On January 9, 1999, a male volunteer fire fighter (the victim) died of smoke inhalation while performing an interior attack on a fire at a single-family dwelling. A city police officer, who was first on-scene, entered the structure to try to extinguish the blaze with a portable fire extinguisher, and assisted the exit of family members from the structure. A volunteer engine company composed of a driver/operator and a fire fighter (the victim), were the first arriving company to the fire. When the engine company arrived, the driver/operator reported heavy smoke and fire showing from the northwest corner of the house. The Chief arrived within minutes of the first engine. The Chief then assisted the driver/operator in connecting the supply line to a fire hydrant approximately 150 feet away. At the same time, the victim and the police officer dragged the 1 3/4-inch hose from the engine to the front porch of the structure. The victim, wearing full turnout gear, donned an self -contained breathing apparatus (SCBA) and entered the structure to extinguish the fire. The Chief, returning from hooking up to the hydrant, noticed that the victim was not present and went around the exterior of the house to locate him. The Chief went to the hoseline that was inside the front door of the structure and pulled on it to get the victim's attention. He did not feel any resistance on the line. The Chief then called "Man Down." At that same time, the Assistant Chief and three other fire fighters arrived in their privately owned vehicles (POVs). The Chief ordered a rescue attempt and the Assistant Chief, one fire fighter, and the driver/operator donned their SCBAs and entered the structure to search for the victim. They could only enter about 2 feet due to heavy smoke and extreme heat. Within minutes of the Assistant Chief entering the building, the water pressure dropped. Because of construction in the area, the water company previously reduced the flow of water on the main water line. The crew was forced to retreat because their SCBA low-air alarms began to sound. After the Assistant Chief and fire fighter's changed their air bottles, the porch and part of the roof collapsed. The Chief then ordered an exterior attack with three charged lines. Approximately 2 hours after arrival, the fire was knocked down, and the attempts to locate the victim continued. The victim was found approximately 10 feet inside the structure. NIOSH investigators concluded that, to minimize similar incidents, fire departments should: establish and implement an incident management system with written standard operating procedures for all fire fighters and ensure all fire fighters are trained on the system; ensure that command conducts an initial size-up of the incident before initiating fire fighting efforts and continually evaluates the risk versus gain during operation at an incident; ensure at least four fire fighters are on the scene before initiating interior fire fighting operations at a working structure fire; ensure that fire fighters wear and use PASS devices when involved in fire fighting, rescue, and other hazardous duties; ensure that fire fighters who enter hazardous areas, e.g., burning or suspected unsafe structures, be equipped with two-way communications with incident command; ensure automatic aid is established when known water pressure problems exist.