On August 13, 2000, a 28-year-old male fire fighter/self-contained underwater breathing apparatus (SCUBA) diver (Diver #1 [the victim]) died during a training evolution. The victim was a member of the career fire department's Dive and Rescue team. The victim and other team members gathered at the site of the incident and prepared to complete training evolutions, which involved search and recovery. After a short class covering vectors for the last known location and a pre-dive briefing of the training evolution, a weighted baby doll was placed in the water, approximately 100 feet from the shore. The victim and his dive partner (Diver #2) entered the water and followed vector points (visual line of site) based on the location where the baby doll was released. Reaching the area where the baby doll was released, they dropped a buoy marker and returned to the shore. After splitting up into two teams, the victim and his partner and two other divers (Diver #3 and Diver #4) entered the water and swam to the buoys, which they had placed earlier to perform underwater search patterns. Divers #3 and #4 descended their buoy line first, and the victim and his partner descended their buoy line shortly after. As both teams performed their search patterns at a depth of 70 feet, the divers from both teams eventually became separated from their partners. Diver #4 searched for his partner (Diver #3) as Diver #2 surfaced to locate the victim's air bubbles and relocate his position. As Divers #2 and #4 searched for their partners, Diver #3 came in contact with a distressed diver whom he determined to be the victim. Diver #3 tried to calm the victim as he frantically screamed and moved around, knocking off Diver #3's facepiece. After re-donning his facepiece, Diver #3 attempted to surface to get help. Diver #3 became entangled in the search lines and eventually received assistance from Diver #2 to get free. Divers #2 and #3 surfaced and reported to the dive instructor that the victim was distressed and was still on the bottom. The dive instructor swam out to the location and the instructor, Diver #3, and Diver #4 pulled up the buoy line that the victim and Diver #2 had descended. The victim, who had become entangled in the buoy line, was pulled to the surface by the buoy line. The victim was unconscious and had red froth near his mouth and nose. En route to the shore (via boat), the victim received medical assistance which continued on the shore. He was then loaded into a helicopter and transported to a nearby trauma center where he was pronounced dead. NIOSH investigators concluded that, to minimize the risk of similar incidents, fire departments should: 1. ensure that positive communication is established among all divers and those personnel who remain on the surface; 2. ensure that underwater searches are completed individually to avoid possible rope entanglement; 3. ensure that equipment checks are performed before each dive; 4. consider that appropriate medical fitness evaluations for SCUBA work are obtained and updated on all divers; 5. ensure that all divers record each dive in a dive log; 6. ensure that divers are trained to perform rescue operations for other divers who may be in distress; 7. consider developing a pre-dive checklist for all diving situations, including training; 8. consider supplying divers with an alternative air source; 9. consider upgrading their diving standard operating procedures (SOPs) and include the 29 Code of Federal Regulations (CFR) 1910 for commercial diving operations; and, 10. consider upgrading manual underwater communication devices with hands-free underwater communication devices.