On August 19, 1997, three male fire fighters (the victim and two injured fire fighters), ages 21-, 27- and 35-years-old, entered a restaurant/tavern structure that had smoke and flames emitting through the roof above the kitchen area. The fire fighters entered the structure by crouching/crawling through the front door and advancing about 15 feet into the interior of the structure. About 10 minutes later, intense heat filled the area. The heat apparently startled or panicked the victim, who tried to run for the doorway entrance. The victim subsequently died from asphyxiation, while the other two fire fighters received serious burns. Also, a fourth fire fighter, age 48 years, received serious burns during a rescue attempt. NIOSH investigators concluded that, to prevent similar incidents, employers should: ensure that defensive (exterior operation) fire fighting tactics are suspended prior to switching the strategic mode of operation to an offensive strategy (interior fire attack with hand lines), and notify all affected personnel of the change in strategic modes; ensure that fire fighters who enter hazardous areas, e.g., burning or suspected unsafe structures, be equipped with two-way communications with incident command; establish and implement an incident-management system with written standard operating procedures for all fire fighters.