On January 11, 2001, a 27-year-old male volunteer fire fighter (the victim) died after becoming separated, disoriented, and lost as he and another fire fighter were trying to escape from the interior of a fully involved mobile home fire. Fire apparatus were dispatched to the site at 1110 hours, and at 1113 hours, the Chief arrived on scene in his privately owned vehicle (POV) and assumed incident command (IC). At 1122 hours, the first apparatus arrived: Engine 19 with the First Assistant Chief, a driver/operator, and two fire fighters (including the injured fire fighter). The Chief told them to set up in the driveway of the mobile home (Side 2), and pull two attack lines. At 1123 hours the next apparatus arrived: Engine 14 (mutual aid) with a driver/operator. Engine 14 set up his apparatus behind Engine 19, and prepared to supply water. At 1125 the final two apparatus arrived: Engine 15 (Captain and two fire fighters) and Engine 16 (Captain, Lieutenant [the victim], driver/operator, and one fire fighter. Both engines set up their apparatus and awaited instructions. The IC sent two crews to attack the fire-one crew entered the basement (Side 2), and the second entered the main floor from the porch (Side 1). The victim and the fire fighter from Engine 15 were in the first crew; they moved their attack from the basement to the porch, and then moved into the structure. A fire fighter from Engine 19, who was originally in the basement, joined them, and the three fire fighters moved down the hallway toward a back bedroom. The low-air alarm went off on the fire fighter from Engine 15, and he exited the mobile home to change his air bottle. The victim and remaining fire fighter hit the fire in the back bedroom until conditions deteriorated, and intense heat and smoke forced them to quit the interior attack and try to leave the structure. The deteriorating conditions also forced the second crew to quit the interior attack, and they were able to exit the home. As the victim and fire fighter from the first crew were trying to exit, thick smoke banked down to the floor and the heat intensified further, forcing them to follow the handline on their hands and knees. However, the line had looped over itself several times, and the two fire fighters became disoriented, got off the line, and crawled into an addition (12 ft x 12 ft) to the mobile home. The fire fighter from Engine 19 found a window, broke through it, and fell outside the mobile home. Other fire fighters assisted him, and he was transported to the local hospital, at 1202 hours. Between 30 and 40 minutes elapsed before it was determined that the victim was missing. At this time, several fire fighters began searching the grounds and the interior, and even called the local hospital to see if the victim had been transported there with the injured fire fighter. The victim was eventually located by a chief from one of the mutual aid departments, who crawled into the addition and saw the victimís boot. His body was removed to the outside and he was pronounced dead at the scene by the local coroner. NIOSH investigators concluded that, to minimize the risk of similar occurrences, fire departments should: 1) 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; 2) ensure that fire command always maintains close accountability for all personnel at the fire scene; 3) ensure consistent use of personal alert safety system (PASS) devices at all incidents and consider providing fire fighters with a PASS integrated into their self-contained breathing apparatus; 4) ensure that a rapid intervention team is established and in position immediately upon arrival; 5) ensure that a separate incident safety officer, independent from the incident commander, is appointed; 6) ensure fire fighting tactics and operations do not increase hazards on the interior-e.g., opposing hose streams; 7) ensure that any hoseline taken into the structure remains inside until all crews have exited; 8) use evacuation signals when command personnel decide that all fire fighters should be pulled from a burning building or other hazardous area; 9) ensure that personnel equipped with a radio, position the radio to receive and respond to radio transmissions; 10) ensure that team continuity is maintained; 11) ensure that ventilation is closely coordinated with the fire attack.