On June 16, 1999, a 38-year-old male fire fighter/Captain (the victim) died after falling approximately 20 feet from the top of a ladder which had been previously raised to the second-story window of a fire building at a fire training center. On the morning of the incident, several fire departments were involved in a multi-jurisdictional, multi-company training exercise. The exercise was conducted by three divisions performing separate evolutions simultaneously. Division A demonstrated proper tactics and procedures during live fire-attack operations and proper search-and-rescue techniques within a simulated single-family residential occupancy. Division B demonstrated proper search-and-rescue techniques and ladder-rescue operations from a second-story elevated platform and/or window, and Division C demonstrated proper tactics and procedures for advancing a fire-attack hoseline to gain access to a third floor fire by entering a second-floor window via a ladder and extending the hoseline up a stairwell to the fire. The evolutions were to be performed twice a day over a 3 day period (session #1 in the morning, and session #2 in the afternoon). The incident occurred near the end of session #1 on the first day of training. The victim, who was acting as a proctor for the training exercise and monitoring Division C, was positioned on the second floor of the training facility with Division C, which had just completed their evolution when the incident occurred. The victim and fire fighters from Division C were assembled on the second story when the air horn sounded to evacuate the building as previously planned. At that time, and for unknown reasons, the victim announced he was going to attempt a new procedure he had learned previously at a Rescue Intervention Training Course, which was referred to as the "bail out." The new procedure involved a head-first advance over the top of the ladder, hooking an arm through a ladder rung, and grasping a side rail, swinging the legs around to the side of the ladder and sliding down the ladder to the ground. Without hesitation or comment, the victim, who was about 3 feet away from the top of the ladder, took one step and leaped over the top of the ladder. The victim was unable to adequately hook the ladder rungs or grasp a ladder side rail and fell about 20 feet headfirst to the concrete landing. Although the victim received immediate attention from fire fighters and medics in the area, the victim was transported to the local hospital where he was pronounced dead, about 40 minutes after the incident. NIOSH investigators concluded that, to minimize similar occurrences, fire departments should: Ensure that all new training programs undergo a comprehensive review prior to the implementation of the program. Collaborate with other fire-related organizations regarding the feasibility of all new training procedures before the programs are implemented. Ensure that all aspects of safety are adhered to per established standards and recommendations while training is being conducted. Designate individual safety officers at all significant training exercises to observe operations and ensure that safety rules and regulations are followed.