On January 19, 2003, a 32-year-old volunteer fire fighter died while fighting a structure fire at a specialized vehicle restoration shop. Soon after beginning interior attack operations, the fire intensified and rolled over the heads of the 4-member crew. Within minutes, the nozzleman had to exit the building due to burning hands and another fire fighter took the nozzle. As he was exiting, an air horn was sounded warning the crew to exit the building. Two of the three remaining crew members made it to safety. Less than a minute after they exited, a nitrous oxide cylinder that was attached to a race car in the building exploded. A Rapid Intervention Crew (RIC) was assembled to rescue the missing fire fighter (the victim). The RIC made two attempts to rescue the victim but had to exit because of the intensity of the fire. After approximately 40 minutes of master stream application, three teams entered the structure and found the victim lying near the office door. The alarm for his Personal Alert Safety System (PASS) device was functioning but was not audible due to his prone position. NIOSH investigators concluded that, to minimize the risk of similar occurrences, fire departments should: 1) develop and enforce standard operating procedures (SOPs) for structural fire fighting that include, but are not limited to, Accountability, Rapid Intervention Crews (RIC), and Incident Command System; 2) ensure that a complete size-up is conducted before initiating fire fighting efforts, and that risk versus gain is evaluated continually during emergency operations; 3) ensure that team continuity is maintained; 4) ensure that the Incident Commander maintains the role of director of fireground operations and does not become involved in fire-fighting efforts; 4) ensure that an adequate fire stream is maintained based on characteristics of the structure and fuel load present; 5) ensure that pre-incident planning is done on commercial structures; 6) establish and maintain training programs for emergency scene operations; 7) review dispatch/alarm response procedures with appropriate personnel to ensure that the processing of alarms is completed in a timely manner; 8) in addition, manufacturers and researchers should continue to refine existing and develop new technology to track and locate lost fire fighters on the fireground.