On March 5, 2008, a 35-year-old male volunteer Fire Lieutenant (the victim) died while fighting a basement fire. About 30 minutes after the fire call had been dispatched and the crews had been evacuated from the structure and accounted for, a decision was made to re-enter the structure to try and extinguish the fire. The victim, an Assistant Chief (AC), and a Captain had made their way down an interior stairway to the basement area where the victim opened a 1 ¾-inch hoseline. Shortly thereafter, the Captain told the AC that he had to exit the basement stairs. A few seconds later, the AC told the victim to shut down the line and evacuate the basement because the fire was intensifying. The AC was second up the stairs and told a fire fighter at the top of the stairway landing that the victim was coming up behind him. The AC exited the structure while the fire fighter stayed at the top of the stairway and yelled several times to the victim, but received no response. The fire fighter exited the structure and informed the AC that the victim had not come up from the basement. The AC then notified the Incident Commander who activated a rapid intervention (RIT) team. The RIT made entry into the structure but was repelled by the intensity of the fire. After several more rescue attempts, the victim was removed from the building and later pronounced dead at the hospital. Four other fire fighters were treated for minor injuries and were released from the hospital. The following factors were identified as contributing to the incident: an absence of relevant standard operating guidelines; lack of fire fighter team continuity; suboptimal incident command and risk management; and lack of a backup hose line. NIOSH investigators concluded that, to minimize the risk of similar occurrences, fire departments should: 1. review, revise as necessary, and enforce standard operating guidelines (SOGs) to include specific procedures for basement fires and two-in/ two-out procedures; 2. ensure that team continuity is maintained with two or more fire fighters per team; 3. ensure that the Incident Commander continuously evaluates the risks versus gain when determining whether the fire suppression operation will be offensive or defensive; 4. enforce standard operating guidelines (SOGs) regarding thermal imaging camera (TIC) use during interior operations; 5. ensure that a separate Incident Safety Officer, independent from the Incident Commander, is appointed and utilized when incidents escalate in size and complexity; 6. ensure that a backup hose line is pulled and in place prior to entry into fire-involved structures; 7. ensure that all fire fighters have portable radios and they are operable in the fireground environment; 8. ensure that fire fighters are trained on initiating Mayday radio transmissions immediately when they are in distress, and/or become lost or trapped; 9. while the following recommendation may not have prevented the death of the fire lieutenant, fire departments should ensure periodic mutual aid training is conducted.