As part of the Health Hazard Evaluation program at NIOSH, investigators assessed health and safety practices by fire fighters at a site where a fire fighter died of heat stroke. The victim was a 25 year old man who died during a brush fire on September, 6, 1990, in Sedgwick County, Kansas. NIOSH investigators visited the site during November 13 to 15, 1990. They toured the fire scene, and conducted interviews with fire fighters, administrators, and support personnel. Others reported that the victim fought the fire until he was exhausted and instructed by his captain to rest and drink fluids. He was reassigned to drive a tank truck. There was confusion about whether the victim was another downed fire fighter. The victim's body was found in a wooded area near the fire scene. Cause of death on the coroner's report was heat stroke. The factors contributing to the victim's death were hot ambient temperature, high radiant heat load, and performing moderate to heavy work while wearing protective clothing. The NIOSH investigators concluded that a preventable series of events preceded the fire fighter's death. They recommend separating command and safety positions at complex fire scenes so that standard operating procedures of safety can be established; that all fire fighters wear personal alert safety systems; that fire fighters operate in teams; and that departments conduct periodic reviews of heat stress related topics.