On January 21, 1998, one male volunteer fire fighter (the victim) died of smoke and soot inhalation and a second fire fighter escaped without injury while attempting to determine the origin of fire in a supermarket. A volunteer Engine Company composed of three fire fighters (Lieutenant, Captain, and fire fighter), responded to a structure fire at a local supermarket. When the Engine Company arrived at the fire scene, the Lieutenant reported heavy black smoke emitting from the ventilation system at the rear of the store. Equipped with full turnout gear, self-contained breathing apparatus (SCBA), ax, light, and portable radio, the Captain and the victim entered through the front doors of the store to determine the fire's origin. Both fire fighters proceeded through heavy black smoke to the rear of the store, became disoriented, and radioed for help. The victim ran out of air and died from smoke and soot inhalation while the Captain managed to escape through the front of the store. Rescue attempts were made but failed due to heat and smoke. NIOSH investigators concluded that, in order to prevent similar incidents, fire departments should: ensure that fire fighters who enter hazardous areas, e.g., burning or suspected unsafe structures, be equipped with life lines or a hose line ensure that fire fighters wear and use PASS devices when involved in fire fighting, rescue, and other hazardous duties ensure that departments establish and implement an incident management system with written standard operating procedures for all fire fighters ensure that backup personnel stand by with equipment, ready to provide assistance or rescue.