On November 15, 2004, a 47-year-old male Battalion Chief (BC) arrived for duty at his office around 0700 hours. He performed administrative functions throughout the morning and was last seen working at his desk shortly before 0900 hours. At 0917 hours, he was found collapsed at his desk. Despite exhaustive cardiopulmonary resuscitation (CPR) performed at the scene, in the ambulance, and in the emergency department (ED) of the local hospital, the BC died. The autopsy, completed by the District Coroner-Medical Examiner, revealed an enlarged heart with left ventricular hypertrophy and 50%-75% occlusions of the left anterior descending and right coronary arteries. The death certificate, completed by the District Coroner-Medical Examiner, listed "atherosclerotic cardiovascular disease (CVD)" as the immediate cause of death. The NIOSH investigator concluded the BC's underlying heart disease caused his sudden cardiac death (SCD). His death may have been avoided at this time if the fire department (FD) had followed National Fire Protection Association (NFPA) 1582, Standard on Comprehensive Occupational Medical Program for Fire Departments. NIOSH investigators offer the following recommendations to prevent similar incidents and/or to address general safety and health issues: 1. Provide mandatory annual medical evaluations to ALL fire fighters consistent with NFPA 1582 to determine their medical ability to perform duties without presenting a significant risk to the safety and health of themselves or others. 2. Ensure fire fighters are cleared for duty by a physician knowledgeable about the physical demands of firefighting, the personal protective equipment used by fire fighters, and the various components of NFPA 1582. 3. Provide fire fighters with medical evaluations and clearance to wear self-contained breathing apparatuses (SCBA). 4. Collaborate with the local union to develop a wellness/fitness program consistent with NFPA 1583, Standard on Health-Related Fitness Programs for Fire Fighters and/or the Fire Service Joint Labor Management Wellness/Fitness Initiative to reduce risk factors for cardiovascular disease (CVD) and improve cardiovascular capacity. 5. Collaborate with the local union to phase in an annual physical performance (physical ability) evaluation to ensure fire fighters are physically capable of performing the essential job tasks of structural firefighting. Although unrelated to this fatality, the FD should also designate a City employee to administer the FD pre-placement and annual medical evaluations and their outcomes.