On April 14, 2003, at 2145 hours, a 54-year-old male career Lieutenant (LT) was on the roof of the fire building awaiting orders to ventilate when he suddenly collapsed. His Driver/Engineer (D/E), on the roof with him, alerted the Incident Commander (IC), who had crew members bring resuscitation equipment to the roof and begin medical treatment. Although unresponsive, the LT had a pulse, and was still breathing as he was removed from the roof. During the descent, however, he became pulseless and stopped breathing. Once on the ground, cardiopulmonary resuscitation (CPR) was begun as the LT was placed on a backboard and stretcher and loaded into an ambulance. He received advanced life support (ALS) treatment, including defibrillation and intravenous (IV) resuscitation medications, in the ambulance and was transported to the hospital where ALS measures continued for an additional 27 minutes with no improvement in his status and he was pronounced dead. The death certificate and autopsy, completed and performed by the Medical Examiner, listed "cardiac dysrhythmia" due to "atherosclerotic coronary artery disease" as the immediate cause of death and "superimposed physical exertion" as a contributing factor. The following recommendations address some general health and safety issues. This list includes some preventive measures that have been recommended by other agencies to reduce the risk of on-the-job heart attacks and sudden cardiac arrest among fire fighters. These selected recommendations have not been evaluated by NIOSH, but represent published research, or consensus votes of technical committees of the National Fire Protection Association (NFPA) or fire service labor/management groups. 1) Provide mandatory annual medical evaluations to ALL fire fighters consistent with NFPA 1582 to determine their medical ability to perform duties without presenting a significant risk to the safety and health of themselves or others; 2) Consider requiring exercise stress tests for fire fighters with two or more risk factors for coronary artery disease (CAD); 3) Phase in a mandatory wellness/fitness program for fire fighters to reduce risk factors for cardiovascular disease and improve cardiovascular capacity; 4) Although unrelated to this fatality, the Fire Department should consider this additional recommendation based on safety and economic considerations, Provide pre-placement medical evaluations consistent with NFPA 1582 to determine their medical ability to perform duties without presenting a significant risk to the safety and health of themselves or others; 5) Perform an annual physical performance (physical ability) evaluation to ensure fire fighters are physically capable of performing the essential job tasks of structural fire fighting; 6) Provide adequate fire fighter staffing to ensure safe operating conditions; 7) Provide fire fighters with medical evaluations and clearance to wear SCBA.