On April 30, 2000, a volunteer fire department prepared to complete a controlled-burn training evolution. At 0700 hours, the following volunteer fire fighters gathered at the fire station to discuss their plan of action: the Chief, Assistant Chief (the victim), Captain, Second Rescue Lieutenant, Chief Engineer, Third Assistant Chief Engineer, and four fire fighters. At 0730 hours, they arrived on the scene of a 2½-story farmhouse which they would use to complete the controlled-burn training evolution. After completing their setup of laying out water curtains (a stream of water projected through a pipe to cool exposures) and hoselines, the fire fighters walked through the structure to familiarize themselves with the layout. The Chief, victim, and Second Rescue Lieutenant entered the front door of the structure and placed hay on the floor. The fire fighters ignited the hay and completed the first training evolution by extinguishing the fire. The fire fighters then completed three additional training evolutions (all the same) before taking a break. The fire fighters then completed additional training using gasoline-powered saws to cut holes in the interior floors and porch roof. The fire fighters then regrouped and prepared to complete the last training evolution, which involved burning the structure from top to bottom. The victim, Second Rescue Lieutenant, Third Assistant Chief Engineer, and a fire fighter proceeded to the attic of the structure (a room approximately 1,000 square feet with an 8-foot ceiling). The victim used a small liquid sprayer to spray diesel fuel on debris, which was spread throughout the attic. The Second Rescue Lieutenant and the Third Assistant Chief Engineer struck a flare and ignited the debris in several places throughout the attic. The fire quickly accelerated and all the fire fighters in the attic, except for the victim who was wearing full turnouts and a self-contained breathing apparatus, exited. The victim stated that he was going to stay in the attic to make sure that the fire was burning adequately. The fire intensified and smoke and heat started banking down the attic stairs. The Chief and fire fighters noticed that the victim did not exit and made several attempts to locate him. The Captain and Second Rescue Lieutenant were able to locate the victim, who was unconscious on the attic floor, but were unable to remove him. Shortly after, the attic roof collapsed, forcing the fire fighters to make a defensive attack. The fire was eventually extinguished and the fire fighters removed the victim, who was pronounced dead at the scene. NIOSH investigators concluded that, to minimize the risk of similar incidents, fire departments should: 1. ensure that flammable or combustible liquids as defined in NFPA 30 not be used in live fire training; 2. ensure that proper ventilation is in place before a controlled burn takes place; 3. ensure that fires not be ignited in any designated path of exit; 4. ensure that an evacuation signal is communicated to all fire fighters prior to ignition; 5. ensure that a building evacuation plan is in place and all fire fighters are familiar with the plan; 6. ensure that a method of fireground communication is established to enable coordination among the incident commander and fire fighters; 7. ensure that a safety officer be appointed for all live fire training; 8. ensure that each fire fighter be equipped with full protective clothing and a SCBA; 9. ensure that backup personnel are standing by with equipment, ready to provide assistance or rescue; 10. ensure that only one person be assigned as the "ignition officer" and it not be a fire fighter participating in the training; 11. ensure that exterior fire attack is at a minimum during search and rescue; and, 12. ensure that fire fighters who enter a hazardous condition enter as a team of two or more.