On July 15, 1999, one male fire fighter/paramedic/rescue diver (the victim) drowned while taking part in a drill. The victim, one of four rescue divers and a boat driver participating in a training drill, was assigned the "Pivot Diver" position. During the drill, a Safety Diver was to remain at the surface. The Pivot Diver (the victim), was to enter the water, follow the anchor line to the bottom, set up with a 50-foot length of rope, then signal the Pattern Diver (whose duty is to swim in a circular pattern searching for a rescue/recovery target) to descend and proceed with the drill. The crew on the surface observed air bubbles as the victim descended. Approximately 2 minutes later the rope bag surfaced while the bubbles continued. It appeared to the crew on the surface that the victim was searching for the rope bag because the air bubbles appeared to be moving back and forth. The Lead Diver instructed the Pattern Diver to descend and retrieve the victim. The Lead Diver also started to knock on the bottom of the rescue boat with a dive knife in hopes of signaling the victim to return to the surface. When the Pattern Diver surfaced, he reported the victim could not be found. The Lead Diver then instructed the Boat Driver to radio for emergency assistance and implement the department's Incident Command System (ICS). The Lead Diver also directed the Safety Diver to initiate rescue of the victim. When the Safety Diver surfaced without the victim, the Lead Diver instructed the Safety Diver to assume the role of Pivot Diver. The Lead Diver assumed the role of Pattern Diver. Both the Safety Diver and Lead Diver dove below the surface to initiate a rescue of the victim. The victim was found during the search and brought to the surface approximately 11 minutes after the Boat Driver initially requested emergency assistance. When the victim was brought to the surface, the air regulator was not in his mouth and he was noticeably cyanotic and unresponsive. The victim received immediate medical attention on the Rescue Boat and while en route to a regional trauma center, where he was pronounced dead upon arrival. NIOSH investigators concluded that, to reduce the risk of similar incidents, fire departments that provide Public Safety Diving (PSD) rescue services should: review and update fire department policies and Standard Operating Procedures to incorporate information contained within NFPA 1670-1999, Standard on Operations and Training for Technical Rescue deemed as appropriate. Consider that whenever water-based training sessions are conducted, all participants have practiced the specific evolution in a controlled environment such as a swimming pool before attempting the evolution in open water. Ensure that positive communication is established between all divers and those personnel who remain on the surface. Additionally, the membership of the National Fire Protection Association (NFPA) should consider adding relevant sections that establish minimum job performance requirements for Rescue Technicians engaging in Public Safety Diving activities during the next adoption cycle of NFPA 1006, Standard for Rescue Technician Professional Qualifications.