On March 18, 2001, two volunteer fire fighters, a 36-year-old male lieutenant (Victim #1) and a 39-year-old male fire fighter (Victim #2) died, and an Assistant Chief was injured while trying to exit the first floor of a private residence after a partial collapse of the second floor. At approximately 0025 hours, Central Dispatch received a call from the owner of the residence stating that the upstairs was on fire. Central Dispatch immediately notified the volunteer department of the incident. The Assistant Police Chief was the first to arrive on the scene and noticed smoke venting from the second floor roof on both the east and west sides of the structure. At 0029 hours, the Assistant Police Chief confirmed that all occupants were out of the house and proceeded with traffic control. Engine 78 arrived on the scene at 0033 hours with an Engine Operator (Victim #1) and was positioned to the north side of the structure. The Assistant Chief arrived on the scene at 0041 hours and shortly thereafter entered the structure to man the nozzle of a 1½-inch handline already inside from an initial assessment conducted by Victim #1 and a fire fighter. Victim #1 and Victim #2 entered the structure just after the Assistant Chief to provide backup for an aggressive fire search and interior suppression. Both the Assistant Chief and Victim #2 became low on air. The Assistant Chief instructed Victim #1 to lead Victim #2 out of the structure by following the hoseline. The Assistant Chief continued to fight the fire while the two victims attempted to exit. The two victims left the area together, but apparently became disoriented from a partial collapse of the second floor and ended up in the laundry room. When the Assistant Chief tried to exit, it is believed that he was knocked down in the living room by part of the second-floor collapse. Crew members on the scene were able to pull the Assistant Chief from the structure, but the intensity of the fire and the lack of backup self-contained breathing apparatus (SCBAs) hindered additional rescue attempts. The mutual-aid departments were able to get the fire under control for the removal of the two victims at approximately 0146 hours. Both victims were found on the floor of the laundry room at the east end of the hallway. They were removed from the structure by a mutual-aid company and later pronounced dead at the hospital. NIOSH investigators concluded that to minimize the risk of similar occurrences, fire departments should: 1. ensure that an adequate number of staff are available to immediately respond to emergency incidents; 2. ensure that 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 the incident; 3. ensure that officers enforce and fire fighters wear their SCBAs whenever there is a chance they might be exposed to a toxic or oxygen deficient atmosphere, including the initial assessment; 4. 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 which provides for automatic activation; 5. ensure vertical ventilation takes place to release any heat, smoke, and fire; 6. ensure supervisors remain accountable for all who operate under their supervision and ensure that a team continuity of at least two fire fighters is maintained; 7. provide adequate on-scene communications including fireground tactical channels; 8. implement an emergency notification system to rapidly warn all persons who might be in danger if an imminent hazard is identified or if a change in strategy is made; 9. ensure that adequate personal protective equipment is available while fire fighters are engaged in fire activity; and, 10. develop and implement a preventative maintenance program to ensure that all self- contained breathing apparatus (SCBAs) are adequately maintained.