On January 6, 1998, a 58-year-old male career fire fighter with a 28-year service record with the employing fire department collapsed while responding to a residential oil heater fire. The ladder truck to which the fire fighter was assigned was the first piece of equipment to arrive at the fire scene and approached the dwelling from the street in front. After parking the vehicle, the fire fighter and three other fire fighters exited the truck wearing full protective gear and headed toward the front door of the dwelling. The homeowner stated that the fire was from an oil heater in the basement. Ground-level access to the basement was in the rear of the building. The fire fighter and his partner hurried to the back of the building, while the other two fire fighters began placing ladders to access the roof of the structure. When the fire fighter and his partner reached the basement access, he stopped, said, "Hold on, I'm tired," and placed his hands on his knees. When his partner asked if he was okay, the fire fighter did not respond. The fire fighter then fell face-first to the pavement. His partner turned him onto his back, and noted that he was cyanotic. The partner immediately called for assistance from other fire fighters on the scene, cut the strap to the fallen fire fighter's SCBA so it could be removed, and initiated cardiopulmonary resuscitation (CPR). Other firefighters arrived and assisted with CPR administration and removal of gear. Resuscitation efforts of rescue unit fire fighters, advanced life support medics, and hospital emergency department personnel failed. The medical examiner listed cardiac tamponade due to a ruptured myocardial infarct as the cause of death. Arteriosclerotic cardiovascular disease was listed as a contributing factor. A three-pronged strategy for reducing the risk of heart attacks among fire fighters has been proposed by other agencies. This strategy consists of (1) minimizing physical stress on fire fighters; (2) screening to identify and subsequently rehabilitate high-risk individuals; and (3) encouraging increased individual physical capacity. The following recommendations address potential health and safety problems uncovered during the NIOSH investigation. Some of the recommendations are specific to this fatality; others are more general in nature. Consider modifying the current medical evaluation of fire fighters to include stress electrocardiography for those above the age of 35 with at least one risk factor for coronary artery disease. Consider including a physician-signed medical clearance to wear respiratory protection, including self-contained breathing apparatus with full turnout gear, as a part of the existing medical evaluation program. Reduce risk factors for cardio-vascular disease and improve cardiovascular capacity by implementing a wellness/fitness program for fire fighters. Clarify the department's policy regarding Incident Command and improve fire fighter training on this policy. Review the department's policy regarding equipment provided for First Responders.