On September 14, 2002, a 53-year-old male career fire fighter died after falling through a roof following roof ventilation operations at a house fire. The victim, who was not wearing a self-contained breathing apparatus (SCBA), was observing another fire fighter who was wearing an SCBA while making ventilation cuts. After making the last cut, the victim, who had been covering his face with his hands, told his partner that they had to leave immediately. The fire fighters retreated toward the aerial platform, but the victim stopped a few feet from the platform, saying he could not continue. Seconds later, the area of the roof under the victim failed, and he fell through the roof into the structure and the fire. Within minutes the interior attack crew found the victim and, with the help of the Rapid Intervention Team (RIT), removed him. He was transported to a local hospital where he was pronounced dead. NIOSH investigators concluded that, to minimize the risk of similar incidents, fire departments should: 1. enforce existing standard operating procedures (SOPs) for structural fire fighting, including the use of self-contained breathing apparatus (SCBA), Incident Command System, Truck Company Operations, and Transfer of Command; 2. ensure that the Incident Commander evaluates resource requirements during the initial size-up and continuously evaluates the risk versus benefit when determining whether the operation will be offensive or defensive; 3. develop, implement and enforce SOPs regarding vertical ventilation procedures; 4. review dispatch/alarm response procedures with appropriate personnel to ensure that the processing of alarms is completed in a timely manner and that all appropriate units respond according to existing SOPs; 5. ensure that Incident Command maintains the role of director of fireground operations and does not become involved in fire-fighting efforts; 6. ensure that adequate numbers of staff are available to immediately respond to emergency incidents; and, 7. consider using a thermal imaging camera (TIC) as part of the exterior size-up.