On February 15, 2005, a 51-year-old male career Lieutenant (LT) assisted in washing a Fire Department (FD) engine and a squad truck. When driving the squad truck to his fire station he suddenly collapsed onto the seat. The squad truck ran off the road and crashed over an embankment. Two witnesses in a nearby store parking lot saw the accident and notified 911, who dispatched an ambulance and the FD. Cardiopulmonary resuscitation (CPR) was performed, advanced life support (ALS) treatment was given, and the LT was transported to the local hospital's emergency department (ED). In the ED, he was noted to have a heart attack and was transferred to a regional hospital for emergent cardiac catheterization and angioplasty. Despite these procedures and other ALS measures, the LT died 4 days later. The death certificate, completed by the County Coroner, listed "anoxic encephalopathy" due to "sudden cardiac arrest" due to "atherosclerotic cardiovascular disease" as the cause of death. The autopsy, completed by the State Chief Assistant Medical Examiner, listed "anoxic encephalopathy" due to "cardiac arrest" due to "atherosclerotic coronary vascular disease with acute thrombosis of the right coronary artery" as the cause of death. The NIOSH investigator concluded that the LT's heart attack and eventual death was due to his underlying atherosclerotic coronary artery disease (CAD) possibly triggered by the physical exertion associated with washing the engine and the squad truck. NIOSH investigators offer the following recommendations to prevent similar incidents or to address general safety and health issues: 1. Provide pre-placement and annual medical evaluations to ALL fire fighters to determine their medical ability to perform duties without presenting a significant risk to the safety and health of themselves or others. 2. Consider conducting exercise stress tests for male fire fighters over the age of 45 years with two or more risk factors for coronary artery disease. 3. Phase in a MANDATORY wellness/fitness program for fire fighters to reduce risk factors for cardiovascular disease and improve cardiovascular capacity. 4. Perform an annual physical performance (physical ability) evaluation to ensure fire fighters are physically capable of performing the essential job tasks of structural fire fighting. 5. Staff all fire stations with a minimum of two fire fighters.