On April 4, 2004, a career fire fighter (the victim) died while fighting a night club arson fire. Crews were dispatched at 0555 hours to a reported truck fire (hazardous material incident), but arrived on the scene to discover a structure fire. Engine 50 was the first to arrive on the scene. The Captain and two crew members (a fire fighter and the victim) initiated a "fast attack." District Chief 5 arrived on the scene and assumed command. Ladder 38 arrived shortly after Engine 50, and the Ladder 38 crew entered the building to assist the Engine 50 crew. Fire fighters decided to exit the building as conditions were deteriorating. It is believed that the victim became separated from his crew at this time. The Incident Commander called for operations to go defensive at the same time the crews were making their way out of the building. A fire fighter from Ladder 38 reentered the building after realizing that his Captain had failed to exit with the crew. He found and dragged the Engine 50 Captain (unconscious) to safety before returning and assisting the Ladder 38 Captain (semi-conscious) out of the building. The victim failed to exit the building and was later found in the debris. NIOSH investigators concluded that, to minimize the risk of similar occurrences, fire departments should: 1. ensure that the first arriving officer conducts a complete size-up of the incident and evaluates the risk versus gain prior to committing crews to interior operations; 2. ensure that fire fighters conducting interior operations provide progress reports to the Incident Commander; 3. ensure that fire department standard operating procedures (SOPs) are followed regarding thermal imaging camera (TIC) use during interior operations; 4. ensure that all fire fighters and line officers receive annual refresher training regarding structural fire fighting; 5. establish and implement an orientation and training program for all newly appointed, promoted, or reassigned officers; and, 6. consider ways to enhance the effectiveness of the personnel accountability system.