On March 31, 2000, a 36-year-old male career fire fighter (the victim) died, and three other fire fighters were injured while fighting a residential garage fire. The fire fighters had responded to a call that had come in from Central Dispatch at 2200 hours. As Engine 1 approached the scene from the south, at 2207 hours, the Captain assumed Incident Command (IC) and conducted a quick size-up of the south, east, and north sides of the structure as Engine 1's driver drove past and parked the apparatus just north of the scene. The IC reported to Central Dispatch smoke and flames showing at the garage window on the south side of the structure and smoke coming from around the edges of the closed garage door. The IC proceeded to the garage door where he kicked in one corner of the door while the two fire fighters from Engine 1 (victim and Fire Fighter #1) stood at the door with 200 feet of charged 1 3/4-inch hose line. They quickly knocked down most of the fire in the garage. Believing that the fire was knocked down, the IC instructed the victim and Fire Fighter #1 to enter the structure, go upstairs, search for any civilians who may be inside, and open some windows for ventilation. The victim and Fire Fighter #1 proceeded with their 1 3/4-inch hose line through the front door. The smoke just inside the front door was thick and black and was banked from the ceiling to just above floor level. The Lieutenant from Engine 2 (Lieutenant and two fire fighters), who had just arrived on the scene, was directed by the IC to follow the 1 3/4-inch line into the structure and provide assistance to the two fire fighters (victim and Fire Fighter #1) who had just entered the structure. The Lieutenant followed the hose line until he reached the two fire fighters upstairs at the end of the hall, in front of the master bedroom door. The Lieutenant noticed a glow at the end of the hall near the stairway and that the heat had dramatically increased. He then turned and sprayed water down the hall, hoping to knock down the heat. Unsuccessful at knocking down the heat, the Lieutenant, Fire Fighter #1, and the victim moved farther down the hall to try and escape the heat. The Lieutenant then decided that they had to exit by following the hose line back to the front door. Fire Fighter #1 came out the front door followed by the Lieutenant, who believed that the victim was following him, but the victim never came out. A Rapid Intervention Team (RIT) consisting of two fire fighters from Ambulance 1 were assembled and were able to enter through bedroom #2's window. At approximately 2239 hours, the RIT located the victim in the master bedroom and dragged him back through bedroom #2 and out the window to the fire fighters waiting on the garage roof and in the driveway. The victim was transported by ambulance to a nearby hospital where he was pronounced dead at 2317 hours. NIOSH investigators concluded that, to minimize the risk of similar occurrences, fire departments should: establish and implement written standard operating procedures (SOPs) regarding emergency operations on the fireground; ensure that the Incident Command conducts a complete size-up of the incident before initiating fire fighting efforts, and continually evaluates the risk versus gain during operations at an incident; ensure that fire fighters conducting a search above a fire take safety precautions to reduce the risk of being trapped; ensure that a separate Incident Safety Officer (ISO), independent from the Incident Commander, is appointed; ensure that Incident Command always maintains close accountability for all personnel at the fire scene; ensure that a Rapid Intervention Team (RIT) stand by with equipment, ready to provide assistance or rescue; consider providing fire fighters with a Personal Alert Safety System (PASS) integrated into their Self-Contained Breathing Apparatus (SCBA); ensure that the Incident Commander be clearly identified as the only individual responsible for the overall coordination and direction of all activities at an incident; ensure that the Incident Commander maintains the role of director and does not become involved as a laborer.