It was to be remembered as the Cramer Fire in Salmon-Challis National Forest.

That frightful story has now been recounted by writer Alex Markels, on U.S. News & World Report’s website, USNews.com. He calls it “A System in Trouble.” We’ll reprint most of it for you here, but you may find it hard to take. Read on:

All Jodi Heath wanted was the truth. But as she read through a report on the mistakes that led to her firefighter son Shane's death, "everything was whited out about who said what to whom," she recalls of the day Jack Troyer, the U.S. Forest Service's regional forester, showed her the agency's account of what went wrong at the Cramer Fire. "So I asked him, 'Why aren't the names in here?’”

Citing privacy concerns, Troyer explained that government attorneys had shielded the identities of half a dozen staff members implicated in the report for failing to follow the Forest Service's safety procedures, leaving Shane and Allen trapped in the path of a wildfire that consumed them in a 2,000-degree inferno.

“‘I want you to know that the boys had no fault in this,’” Heath recalls Troyer telling her. "Well, if the boys had no fault in it, then who did? The families and the public deserve to know that people are being held accountable."

But more than a year after that July, 2003, blaze, no one does, at least not officially. While a subsequent investigation by the federal government's Occupational Safety and Health Administration (OSHA) named names, Forest Service officials still decline to identify the individuals responsible or to clarify whether they were disciplined.

Meanwhile, some Forest Service workers say their agency's own postmortem failed to get to the bottom of what went wrong.

Controlling fires in today's tinderbox forests demands aggressive action before small fires erupt into big ones. "The best way to keep people safe and manage costs is a rapid attack to try to catch it while it's still small," says Mike Dudley, fire director for the Forest Service's intermountain region, which oversaw the Cramer Fire.

But with so much pressure to put fires out quickly, he admits that managers sometimes don't recognize the key transitional moment when a fire gets out of hand and it becomes necessary to pull back and reassess. "That was the biggest issue with Cramer," he says. "We kept the same tactics even though the fire conditions changed."

That was hardly the only problem. The government's postmortems read like a handbook of what not to do.

The lightning-caused Cramer fire had burned only a few acres when a lookout spotted it on the morning of July 21, 2003. Fire managers soon sent a water engine, air tankers and a helicopter to fight it.

Some have since argued that the first mistake was the decision to even bother fighting a backwoods fire. Others believe the root of the trouble was chronic understaffing: critical but unfilled fire management and safety officer positions, for instance. "People were doing dual jobs, and more responsibility was put on people with less experience," says Rowdy Muir, a Bureau of Land Management fire manager who was detailed to Salmon-Challis during the Cramer Fire. "That's when things fall through the cracks."

Sources told U.S. News that the Forest Service's official report blamed incident commander Alan Hackett's decision to locate a helicopter landing zone midslope on the mountain, where workers were unable to keep watch on the fire below.

And there was no lookout system in place when Shane Heath and Jeff Allen were sent to clear a landing spot with chain saws. Although the commander identified four safety zones where the men could flee in case of fire, three were later determined to be unsafe.

Worried that Hackett, who was pulling double duty as fire safety manager, was in over his head, aviation officer Randy Lambeth recommended that Hackett be relieved of his duties, sources told U.S. News . But District Ranger Patty Bates took no action and later denied that she had been warned of problems with Hackett. Hackett and Bates both declined to comment.

Aviation officers spotted a flare-up downhill of Heath and Allen but didn't warn them. Fire officials soon decided to retrieve the two, but the order was never carried out and the helicopter assigned to pick them up was flown back to its base camp.

When Allen called the base asking to be picked up, a radio operator told him that the helicopter would be there soon, even though it was still on the ground. Eight minutes later, Allen radioed again: "Oh God! We've just got fire down below us. . . . just make them hurry up." Unable to reach a safe zone, the two young men were soon overtaken by flames so hot that the only thing that remained were the brass screws from the soles of their shoes.

When the accident report was finally released in January, Shane’s mother Jodi couldn't believe what she was reading. "Until then, I had called it an accident," she says. "But after seeing all the mistakes that were made, I can't bring myself to call it that anymore. It wasn't an accident. It was gross negligence."

Even more infuriating was the fact that the names of those responsible were left out of the report. And while Forest Service officials have since proposed disciplinary action against the six employees, "We still don't know today if anyone has actually been punished," says Bill Allen, Jeff Allen's father. "Meanwhile, the Forest Service is saying they're doing more training and safety. You can teach safety, safety, safety until you're blue in the face. But until you hold someone responsible, nothing's going to change."

The tragic outcome of the Cramer fire, say some wildfire experts, is a worrisome example of the growing problems facing an agency struggling to deal with what Forest Service Chief Dale Bosworth has called the nation's "most serious natural resource problem": millions of acres of overgrown forests in the West that are tinderbox dry.

Combine that with a grounded fleet of air tankers, an often understaffed team of managers overseeing an army of lightly trained, part-time firefighters, and a system of oversight that some say fails to hold those responsible fully accountable, and "you've got a Perfect Storm scenario unfolding," says Stephen Pyne, a historian whose forthcoming book, Tending Fire: Coping With America's Wildland Fires, details how things got so bad. "Our whole system of wildland firefighting is in need of reform."

Some Forest Service officials dispute the notion that the system needs an overhaul. But most agree on this: "Wildland firefighting has never been more dangerous than it is today," says Jim Furnish, the agency's former deputy chief, who served as lead investigator of another fatal blaze three years ago, Washington State's Thirtymile Fire.

"We're dealing with a long legacy of fire suppression and an old mentality that still exists among many firefighters of 'we'll put fires out at all cost,' which is a recipe for disaster."

In the decade since a wildfire killed 14 firefighters on Colorado's Storm King Mountain, the Forest Service has worked hard to change such attitudes and re-emphasize firefighter safety. With help from the U.S. Marine Corps and Harvard's Kennedy School of Government, it has added new leadership programs that stress safety over heroism, and it has beefed up policies that allow firefighters to turn down assignments they believe are unsafe.

"It's a safety record that's been improving over time," says Jerry Williams, the agency's director of fire and aviation.

Yet last year was the deadliest since Storm King, totaling 30 fatalities; more than 200 wildland firefighters have died since 1994. Vehicle accidents and heart attacks account for the majority, but fiery burnovers like Thirtymile and Cramer "are troubling reminders that the agency still has a long way to go," says Furnish.

A haunting illustration of how the heroic, can-do attitude typical among many firefighters can backfire, the Thirtymile Fire began as what seemed a containable blaze that escaped from an abandoned picnic fire in Washington's Okanogen National Forest on July 9, 2001.

A small crew was sent in that evening and began to make headway. Commanders then assigned a crew of 21 firefighters, who arrived the following morning believing they'd have the fire controlled by nightfall.

But the temperature was nearing 100 degrees, and the blaze spread. By midafternoon, "the fire boss needed to put his hands on his hips and say, 'We've lost it, folks,' " Furnish says. "They needed to put their axes down and walk away."

Instead, as most of the team took a break and watched the fire race up a slope on the canyon's opposite side, a call came in from an engine crew just up the road, where three firefighters were trying to extinguish a small fire. “We've got some hot spots up here, and we need some help,” their radio crackled.

"The fire bosses should have said, 'What are you doing? Reel in your hoses, and get back down here!' " recalls Furnish. "But their knee-jerk reaction was to grab their tools and go try to help."

Over the next 90 minutes, the firefighters proceeded to break most all of the Forest Service's cardinal 10 Standard Fire Orders, failing to do everything from posting lookouts to identifying escape routes. Trapped when the fire began burning across the only road out of the area, "the crew was not prepared for the suddenness with which it arrived," the Forest Service's accident report states. "A rain of burning embers was followed by a rolling wave of heat, fire, smoke and wind."

As the crew members frantically tried to deploy their portable fire shelters, the fire overtook Karen FitzPatrick, 18; Jessica Johnson, 19; Devin Weaver, 21, and crew boss Tom Craven, 30--asphyxiating them in heat so intense that it transformed a pickup truck into a pile of molten aluminum. "The scariest part is that we almost had 16 fatalities that day," says Furnish.

His investigation laid blame squarely on those in charge and called for renewed emphasis on safety. "Safety and fire suppression need not be mutually exclusive, and safety must come first," his report's epilogue stated. "We need to drive this message home."

Yet whether that message got across remains unclear. In a profession for which advancement has long been tied to "having the zeal to be out there on the fire line," Furnish says that refocusing fire managers' priorities on safety first remains problematic. "Walking away from a fire . . . certainly hasn't been the sort of attribute that would secure a leadership position or a promotion."

OSHA investigators’ published their conclusions about the Cramer Fire in their report, which came out in March. "The wildland firefighting community still has a long way to go before they truly have a zero tolerance for infractions of firefighting safety standards," the report says. "Except after a tragic event, it appears upper management has rarely been held accountable for safety on the fire line."

Congress sought to address just that issue after the Thirtymile Fire, when it passed provisions requiring the Department of Agriculture's Office of the Inspector General to investigate burnover incidents like Cramer. The OIG is, indeed, close to completing a report on the Cramer fire.

But some contend such after-the-fact investigations are no substitute for the sort of on-the-job enforcement OSHA now oversees in the private sector but from which most of the government is exempt. Others have suggested that the Forest Service, which as a federal agency is also largely exempt from civil lawsuits, be held financially liable for the gross negligence of its employees.

"Sometimes people only change things when it hits them in the pocketbook," says Jodi Heath. "I just hope to God that three years from now I'm not looking at some other parent and saying, 'I really thought this would never happen again.'"