On May 3, 2002, a 38-year-old male career fire fighter (Victim #1) died after he became lost and ran out of air while searching for a missing 38-year-old male career fire fighter (Victim #2) at a four-alarm, two-story structure fire. Victim #2 was identified as missing when he failed to respond to a member accountability roll call (MARC). Victim #1 reentered the structure to search for Victim #2 as part of a search-and-rescue team. Shortly thereafter, Victim #1 became lost and radioed Mayday several times. After extensive searches for both victims, they were removed from the structure and provided medical attention on the scene. They were then transported by Emergency Medical Services (EMS) to a local hospital. Victim #1 was pronounced dead on arrival, and Victim #2 was pronounced dead the following day. NIOSH investigators concluded that, to minimize the risk of similar occurrences, fire departments should: 1. ensure that team continuity is maintained; 2. ensure that a rapid intervention team is established and in position immediately upon arrival; 3. ensure that the incident command system is fully implemented at the fire scene; 4. ensure that fire fighters, when operating on the floor above the fire, have a charged hoseline; 5. instruct and train fire fighters on manually activating their PASS device when they become lost, disoriented, or trapped; 6. ensure that a separate Incident Safety Officer (ISO), independent from the Incident Commander, is appointed; 7. ensure that Standard Operating Procedures (SOPs) and equipment are adequate and sufficient to support the volume of radio traffic at multiple-alarm fires; and, 8. ensure that self contained breathing apparatus (SCBAs) are properly inspected, used, and maintained to ensure they function properly when needed.