On March 14, 2001, a 40-year-old male career fire fighter/paramedic died from carbon monoxide poisoning and thermal burns after running out of air and becoming disoriented while fighting a supermarket fire. Four other fire fighters were injured, one critically, while fighting the fire or performing search and rescue for the victim. The fire started near a dumpster on the exterior of the structure and extended through openings in the loading dock area into the storage area, and then into the main shopping area of the supermarket. The fire progressed to five alarms and involved more than 100 personnel. Fire fighters removed the victim from the structure and transported him to a local hospital where he was pronounced dead. 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 continuous refresher training is provided; 2. ensure that a proper size-up, using common terminology, is conducted by all fire fighters responsible for reporting interior/exterior conditions to the Incident Commander (IC); 3. ensure that pre-incident plans are established and updated on mercantile occupancies in their district; 4. ensure that fire fighters manage their air supplies as warranted by the size of the structure involved; 5. instruct and train fire fighters on initiating emergency traffic (Mayday-Mayday) and on the importance of activating their personal alert safety system (PASS) device when they become lost, disoriented, or trapped; 6. ensure that multiple Rapid Intervention Crews (RIC) are in place when an interior attack is being performed in a large structure with multiple points of entry; 7. consider placing fire fighter identification emblems on the fire fighters' helmet and turnout gear; 8. consider placing a bright, narrow-beamed light at all entry portals to a structure to assist lost or disoriented fire fighters in emergency egress. Additionally, 1. Building owners should consider upgrading or modifying structures to incorporate new codes and standards to improve occupancy and fire fighter safety. 2. Fire departments should consider as a part of their pre-incident planning, educating the public they serve on the importance of building owners, building personnel, or civilians immediately reporting any fire conditions to the first-arriving fire company on the scene. 3. Manufacturers and research organizations should conduct research into refining existing and developing new technology to track the movement of fire fighters inside structures.