On October 29, 2000, a 26-year-old male volunteer Assistant Chief (the victim) was seriously injured and two other fire fighters (Fire Fighter #1 and Fire Fighter #2) were injured while fighting a townhouse fire. The fire fighters responded to a call that had come in from Central Dispatch at 1909 hours as a reported chimney fire. Engine 9 was the first apparatus to arrive on the scene. The victim conducted a scene size-up and reported to Central Dispatch "smoke showing with fire extension to the roof" and that they were "in-service with a 1¾-inch hoseline." The victim then proceeded with a fire fighter (Fire Fighter #1) with 200 feet of charged 1¾-inch hoseline from Engine 9 into the townhouse's front door and up the stairs toward the back bedroom. At 1923 hours, Engine 8 arrived on the scene, and the Captain assumed incident command (IC). The IC sent a fire fighter (Fire Fighter #2) from Engine 8 with a portable radio into the structure to provide assistance to the Assistant Chief (victim). Fire Fighter #2 followed the hoseline until he met up with the victim and Fire Fighter #1 at the top of the stairs. At 1927 hours, Engine S7 arrived on the scene. The Captain of Engine 8 transferred command to the Assistant Chief of Engine S7. Upon entering the back bedroom, the victim, who was on the nozzle, encountered and quickly knocked down a fire that was burning from floor to ceiling near the window in the back corner. The victim advanced the hoseline to the window to attack the fire on the outside of the building near the top of the chimney. While attacking the fire, the victim had Fire Fighter #2 search for fire extension above the bedroom ceiling. Using a Halligan tool, Fire Fighter #2 began pulling ceiling in the bedroom and encountered heavy, black smoke and an increase in heat. As the victim was leaning out of the window attacking the fire around the chimney, he noticed fire coming from the window directly below him. He shut down the nozzle and proceeded toward the bedroom door. Due to the deteriorating conditions of the interior, the IC called Central Dispatch and requested an emergency evacuation. The victim proceeded toward the top of the stairs where he encountered intensifying heat. He then yelled to Fire Fighter #1 and Fire Fighter #2 that they needed to get out. Fire Fighter #1 and Fire Fighter #2 dropped to their knees and followed the hoseline toward the bedroom door. As the victim began hearing the sirens and air horns (signaling an emergency evacuation) he turned and saw the other two fire fighters coming toward the top of the stairs. He then forced himself to descend the stairs through the intense heat. When he got to his feet, he believed he was standing outside the front door due to the cooler air temperatures, so he removed his helmet, facepiece, and hood. After taking a breath, he quickly realized that he was not at the front door but was still inside. He used his helmet to break the window and began climbing out. A fire fighter and a police officer pulled him out of the window, and he was taken to an ambulance for medical treatment. The victim was transported to the regional level 1 trauma center before being life-flighted to the regional burn center. Fire Fighters #1 and #2 also encountered intense heat at the top of the stairs and could hear the sirens and air horns. Fire Fighters #1 and #2 forced themselves to descend the stairs through the intense heat. They were transported to the hospital and treated for their injuries. NIOSH investigators concluded that, to minimize the risk of similar occurrences, fire departments should: 1. ensure that the department's Standard Operating Procedures (SOPs) are followed and refresher training is provided; 2. ensure that fire fighting teams check each other's personal protective equipment (PPE) for complete donning; 3. ensure that a Rapid Intervention Team (RIT) stands by with equipment, ready to provide assistance or rescue; 4. ensure that the Incident Commander conducts a complete size-up of the incident and continually evaluates the risk versus gain during operations at an incident; 5. ensure that fire fighters report conditions and hazards encountered to their team leader or Incident Commander; 6. ensure that team continuity is maintained; 7. ensure that a separate Incident Safety Officer (ISO), independent from the Incident Commander, is appointed; 8. ensure that the assignment of a tactical channel is established by Central Dispatch prior to personnel entering a hazardous environment; 9. consider providing fire fighters with a Personal Alert Safety System (PASS) integrated into their Self-Contained Breathing Apparatus (SCBA); and, 10. ensure that ventilation is closely coordinated with the fire attack.