On November 25, 2000, a 30-year-old career male fire fighter (the victim) died in a residential house fire. At 0135 hours, fire fighters received a call of a reported structure fire. Engines 5, 2, 1, Ladder 11, and Rescue 32 responded to the early morning call. At 0141 hours, Engine 5 arrived on the scene and the Captain assumed incident command (IC). The IC reported to dispatch that they had a well-involved, single-story house fire. He then decided to send a search team inside the structure because it was unclear if the homeowners had exited. The victim from Engine 5, and the Captain and the Lieutenant from Rescue 32, teamed up to enter the house and complete the search. The victim, Captain, and Lieutenant advanced a 1ĺ-inch handline through the front door as the Captain and Lieutenant from Ladder 11 were ordered to set up a positive pressure ventilation (PPV) fan at the front door and then back up the search crew. The Lieutenant and a fire fighter from Engine 1 advanced a second line to the rear of the structure to attack the fire. The victim, and the Captain and Lieutenant from Rescue 32, advanced their line down a hallway and into a bedroom when the Captain noticed heavy fire in a room off to their right. The Captain requested that the victim pass him the nozzle because there was heavy fire in an adjacent room in the rear of the structure and he was afraid it was going to flash. The Lieutenant responded, saying that they could not locate the nozzle. In fear of a possible flashover, the Captain ordered the victim and Lieutenant to exit immediately. As the three attempted to exit, the hallway became heavily involved with fire. The Lieutenant and Captain fell over debris and the victim became disoriented. The Captain and Lieutenant exited the structure but the victim did not exit. The IC immediately ordered exterior crews to enter the structure and search for the missing victim. Approximately 56 minutes later, fire fighters found the victim. He was pronounced dead at the scene. NIOSH investigators concluded that, to minimize the risk of similar occurrences, fire departments should: 1) ensure that the departmentís standard operating procedures (SOPs) are followed; 2) ensure that when entering or exiting a smoke-filled structure, fire fighters follow a hoseline, rope, or some other type of guide and refresher training is provided to reinforce the procedures; 3) ensure that a rapid intervention team(s) (RIT) is established when fire fighters enter an immediately dangerous to life and health atmosphere, and the RITs be properly trained and equipped; 4) consider providing all fire fighters with a personal alert safety system (PASS) integrated into their self contained breathing apparatus; 5) consider increasing the number of fire fighters on engine companies to perform in accordance with NFPA standards; 6) consider providing all fire fighters with portable radios or radios integrated into their face pieces. Additionally, dispatchers and emergency call takers should; 7) obtain as much information as possible from the caller and report it to the responding companies.