federacommunity have not addressed the need to staratings. There is no requirement in the FederaManagement Policy to develop a specific standarating. The Board finds that the Bandelier staresponsibility nor control over the lack of a starating system among agencies in the Southwest No NPS policy, procedures, or standards were viopresented by Finding 1.B. The Board generally agrees with the Investigatrecommendation. Wildland fire management agenstandard complexity rating system framework. Tincorporate locally developed standards based on and topographic influences. 

Finding 1.C.: A number of the prescribed fire complexity elements in the rating guide were consistently underrated based on the 

Mike Powell, Burn Boss; Al King, FMO; Charisse Sydoriak, 

The Board agrees that at least one of three delements (Threats to Boundaries, Fuels and Firin the rating guide was underrated. The increa

Cerro Grande Prescribed Fire Board of Inquiry Final Report 
investigation team report. This underrating 

coupled with the apparent misuse of the system identified in Finding A resulted in a significant misclassification of the complexity. An analysis of where each complexity element was underrated is shown in Table 1 of the Investigation Team Report. 

Chief of Resources these elements when applied to the correct com

result in a final complexity rating of high. Complexity determinations are not absolute and iteaches their interpretation using intuitive judgmUsing intuitive judgment and experience to refine several subject matter experts have rated compl“high”. The increase in complexity would likely have been numbers and skill levels of personnel on-site. Howpolicy requirement at the time of this burn that tcomplexity level. The FMO, Al King, and Chief of Resources, Charisresponsible for review of the complexity rating. because both have an extensive background in firqualified to complete this review. During the plaburn, considerable discussion of complexity took of Resources and Burn Boss. Originally this projeBased on discussion between the FMO and Chief ocomplexity rating was increased to moderate. Complexity determinations are made during burn may occur several months in advance of project imBoard believes that complexity should have beeday of the burn to account for any changes th

Cerro Grande Prescribed Fire Board of Inquiry Final Report 
since the plan was finalized, but policy does no

Finding 1.D.: The prescribed fire plan was not substantively reviewed before it was approved by the agency administrator (Superintendent). 

Roy Weaver, Superintendent 

Contrary to the Investigation Team Report findinthe Burn Plan was reviewed and approved by the Sprincipal staff. Although “substantive review” is materials and testimony submitted to the Board iSuperintendent, Chief of Resources, and Fire Maninvolved in discussions of this specific prescribed meetings over a period of approximately 18 monthmeetings indicate substantive review to the BoarThe Board finds that the Bandelier staff complierequirement listed in DO-18, 5.7a: “All prescribea burn plan approved by the Superintendent.” 

The Board believes that future policy modificatconsiderations of off-site technical review of b

Finding 1.E.: The prescribed fire planner did not receive sufficient oversight, guidance, and support to prepare the prescribed fire plan. 

Al King, FMO; Charisse Sydoriak, Chief of Resources 

The Board finds that the Prescribed Fire Planner Powell,developed a burn plan that had significant plan addressed all required elements. However, as Finding 1.C.,1.F., and 1.G., the Board feels that whspecific guidance, several weaknesses in the plan review and oversight by the FMO and Chief of ReDuring the course of the plan development, the Pr(Burn Boss), Mike Powell, received feedback and iand current FMOs, and Chief of Resource Manageon prescription development and content. Testim

Cerro Grande Prescribed Fire Board of Inquiry Final Report 
plan was reviewed by the FMO, Al King, and Chief 

Sydoriak, and went through several revisions baseinitial statements provided to the Investigation Tclarified through testimony to this Board. The Board finds that the Bandelier staff comprequirement listed in DO-18, 5.7b: “All burn pusing a systematic decision-making process, and cobjectives, predetermined prescription, and envirdocumentation,” and in RM-18, Chap. 10, B., Prescr

Finding 1.F.: The prescribed fire plan prescription was inadequate for all phases of the burn due to wide elevation variations, varying aspects, and different fuel types. The prescription necessary to meet objectives at the upper elevations would cause unacceptable resource damage on the lower elevations of the burn unit. 

Mike Powell, Burn Boss; Al King, FMO; Charisse Sydoriak, Chief of Resources; Roy Weaver, Superintendent 

The Board finds that the prescribed fire plan requirements for prescription parameters. The comprised of three phases representing differenponderosa pine, aspen). Although each fuel type (length requirement to meet objectives, the prescnot specific to each phase (different fuel types) project. Each phase had different objectives whdiffering prescription parameters. The wide rangparameters used in this burn plan, given the variaaspect, and fuels, would indicate that a Type I Budesirable to tailor components of the prescriptioto achieve the objectives (Reference Finding 3.Aassessment that complexity on this project shoulhigh, it would have indicated a Burn Boss, Type 1 Burn Boss assigned to the burn was a type 2 (loweThe Board concurs with the summary statement b

Cerro Grande Prescribed Fire Board of Inquiry Final Report 
Analyst, Dan O’Brien, provided in the Investigatio

6. This summary states, “Improvements could be content of the Upper Frijoles Unit 1 and 5 fire plparameters need to be tightened down to limit trfuel moistures more closely monitored to better mconsumption. Given the multiple fuel profiles exisprescriptions specific to each profile would bettemonitor ignitions on the ground. Spotting and conalso need to be added to the fire plan to provide for establishing containment and contingency objcurrently written, the plan is implementable given expertise and experience who understands the plwithout this background would have more difficulimplementing the plan.” The Board feels that for landscape scale prescdifferent fuel types, elevations, aspects, and sobjectives, prescriptions should be tailored to 

Finding 1.G.: The prescribed fire plan prescription projected flame lengths in excess of the limits set in the Bandelier National Monument Fire Management Plan.

Mike Powell, Prescribed Fire Planner (Burn Boss); Al King, FMO; Charisse Sydoriak, Chief of Resources 

The Board concurs with this finding. NPS policestablishment of prescribed fire flame lengths in (FMP). However, NPS policy requires that the uspermissible only when a FMP that authorizes and has been completed and approved (DO-18, 5.6). Pbe consistent with descriptions established in FMlengths were established as limits in the FMP, thecarried forward into the Prescribed Fire Plan as lFMP. 

Cerro Grande Prescribed Fire Board of Inquiry Final Report 
This finding represents a procedural inconsistenc

does not believe that this inconsistency influenceflame length discrepancy was only one foot (eight specified in the FMP and nine feet described in t

Finding 1.H.: Bandelier National Monument personnel did not receive or solicit comments from all cooperating agencies in the planning process. After the incident, cooperating agencies expressed concern about the decision to ignite the prescribed fire. 

Mike Powell, Burn Boss; Al King, FMO; Charisse Sydoriak, Chief of Resources 

The Board finds that all individual and cooperastandard notification list for Bandelier Nationafires were contacted during the planning procesNPS policy and Federal Wildland Fire Managemennotification of cooperators but not concurrence. Bandelier staff complied with the NPS policy req5.7d: “All burn plans will address the need for ale

appropriate public officials to the objectives and 

burn,” and RM-18, Chap. 10. B.6. Prescribed Fire 

Provisions for interagency and intra-agency pre-b

where applicable, public involvement and burn day 

appropriate individuals, agencies and the public.” 

The Board finds that after the incident, severdid express concern about the decision to ignitwas discussed at several meetings, the complexthe prescribed fire may not have been uniformcooperators. 

Finding 1.I.: The prescribed fire plan amendment prepared the day of the burn did not consider the full consequences of the changes 

Mike Powell, Prescribed Fire Planner (Burn Boss); Al King, FMO; 

During the original planning process, the Baca Ranparticipation in the project, but after the proposU.S. Government became likely, the Baca Ranch e

Cerro Grande Prescribed Fire Board of Inquiry Final Report 
and actions necessary for successful completion 

and coordination of the prescribed fire. 

Charisse Sydoriak, Chief of Resources; Roy Weaver, Superintendent 

as part of this project. The amendment removed private property from the burn unit on the west famendment described implementation actions necthat private property, and developed a contingencthe fire escaped onto those lands. The amendment to the burn plan was approved by complied with the NPS policy requirement listed i

“Prescribed Fire Prescription: Any changes to pr

must be approved by the same level of authority 

approval.”

The Board finds that the prescribed fire plan affect the outcome. The escape did not occur which the amendment was developed. 

Finding 1.J.: The contingency plan inadequately identified actions needed to keep the prescribed fire within the prescribed parameters and necessary actions to be taken if it escaped. 

Mike Powell, Prescribed Fire Planner (Burn Boss); Al King, FMO; Charisse Sydoriak, Chief of Resources; Roy Weaver, Superintendent 

The Board finds that completion of the contingenprescribed fire plan complied with the NPS policy RM-18, Chap 10. B. 7.: “Contingency Plan: Identif

actions to be taken if the fire exceeds prescript

line holding capabilities and cannot be returned to 

Contingency Plan actions cannot maintain the pres

planned parameters, use the Wildland Fire Situat

process to determine appropriate strategy.”The contingency plan within the prescribed burthe calculated complexity level of moderate anadequately addressed the policy requirements. 

Cerro Grande Prescribed Fire Board of Inquiry Final Report 
believes that had the prescribed fire plan cont

complexity rating, additional holding resources which would have in turn influenced the call-up contingency plan. NOTE TO READER: The Board finds a strong 

complexity rating, holding resources, and contin

reference to this situation is frequently repeat

is because of the inseparable relationship amon

holding resources, and contingency plan. 

The Board recognizes that three factors influedecisions. The three factors are: Complexity rating, Northern Pueblo Agency (NPA or Black Mesa) creHolding Resources/slopover. Complexity rating: A higher complexity rating as 

appropriate by the Investigation Team and Board 1.C.) should have resulted in more holding resourcwould have influenced the need for call-up of conWith more holding resources on-site, managers wflexibility to mitigate the loss of some personnel Northern Pueblo Agency (NPA) crew). Northern Pueblo Agency (NPA) Crew Release: The 

Cerro Grande Prescribed Fire Board of Inquiry Final Report 
had planned to use the NPA crew during the ignit

remaining night operational period as a holding crbased on a concern surrounding the crew’s ability assigned responsibilities during the operational peMike Powell, decided at approximately 2400 hourfire for rest. After learning that the crew was nnight, he released them to their home units rathethe base of the project site. Once this crew was released, the NPS personnel for the remainder of the night. Because these Noriginally planned to be holding resources for the period, there was now a need to obtain new staffAttempts by the Burn Boss, Mike Powell, to fill thunsuccessful and were not aggressively pursued tNotably the Burn Boss, Mike Powell, was the only inability to fill this need immediately. The remainburn assumed the necessary resources would arriThe Board finds that when the Northern Pueblreleased, an order for replacement resources foperational period should have occurred immediA fundamental error occurred at approximately 0Mike Powell called Santa Fe Dispatch to obtain adthe following day. However, no sense of urgency dispatch office. There is disagreement between M

Cerro Grande Prescribed Fire Board of Inquiry Final Report 
Dispatch regarding this conversation. Mike Powel

confirmation of crew availability and arrival times for rest. At 0600 hours, when the NPS Regional (RWFS) Paul Gleason, (acting as a project observPaul Gleason found that no additional resources hestimated arrival times were available. Gleason torder be placed and followed up on immediately. operational period resources in place would furththe work/rest guidelines by the NPS resources. The Board finds that Mike Powell did not aggrethe order. The Board further finds that it was responsibility to take aggressive steps to ensurneeded for the next day operational period had confirmed. Because of the need to relieve the work period began at 0700 hours on 5/4) from period, the Board does not believe that it was the morning to obtain confirmation on the addiHolding Resources/slopover: The importance of dealing with the burn complexity and the possibilclearly illustrated by the slopover on 5/5. Mike Paggressively pursue obtaining additional resourcecrew adversely compounded holding problems. Wcompromised and those resources on site had mosextended (holding resources at 0800 hours on 5/approximately 25 hours). Had the contingency re

Cerro Grande Prescribed Fire Board of Inquiry Final Report 
for the start of the day operational period on 5/5 

rested personnel starting their work shift would time the slopover occurred. When the slopover oresources on site and precluded the ability of remthe remainder of the prescribed fire. Without asite, personnel were unable to hold the fire in Phaavailable future options and the ability to remain original prescribed fire plan which was to completevaluate options for Phase 2. This led to the decfire. The lack of contingency resources on site puof reliance on aerial retardant support and other Decisions made at the following times were cruciawas irreversible and placed them on a path with doptions: 2100 hours (5/4) – decision to stop extinguishing blacklining operation in phase I, 2400 hours (5/4) – decision to keep the Bandelier resources throughout the night operational perioability to perform these duties during the next dperiod without confirmed replacements, 0300 hours (5/5) – Mike Powell called dispatch (nconveyed) and made a decision to delay confirmatassignment and time of delivery until the morningThe Board is concerned about the passive and 

Cerro Grande Prescribed Fire Board of Inquiry Final Report 
communication link between those on the fire s

Finding 2.A.: The GO/NO-GO Checklist was not completed prior to the burn. 

Mike Powell, Burn Boss The Board finds that all items were discussed 

by the Burn Boss, Mike Powell, the Ignition SpHolding Specialist, Al King, but discussion of thformally documented in writing. NPS policy does not require formal written doc

Finding 2.B.: Contingency resources were not ordered and placed on standby prior to implementation of the prescribed fire. 

Mike Powell, Burn Boss NPS policy does not require standby of conting

ignition. Standby is not consistently interpreted this report, standby is interpreted to mean off-sto other activities and available for immediate sufire project. Mike Powell stated that resources icontingency plan were confirmed prior to ignition within 2 hours, one type III helicopter within 4 hII crews within 4 hours). However, the Board finds that there was disagbetween the park and Santa Fe Dispatch regartiming of availability, and payment processes. Tled to delays in delivery of planned contingency Santa Fe Dispatch mobilized resources to Bandprescribed fire despite the dispatchers’ uncertassignment of suppression resources to prescribconfusion regarding appropriate individual agenccodes, and the direction of the Southwest AreThe resource allocation processes within the Sou

Cerro Grande Prescribed Fire Board of Inquiry Final Report 
are not altogether consistent with National Wildl

Group direction. During this review, members of Coordination Center reflected concerns about the resolve this issue. The Board believes that agency procedures shothat contingency resources identified in the plathrough normal wildland fire procedures to ensuHowever, since normal/standard interagency acnot fully defined, understood, and endorsed by recommends that agencies should jointly develo

Finding 2.C.: On the early morning of May 5, USDA Forest Service contingency resources were ordered and did not arrive until approximately 1100 hours. Lateness of arrival of contingency resources influenced control of an isolated spot fire but did not affect the escape of the fire. 

Mike Powell, Burn Boss; Al King, FMO 

The Board concurs with the Investigation Team Rresources did arrive late (see Finding 1. J.). The Investigation Team Report finding that this late to the escape of the prescribed fire. There were on-site to contain the slopover (not an isolated sp5/5. Lateness of arrival of contingency resourcethe slopover but more importantly, in the view of of these resources precluded the ability of on-sitmaintain the prescribed fire within the boundarieprescribed fire was declared a wildland fire at 13need for resources to contain the slopover triggewildland fire. At this time, the selected Wildland (WFSA) option was to initiate suppression operatand burnout at Highway 4, east fire road, and othburnout operations associated with the suppressiinfluenced the escape of the fire onto Forest Ser

Cerro Grande Prescribed Fire Board of Inquiry Final Report 
Finding 2.D.: Once the prescribed fire was 

declared a wildland fire, wildland fire suppression tactics were used that were not in accordance with the Wildland Fire Situation Analysis. This resulted in additional fire being introduced into the unit, which ultimately produced the source of spotting and escape when high winds developed on Sunday, May 7. 

Paul Gleason, Incident Commander (ICT3)

The Board finds that the wildland fire suppresthe prescribed fire was declared a wildland firwith the Wildland Fire Situation Analysis. However, the Board believes that the location, the west flank firing operation during the supp6th contributed to the escape of the fire. 

Although there is disagreement among witnessetime of the escape to the east, the Board beliplausible explanation is that the escape initiate

The focus of on-the-ground suppression actions wThis area was most threatened based on the prevtopography. The majority of fire spread across tslope effects. On the west flank when the fire rspread came under the influence of the prevailing movement was pushed by the prevailing west wind Frijoles Canyon and spotted onto and the east sloeastern boundary. The fire in the flats along the west flank posed a fact that a red flag warning for high westerly winboth 5/6 and 5/7.

Finding 2.E.: Numerous safety violations occurred, i.e., unanchored fireline, unheeded work/rest guidelines, aviation SAFECOM, lack of 

Mike Powell, Burn Boss (primary) 

The Board finds that the fireline was anchoredPrior to the burn, in the wooded west flank area c

Cerro Grande Prescribed Fire Board of Inquiry Final Report 
identified escape routes, and others. 

(for the purposes of this safety item discussion, this refers to the safety elements listed in Finding 2.E. on page 18 of the Investigation Report). 

were used to clear the proposed west fireline. Awhere the east and west lines connected by burnifollowed by extinguishing the fire with crews. As from this initial point, crews continued to extingupoint created at the Cerro Grande summit was utprogressed to the east. This anchor remained vashort time periods when fire moved back to the wRanch. This fire was quickly extinguished upon dithe integrity of the original anchor point. 

The Board finds that the work/rest guidelines 5.16 states, “All fire business and personnel mana

comply with all instructions prescribed in Referen

Management Compendium, Interagency Incident B

Handbook (NWCG Handbook 2), and 5 CFR, parts 

Interagency Incident Business Handbook (NWCG recommends a 2:1 work/rest ratio (e.g., 16 hours rest). During the prescribed fire, work/rest guidelines Item 6 for a more detailed description). During tis not unusual for work/rest guidelines to be excemobilization and initial operational periods. Incidthe authority to approve work period lengths in ework/rest guidelines in the initial phases of actio

Business Management Handbook, NWCG Handboo

Cerro Grande Prescribed Fire Board of Inquiry Final Report 
The Board finds that a wildland fire suppressio

decision caused the 14 hour helicopter pilot duby 17 minutes. Exceeding the duty hour limitareportable incident requiring an aviation SAFECreport required for all aviation incidents, accidrelated issues). Proper reporting procedures were followed and anactions will be conducted by the appropriate aviatThis SAFECOM did not contribute to the escape suppression fire. The Board finds that escape routes were not iplan, however, all personnel on-site at the timbriefed and knew the location of escape routes Two crewmembers were off-site at the time onot briefed. During interviews, those two crewmembers statelocation of escape route and safety zones from inpersonnel and their pre-ignition work on the burn The Board finds that the Bandelier staff comprequirement listed in RM-18, Chap. 10. B.5.: “analyze the safety hazards unique to the individuproject and specify personnel safety and emergen

Cerro Grande Prescribed Fire Board of Inquiry Final Report 
The following 12 items refer to the safety elements listed on page 15 of the Investigation Report. For the purposes of this repo

addressed each item individually. Unanchored fireline. Refer to Finding 2.E. above.There was no handline along the boundary of adjacent landowner (Baca Ranch).

Mike Powell, Burn Boss The Board finds that the Prescribed Fire Plan did 

of a handline in this area and NPS policy does not mechanical fireline to be constructed on prescribfor fire perimeter holding to be accomplished thrfrom backpack pumps to extinguish burning edges changes in fuels and terrain to limit fire spread rof a handline. Further, the burn plan amendment introduced into the Baca Ranch area. This portiosuccessfully implemented. 

No escape routes were identified. Mike Powell, Burn Boss Refer to Finding 2.E. above.Incident Action Plan did not conform to National Wildland fire Coordinating Group standards.

Paul Gleason, Type 3 Incident Commander 

The Board finds there are no National Wildland Group (NWCG) and NPS policy standards for In

Staff not available for extended periods, 0200 – 0300 crew’s relief created personnel shortage.

Refer to Finding 1.J. above 

Inadequate staffing resulted in extended hours and extreme shift periods lasting 12 hours prior to ignition. 

Mike Powell, Burn Boss; Al King, FMO

The Board finds that extended hours and an eoccur prior to ignition. This resulted from manaignite later in the day and to utilize Bandelier staand equipment. With the unplanned release of thshift extensions of Bandelier personnel became nplan requirements. Expectations were that the sonly until the arrival of a replacement crew at 08the burn boss left the fire and contacted dispatchours, 5/5, he learned that the replacement resomeet the desired 0800 arrival time. This resulte

Cerro Grande Prescribed Fire Board of Inquiry Final Report 
30 – 35 hours.

The Board finds that insufficient measures wernecessary resources during the early morning hBandelier FMO (the Burn Boss’ immediate superoccurred to review other alternatives. 

A Spot weather forecast was issued at 1220: ignition was 1930. Weather observations were taken at Cerro Grande summit the morning of May 4th, up to 1100 period. No further weather 

observations were taken until 1735.

Mike Powell, Burn Boss; Al King, Holding Boss 

The Board finds that continuous weather readithe entire period. Readings were being taken site and through a portable weather station locObservations were collected hourly. 

Weather observations were in compliance. Holding Specialist had a telephone consultation with NWS at 1900.

Mike Powell, Burn Boss; Al King, Holding Specialist 

The Board finds that the telephone consultatio1900 confirmed that the 1220 Spot Weather Fovernight. 

Two single resources were not on the fire and were not briefed; dealing with a flare-up on another prescribed fire in the park. 

Mike Powell, Burn Boss The Board finds that two individuals were not bri

briefing. At this time these people were on anothdifferent location. However, they stated that thburn site as a result of assisting with pre-burn prarrival at the prescribed burn, they received adepersonnel on-site to perform their assignment. (R

No resources were identified to relieve current personnel assigned to the fire and the plan was unclear as to where the fire would be stopped. 

Mike Powell, Burn Boss; Al King, FMO; Charisse Sydoriak, Chief of Resources; Roy Weaver, Superintendent 

The Board finds that there was no written docburn plan regarding resource scheduling. The bintention was for the Northern Pueblo Agency crepersonnel during the night operational period. Bareturn for the following day operational period. Plikely have been completed during the day operat

Cerro Grande Prescribed Fire Board of Inquiry Final Report 
additional resources would have been required du

period. (Refer to Item 2.E.). The Board fin

ds that the burn plan does define 

boundaries of each phase. This is not a requireprescribed fire plans. 

Costs were an issue; as an AD crew, the Black Mesa crew could only be used 24 hours prior to ignition and 24 hours after being taken off active assignment. Cost preparation for the unit had not been completed. 

Al King, FMO; Charisse Sydoriak, Chief of Resources; Roy Weaver, Superintendent 

The Board finds the reference to the Black MeAgency) crew to be true, however, it is uncleasafety. There is a funding table presented in the burn pladescribes project costs. FIREPRO funding was aprescribed fire project. 

The complexity of the fire exceeded the management capability of the organization.

Refer to Finding 1.

C., 1.F., and 1.J., above.

End of 12 safety elements 

Finding 2.F.: The weather forecast from Albuquerque on Friday afternoon, May 5, did not provide any wind predictions in the 3-5 day forecast for the period Sunday, May 7 through Tuesday, May 9. This is a period with area wind gusts greater than 30 mph on both Sunday and Monday. This information is critical for multiday incidents.

The Board concurs with the finding of the Indepe

the National Weather Service (NWS) did comply providing weather information. The NWS Albuquroutinely provide predicted winds in the 3-5 day oprovide reliable information, because of constant(See Independent Review Board Report and telepconducted August 11th). 

Finding 2.G.: There are a significant number of other issues with regard to coordination and use of National Weather Service forecasting in 

See comments on Issues 1 – 12 below.

Cerro Grande Prescribed Fire Board of Inquiry Final Report 
the implementation in the prescribed fire. 

These issues and recommendations are identified below: Issue 1:Moderate drought existed in northern New Mexico and surrounding regions in the spring of 2000, having built since the fall of 1999. NPS did not adequately account for the effects of this drought in planning or implementing the Cerro Grande prescribed fire. 

Mike Powell, Burn Boss; Al King, FMO; Charisse Sydoriak, Chief of Resources 

The Board finds that moderate drought existed Mexico during the spring of 2000 as confirmed measures of drought (Potential Assessment distInteragency Coordination Center in Boise, ID; Index; and the National Fire Danger Rating SyComponent). But fire managers accept that long-term forecascontinuing drought, while useful, may not be markevidenced by the declaration of the prognosis for the Southwest in 50 years in March of 1999, follosevere winter snowfall that rendered the declarastrongly contributed to the disintegration of conterm drought). Because of this inability to correconditions, it was difficult for BAND personnel to persistence of the drought. On the burn site, threpresentative of springtime conditions prior to vtime of the highest annual live fuel moisture condat 10,000 feet had received .25 inches of precipi

snow had been on the site three weeks prior to thComponent (ERC), an indicator of fire danger incoconditions, showed a sharp decline after these prThe Board finds that Bandelier personnel did n

Cerro Grande Prescribed Fire Board of Inquiry Final Report 
indications of the likelihood and speed with whi

conditions could return or escalate. The Board not an identified violation of policy, procedures

Issue 2: Light precipitation fell at the burn site on April 29 thru May 1. However, the prevailing warm, dry pattern under a ridge of high pressure aloft returned on May 2. 

None applicable The Board finds that this issue is not an ident

procedures, or standards but is statement of f

Issue 3: The NPS followed policy in asking for, receiving, and making use of a site-specific (spot) weather forecast from the National Weather Service Forecast Office in Albuquerque for the Cerro Grande Prescribed Fire. 

Mike Powell, Burn Boss; Al King, FMO; Charisse Sydoriak, Chief of Resources 

The Board concurs with the Investigation Team Rstaff complied with NPS policy listed in RM-18, C

Fire Prescription: A prescribed fire prescription 

parameters needed to achieve desired results. Pr

prescription elements, both individually and collec

weather forecasts and any other predicted condi

Issue 4: On the night of May 4 and the morning of May 5, the Haines Index, which is a measure of atmospheric stability and dryness and indicates the potential for large fire growth, did not contribute to the escape of the Cerro Grande Prescribed Fire. 

None applicable The Board finds that this issue is not an ident

procedures, or standards but is statement of f

Issue 5: Onsite weather observations provided by the NPS for the Cerro Grande Prescribed Fire on May 4 and 5 were generally well covered in the spot forecast provided by the National Weather Service. 

None applicable The Board finds that this issue is not an ident

procedures, or standards but is statement of f

Issue 6: The 11 MPH wind gust that occurred during the late evening hours of May 4th was at 

ridge-top level and was within forecast ridge-top

None applicable The Board finds that this issue is not an ident

procedures, or standards but is statement of f

Cerro Grande Prescribed Fire Board of Inquiry Final Report 
wind speeds provided by the National Weather 

Service. Issue 7: The standards for wind speed measurements used in National Fire Danger Rating System (NFDRS) fire weather observations are: 1) the anemometer height is 20 feet above the surface, or 20 feet above the vegetative cover, and 2) the standard observation time is 10 minutes. These standards often cause confusion among fire personnel, who don’t measure 10 minute or 20-foot winds.

None applicable The Board finds that this issue is not an ident

procedures, or standards but is statement of f

Issue 8: The NWS Albuquerque practices regarding Fire Weather Watches and Red Flag Warnings may have caused some confusion. Some Fire Weather Watches and Red Flag Warning did not specify affected areas, cause, and valid period. 

None applicable The Board finds that this issue is not an ident

procedures, or standards but is statement of f

Issue 9: Red Flag Warnings can remain in effect for more than 24 hours for continuous wind events. 

None applicable The Board finds that this issue is not an identifie

procedures, or standards but is statement of fac

Issue 10: At times fire management personnel did not have a current spot forecast because the burn boss at the incident had set up no regular schedule for spot forecasts. 

Mike Powell, Burn Boss The Board finds that Spot Weather Forecasts we

requested at least once daily. Activities were conforecast for the period of operation. Morning Spwere re-validated for evening operational periodsfinds no regular schedule for Spot Forecasts was finds that this issue is not an identified violation standards and is not a contributory factor to the 

Cerro Grande Prescribed Fire Board of Inquiry Final Report 
Issue 11: After May 4, there was a decrease in 

communications and feedback between the NPS fire management personnel and NWS forecasters in Albuquerque. 

Mike Powell, Burn Boss; Al King, FMO; NWS Fire Weather Forecasters 

The Board finds that Bandelier staff requested forecasts from the NWS in Albuquerque. This communication and feedback loop between the and fire weather forecasters. However, conticould facilitate better information transfer perforecasts and updated information from the fofeedback and information transfer is not limitecommunication but should be initiated as needestaff and weather forecasters. 

Issue 12: The Incident Action Plan (IAP) for Sunday, May 7 did not include a weather forecast for the day operational period. 

Paul Gleason, Incident Commander Type 3 

The Board finds there are no National Wildland Group (NWCG) and NPS policy standards for Inno requirements for inclusion of written weatheweather forecasts are typically attached to Inthe type 1 and 2 levels, there is great variatiotype 3 level. The Board finds that all operational personnel they were briefed on the weather forecast for 

Finding 2.H.: Conditions adjacent to the prescribed fire boundary were not given adequate consideration with regard to fire behavior, fuel conditions, and public safety in the event the fire crossed the planned burn boundaries. 

Mike Powell, Burn Boss; Al King, FMO 

The Board finds that fire behavior, fuel conditfor areas adjacent to the burn area were evaluplanning process according to NPS standards anwere completed through field observations, reconconsultation with cooperators. However, given incident, it is apparent to the Board that “adea judgment call. Testimony revealed that there regarding how much pre-burn evaluation is adequa

Cerro Grande Prescribed Fire Board of Inquiry Final Report 
It is clear to the Board that the immediate pr

thoroughly evaluated as were the boundaries on However, it is not clear that risk was more brolandscape scales outside of the immediate projrisk in the context of landscape scales is much evaluatin

g risk at simple project scales. 

The Board feels that judgments regarding adjamore thoroughly considered drought, potential persistence of winds, and the risks of exposure operations. 

Finding 2.I.: The current wildland fire situation in the Southwest was not given full consideration when the prescribed fire was initiated. 

Mike Powell, Burn Boss; Al King, FMO 

The Board finds that at the time of this burn Geographic Area was at Area Preparedness LevPreparedness Level III the fire danger and commexisting wildland fire suppression are not significare placed on the application of prescribed fire. 

wildland fires and some prescribed fires were on-commitment of suppression resources (some were phase), competition for local resources was not siPreparedness Levels IV and V restrictions are plaan attempt to reduce potential competition for avresources. At the time of this prescribed fire, the Southwetransition from late spring conditions to summer area at 10,000 feet received 1⁄4 inch of precipitat

was on the site three weeks before this time. En

Cerro Grande Prescribed Fire Board of Inquiry Final Report 
(ERC), an indicator of fire danger based on obser

showed a sharp decline after these precipitation speed with which this condition would reverse waonly on the day that this prescribed fire was initiNational Forest suspended prescribed burning on The Board finds that Bandelier personnel were information about adverse resource draw down than what is contained in the Daily Situation Rcurrent preparedness level. 

Finding 2.J.: The preparedness level coordination and allocation of resources for all wildland fire use is not adequately addressed in the Southwest Geographic Area Mobilization Guide. 

Southwest Geographic Area wildland fire management agencies and Geographic Area Coordinating Group 

The Board concurs with the Investigation Team recommendation that Preparedness Level coordresources for all fire use (wildland fire use and be addressed in the Southwest Geographic Arespecifically strengthening the criteria for presc

Finding 2.K.: Actions taken to notify cooperating agencies and interested parties of this prescribed fire did occur within the time frame specified in the prescribed fire plan. The communications that did happen on May 4, however, did not adequately reflect the complexity and full nature of the prescribed fire about to be undertaken. 

Mike Powell, Burn Boss; Al King, FMO 

The Board finds that notification did comply wrequirement listed in RM-18, Chap. 10. B.6.: “for interagency and intra-agency pre-burn coordiapplicable, public involvement and burn day notificindividuals, agencies and the public.” The Board finds that on the day of the burn, notialerting cooperators to the fact that the burn woSpecific project scope and complexity was discusmeetings during the planning phase. See Finding 

Finding 3.A.: The technical and operational experience of the burn boss was not adequate to 

Al King, FMO The Board finds that given the complexity dete

personnel, the Burn Boss, Mike Powell, was qua

Cerro Grande Prescribed Fire Board of Inquiry Final Report 
plan and conduct the prescribed burn given its 

true complexity.

conduct this project. However, since this burn rated as a higher complexity, the Investigation a valid observation. But, at the time of this bwritten (DO-18, RM-18) did not require a highburn boss for high complexity burns. This aspereview at the time of burn implementation and changed to reflect the need to have a type I bburns. Two type I burn bosses were on the site at the tnot the designated lead burn boss. 

Finding 3.B.: Personnel implementing this prescribed fire met established National Wildland fire Coordinating Group standards for tasks performed on the fire. 

None The Board concurs with the Investigation Team 

Cerro Grande Prescribed Fire Board of Inquiry Final Report 
SUMMARY OF INDIVIDUAL 

FINDINGS 

The following section presents the Board’s findings in regard to individual actions. It 

also contains recommendations from the Board. The Board feels that it is 

appropriate to take actions to assure that future applications in regard to prescribed 

and wildland fire planning and implementation activities do not repeat the Cerro 

Grande experience. To remove the principal employees involved with the fire from 

federal service is not warranted. To whatever extent some of these people made 

mistakes, they are not the mistakes identified in the Investigation Team Report. 

To take advantage of their training, experience, ability, and past record of success in 

the prescription fire program, along with additional training and new experience, 

which can be obtained from relocation, is the recommended course for National Park 

Service to follow. 

ROY WEAVER 

Superintendent (retired) 

The Board finds that Roy Weaver fulfilled his responsibilities at the project level. 

He was familiar with the objectives; he discussed the project with cooperators; he 

asked questions of his staff during burn plan development; and he took responsibility 

for approving the plan. He surrounded himself with a staff that was fully qualified 

and capable of managing the fire program at Bandelier NM. 

The Board has some concerns about the Superintendent’s role at the interagency 

level. It is clear to the Board that differences of opinion and hard feelings separate 

agencies in this sub-geographic area. More direct upper management exchange of 

information on fire and emergency planning efforts may have better addressed 

adjacent landowner and agency concerns regarding the park’s prescribed fire 

program. 

The Board recommends that no action be taken.

CHARISSE SYDORIAK 

Chief of Resource Management 

The Board finds that Charisse Sydoriak clearly had program responsibilities for fire 

management at Bandelier National Monument. She supervised the wildland fire 

management staff and served as the principal advisor to the Superintendent on fire 

management issues. She had regular involvement with staff and managers of other 

agencies dealing with fire management activities in the region. Her training, 

background, and experience in fire management were extensive. 

Cerro Grande Prescribed Fire Board of Inquiry Final Report 41
At the programmatic level, Ms. Sydoriak clearly fulfilled her responsibilities. She 

directed development of the burn plan and provided for a review of the burn plan. 

At the project level, complexity determination for this burn is at issue and has been 

identified as a critical factor in the outcome of this action. Based on her extensive 

background, the Board feels that Ms. Sydoriak has the capability to critically 

evaluate those elements that affect complexity associated with landscape scale 

prescribed fires. In light of several exacerbating factors, including the proximity of 

private land, potential fire behavior, local attitudes and concerns, and objectives that 

influenced the complexity of this prescribed fire, the Board finds that she and her 

staff did not fully recognize and account for the risks surrounding this project. 

The Board recognizes that the complexity rating process followed all required and 

professionally accepted procedures to arrive at the outcome. In addition, the Board 

acknowledges that Ms. Sydoriak assisted in increasing the complexity rating from low 

to moderate based on intuitive judgment and experience. The complexity rating was 

still lower than likely to have been calculated using the correct form. 

The Board recommends that, if Ms. Sydoriak continues to work in a position 

that provides oversight to fire management in any capacity, she be sent to 

training that will provide her additional knowledge in wildland fire management. 

Possible training coursse include: S-580, Advanced Fire Use Applications and 

Fire Management Leadership. 

AL KING 

Fire Management Officer 

Al King was the Fire Management Officer at Bandelier National Monument and was 

responsible for overall fire program management and technical guidance for wildland 

fire management. His role in the Cerro Grande Prescribed Fire planning phase was to 

provide supervisory oversight, conduct technical review of the burn plan, and provide 

recommendations for approval. At the implementation phase of the Cerro Grande 

Prescribed Fire, his role was to serve as Holding Specialist during project 

implementation. While serving as the Holding Specialist during the fire, he 

maintained responsibilities of the park FMO. 

 

The Board finds that Al King was responsible to ensure accurate complexity analysis. 

He followed all required and professionally accepted procedures to arrive at the 

outcome. In addition, based on intuitive judgment and experience he participated in 

the process that raised the rating to a higher complexity level. The complexity 

rating was still lower than likely to have been calculated using the correct form. 

 

The Board finds that although he was Holding Specialist on the day of the burn, as 

the park FMO, he was in position to exercise professional judgment over staffing 

levels and necessary adjustments to maintain subsequent staffing cycles. There 

were several key decision points where Al King could have influenced the burn boss’ 

decisions. These include: 

Cerro Grande Prescribed Fire Board of Inquiry Final Report 42
 Decision to allow the lower edge of the blackline to burn freely. While this 

did not immediately create control problems, it deviated from the original 

plan. Its effects were not recognized and resulted in an increase in holding 

needs, 

 Decision to release the NPA crew without securing replacements, 

 Decision to obtain one hotshot crew and one helicopter rather than more 

resources. 

The Board recommends that Mr. King receive training to improve his skill and 

ability in prescribed fire planning and review and supervision. Courses could 

include Fire Program Management. 

MIKE POWELL 

Fire Use Module Leader 

Mike Powell was the principal author of the Cerro Grande Prescribed Fire Plan. He 

prepared this plan in consultation with the FMO, Chief of Resources, and previous 

FMO and with reference to previous burn plans. He then served as the Prescribed 

Fire Burn Boss during the implementation of the project. In the role of Burn Boss, 

he was responsible for organizing, staffing, and directing activities consistent with 

the burn plan objectives. The plan was prepared, reviewed, and modified consistent 

with policy requirements. 

The Board finds that Mike Powell used an incorrect complexity rating form that led 

to a lower calculated complexity rating than what has been judged to be more 

appropriate by various subject matter experts. The Board does not fault Mike Powell 

because the final rating that was developed in the burn plan was a direct result of 

using an incorrect rating form posted on agency internet websites. Review of the 

burn plan led to agreement among Bandelier staff that the complexity rating should 

be increased from a low to moderate level. 

In his role as burn boss, the Board finds that Mike Powell failed to provide for 

adequate staffing and did not make necessary adjustments to maintain subsequent 

staffing cycles. When staffing became a problem, he failed to communicate to 

others regarding the inability to secure these resources. When the Northern Pueblo 

Agency crew was released near midnight on 5/4, Mike Powell failed to provide for 

adequate staffing in their absence. At approximately 0600 hours, when it was 

observed that the fire was backing faster than anticipated, Mike Powell failed to 

fully anticipate holding needs through the day operational period. Although Mike 

Powell had been replaced as burn boss, his actions regarding holding resources 

continued to affect operations throughout the operational period. Specifically when 

the slopover occurred on the morning of 5/5, it required nearly all holding resources 

to contain it and left the lower edge of the fire perimeter in Phase I unattended. 

Later that afternoon when the fire moved into the Phase II area, holding options 

became greatly diminished. This sequence of events led to the Wildland Fire 

Situation Analysis alternative of indirect attack which required more firing over 

more operational periods, greatly increasing the overall risks. Ultimately, firing 

operations associated with the indirect strategy led to the escape of the fire out of 

the Cerro Grande project area. 

Cerro Grande Prescribed Fire Board of Inquiry Final Report 43
The Board also finds that Mike Powell in his capacity as burn boss did not adequately 

adjust actions when observed fire behavior became different than anticipated fire 

behavior. As an example, it was assumed that the fire backing in Phase I would selfextinguish. When it became apparent that this was not the case, Mike Powell did not 

increase staffing to assure control of the lower perimeter in Phase I. This decision 

eventually allowed the fire to move into the Phase II area, which further 

exacerbated holding problems on the project. These series of decisions/actions set 

the stage for greater difficulty of containment of the burn within Phase I and 

increased the likelihood of exceeding work/rest guidelines, and reduced tactical 

options as the project progressed. 

After making the 0300 telephone call to the Santa Fe Dispatch and finding that his 

request for additional resources could not be confirmed within the desired 

timeframe, Mike Powell should have contacted the Dispatch Center manager and the 

Bandelier FMO to expedite this process. 

The Board recommends that Mr. Powell undergo re-certification as Prescribed 

Fire Burn Boss through the interagency prescribed fire qualification system. This 

will include both completion of formal training courses and on-the-job training 

assignments under a qualified evaluator. 

PAUL GLEASON 

Regional Wildland Fire Specialist 

Paul Gleason had no role in the planning of this burn and served as an observer during 

the initial implementation stages. He first stepped out of that role at 0600 hours on 

5/5 when he urged the burn boss to act on securing replacement orders for holding 

resources. While he had planned to leave the area that day, circumstances caused 

him to volunteer to assume command of the fire as burn boss. He became the Type 

III Incident Commander (IC) when the prescribed fire was declared a wildland fire 

at 1300 hours on 5/5. 

In his role as Incident Commander he was responsible to develop and implement safe 

tactics. Tactics must be consistent with observed and predicted weather, among 

other considerations. It is also the IC’s responsibility to implement the operational 

management plan, including firing operations. 

The Board finds the preferred Wildland Fire Situation Analysis (WFSA) alternative 

to be reasonable and valid. The WFSA called for implementation of a firing operation 

along the east and west fire perimeters. The timing and location of these operations 

were critical given a red flag warning for high west-south-west winds. The Board 

believes that Paul Gleason provided sound direction to the firing operation with 

respect to timing and location. 

The Board recognizes that at the time Paul Gleason volunteered to assume command, 

he was left with few options for influencing the successful outcome of this fire. 

The Board recommends that no action be taken.

Cerro Grande Prescribed Fire Board of Inquiry Final Report 44
CONCLUSIONS 

After thorough review of available documents, witness testimony, and subject matter 

expert analysis of the events surrounding the fire and it’s ignition and suppression 

activities, the Board finds that the escape of the Cerro Grande Prescribed Fire 

occurred as the result of many factors, of which five were the most critical: 

The complexity rating assigned to the prescribed burn did not accurately reflect the 

situation prevailing in the area on the date of ignition and as a result, sufficient 

holding resources were not available for the initial stages of the firing activity. 

The Burn Boss failed to recognize the extreme importance of obtaining replacement 

crews from contingency resources in sufficient time to deal with the daytime burning 

period on Friday May 5th. 

Confusion over the delivery and timing of contingency resources on the morning of 

May 5th, created delays that resulted in the holding resources for the day not being 

able to prevent further spread of the fire into the second phase of the burn plan. 

The extension of the firing line on the West side of the fire created a source of fire 

which ultimately made a run into heavy fuels in the lower end of the burn unit, 

jumped the road into Frijoles Canyon, and ultimately escaped. 

Extreme wind events that were not anticipated or predicted caused the initial run of 

the fire out of the burn unit and into Frijoles Canyon. 

It is clear that the principals involved with the fire carried out their actions with the 

full expectation that they would succeed, and were within the parameters of policy, 

guidelines, and regulations related to prescribed fire activities, on the day of 

ignition. Their actions were commensurate with those of prescribed fire 

practitioners in other federal wildland fire management agencies in regard to 

planning and implementing prescribed fire activities. After-the-fact review 

indicated that there were errors in judgment and planning that may have led to the 

escape of the fire and it’s ultimate destruction of natural resources and private 

residences. 

While the Board did find errors in judgment, it also finds that the planning and 

implementation actions of the principals were not arbitrary, capricious, or 

unreasonable in light of the information they had prior to the burn and were in 

compliance with DO-18, RM-18, and other applicable sections of the National 

Wildland fire policies. 

Cerro Grande Prescribed Fire Board of Inquiry Final Report 45
SUMMARY 

The full project- and program-level implications of the Cerro Grande Prescribed Fire 

will affect both federal and non-federal entities for some time to come. The 

outcome of this incident should serve as a significant milestone in prescribed fire 

management for all federal wildland fire management agencies as fuel hazard 

treatment efforts using prescribed fire increase in volume and complexity and 

increasingly take on landscape-scale application. The uncertainties surrounding 

treatments that can extend over several operational periods during the active 

growing season, are substantial and, largely, unaccounted for in terms of readily 

accepted, endorsed, and understood practices, and grossly under-addressed in local, 

regional, and national training courses and agency workshops. 

Especially at landscape scales, when prescribed burning occurs under relatively highrisk conditions in order to achieve objectives, complexities escalate significantly and 

demand highly professional planning and implementation. Agency prescribed fire 

programs are evolving into significantly larger spatial and temporal scales without 

adequate means to measure and mitigate the social, environmental, and economic 

risks that are inherently involved. Agencies need to identify lessons learned, 

strengthen training programs, clarify guidance and procedures, and disseminate this 

information to all employees to expand beyond this event and ensure response to 

prescribed fire needs. 

The Cerro Grande Prescribed Fire demonstrates the need for all land managing 

agencies to come to common agreement on future guidelines and protocols for dealing 

with complex prescribed burns and to advocate for the highest levels of interagency 

understanding, standardization, and cooperation. A better understanding and use of 

risk assessment and complexity analysis, a commonly understood and endorsed 

definition of the use and availability of contingency resources, and interagency 

provisions for providing sufficient funding to carry out the program are but a few 

examples of items to be addressed. 

Following the Cerro Grande Prescribed Fire, the Secretary of Interior directed a 

review of the Federal Wildland Fire Management Policy, issued in December 1995. It 

is clear to the Board, based on the Cerro Grande Incident, that the fire policy has 

not been widely or uniformly adopted by federal wildland fire management agencies. 

The Board does not recommend revision of this policy. Changes in policy are not 

warranted in the context of the outcome at Cerro Grande. In fact, changes in the 

policy at this time, are likely to only introduce an element of confusion among 

practitioners and our publics, lead to a general lack of full understanding causing a 

failure to obtain endorsement, and, inadvertently, lead to serious problems in 

executing complex, landscape-scale projects like Cerro Grande. Rather, the Board 

recommends that policy emphasis be placed on interagency adoption of the 1995 

policy in a timely and consistent manner by all agencies. 

This Board of Inquiry was assigned to: consider the facts and circumstances of the 

incident and those that may have contributed to it; consider legal and policy 

requirements that apply to the facts of the incident and determine compliance with 

Cerro Grande Prescribed Fire Board of Inquiry Final Report 46
those requirements; conduct an objective critique of the actions of individuals 

directly responsible for the incident, including a review of operational procedures; 

and make written findings to the convening official for the purpose of recommending 

corrective action. This report is the culmination of the most comprehensive 

investigation of the Cerro Grande Prescribed Fire completed to date. It has 

uncovered a disparity in facts and differences in perception of the circumstances 

surrounding this fire that may never be resolved. It does, however, provide the most 

complete summary of the facts and circumstances available and reviews all applicable 

legal and policy requirements. This report represents the completion of the written 

documentation of the findings and recommendations. 

The Cerro Grande Prescribed Fire had tragic results. Employees at all levels of the 

National Park Service, including the management and staff at Bandelier National 

Monument, have expressed deep regret for the impact it had on the lives of those 

people in Los Alamos who experienced property loss. We can and must gain from this 

experience. We must use the lessons learned as a basis to improve and enhance the 

prescribed fire program throughout the country and all agencies, for indeed we will 

need to continue to employ these methods to protect life and property in the future. 

REFERENCES 

National Park Service, Bureau of Land Management, U.S. Forest Service, Department 

of Energy, and New Mexico Energy, Minerals, and Natural Resources 

Department. 2000. The Cerro Grande Fire Investigation Report. National 

Interagency Fire Center. Pages. 

National Park Service, USDA Forest Service, Bureau of Indian Affairs, U.S. Fish and 

Wildlife Service, Bureau of Land Management, 1998. Wildland and 

Prescribed Fire Management Policy, Implementation Procedures Reference 

Guide. National Interagency Fire Center, Boise, ID. 154 p. 

State of Florida, Bureau of Land Management, U.S. Forest Service, and White 

Mountain Apache Tribe. 2000. Cerro Grande Prescribed Fire: 

Independent Review Board Report. National Park Service. Washington, D.C. 

15 pages.

U.S. General Accounting Office. 2000. Fire Management: Lessons Learned from the 

Cerro Grande (Los Alamos) Fire. GAO/T-RCED-00-257. U.S. General 

Accounting Office. Washington, D.C. 52 pages. 

U. S. Department of the Interior/U.S. Department of Agriculture. 1995. Federal 

wildland fire management policy and program review. Final Report. Boise, 

ID: National Interagency Fire Center; 45 p. 

(www.fs.fed.us/land/wdfire.htm). 

Cerro Grande Prescribed Fire Board of Inquiry Final Report 47