On August 29, 1998, two male volunteer fire fighters, a 35-year-old (Victim #1) and a 21-year-old (Victim #2), died of smoke inhalation while performing separate tasks during a fire at a commercial building (strip mall). Victim #1 was the nozzle man during an interior attack on one of the five stores comprising the commercial building, while Victim #2 was attempting to ventilate the roof of the same store when the roof collapsed. The two fire fighters were members of a volunteer engine company who responded to the fire at 0102 hours. The Chief and Assistant Chief arrived on scene at 0104 hours. The Chief assumed the duties as the Incident Commander (IC) and reported fire in the storage room in the rear of one of the stores. Within minutes, the IC called for additional backup and a neighboring volunteer fire department responded. Victim #2 and a fire fighter were assigned to ventilate the roof, while Victim #1 and a fire fighter and the Chief from a neighboring department started an interior attack on the same store. After about 25 minutes on the fire scene, the roof collapsed, trapping Victim #1 inside the store. The Chief and fire fighter who were with Victim #1 escaped. At the same time, but unknown to all other personnel at the scene, Victim #2 had fallen through the roof inside the same store and was also trapped. Although an attempt was made to locate Victim #1, who was 15 feet inside the front doorway and not wearing a PASS device, fire fighters could not locate him. Also, both fire departments had exhausted their breathing air supply and could not make any more rescue attempts until additional bottles of breathing air arrived. About 0150 hours, Victim #2 was discovered missing. At 0330 hours, after additional bottles of breathing air arrived, further rescue attempts were made and Victim #1 was located and removed from the structure. Victim #2 was located and removed during overhaul of the building around 0600 hours. NIOSH investigators concluded that, to minimize similar incidents, fire departments should: use defensive firefighting tactics when they do not have adequate apparatus, equipment and training ensure that accountability for all personnel at the fire scene is maintained establish and implement an incident command system with written standard operating procedures for all fire fighters ensure that fire fighters who enter hazardous areas, e.g., burning or suspected unsafe structures, are equipped with two-way communications with incident command establish standard operating procedures for fire fighters who conduct vertical ventilation ensure that Rapid Intervention Teams be established and in position immediately upon arrival at the fire scene enforce the wearing and use of PASS devices when fire fighters are involved in fire fighting, rescue, and other hazardous duties ensure that adequate personal protective equipment is available while fire fighters are engaged in fire activity.