On April 16, 2006, a 39-year-old male career airport Fire Apparatus Operator (FAO) arrived for duty at his station around 0700 hours. Throughout his shift, he performed normal station training and duties and did not respond to any calls. He went to exercise at about 2100 hours, but his station was alerted with a call at approximately 2200 hours. When he heard the apparatus siren, he ran into the vehicle bay thinking it was his apparatus. When he realized his vehicle was not needed, he returned to the exercise room. He walked into the day room approximately 5 minutes later, said he needed help, and fell to the ground. An advance life support ambulance was summoned; when it arrived the paramedics found him alert and oriented lying on the floor holding his chest and complaining of pain. The paramedics performed a 12-lead electrocardiogram (EKG), which indicated the FAO was having an acute myocardial infarction (MI). The FAO was transported to the Emergency Department (ED) and quickly transferred to the cardiac catheterization lab where his proximal left anterior descending artery showed a 100% blockage. A stent was placed that completely eliminated the blockage, but his clinical course was complicated by aspiration pneumonia and persistent hypotension. Despite 9 days of intensive care, his cardiac and respiratory function never improved and he died on April 25, 2006. The FAO's death certificate lists his immediate cause of death as "Acute Respiratory Distress Syndrome due to an acute myocardial infarction." The autopsy revealed a massive MI. The NIOSH investigator concluded the FAO's strenuous exercise while on-duty, coupled with the response to the activation alarm, and his underlying coronary artery disease (CAD) triggered his MI, which led to his death. NIOSH investigators offer the following recommendations to prevent similar incidents and to address general safety and health issues: 1. Collaborate with the local union to develop a wellness/fitness program consistent with National Fire Protection Association (NFPA) 1583, Standard on Health-Related Fitness Programs for Fire Fighters and/or the Fire Service Joint Labor Management Wellness/Fitness Initiative. 2. Funding for the Wellness/Fitness Program described above should be secured by the FD from the governing municipality. 3. Consider symptom limiting Exercise Stress Test for fire fighters at increased risk for CAD and SCD. 4. Negotiate with the local union to phase in an annual physical ability test.