On May 14, 2006, a 61-year-old male career Lieutenant (the victim) was fatally injured at a residential structure fire as a result of smoke inhalation. Dispatch had reported a residential two-story structure fire with possible trapped victims. The victim's engine (E9) was first on the scene followed shortly by a ladder truck, where they encountered heavy smoke pouring out of the back of the residence. The victim and two fire fighters from E9 entered the structure in a fast attack mode while fire fighters from the other apparatus rescued a civilian. The victim and fire fighters donned their self-contained breathing apparatus (SCBA) once inside the smoky kitchen. Then the victim and fire fighters advanced the attack line through the first floor of the house and up the stairs where they encountered high heat and zero visibility. After further advancing into what the victim and fire fighters thought was a hallway (it was actually a small bedroom), they concluded that they were not in the fire room. They felt heat and believed they had fire in the attic above them, so they backed out to regroup at the top of the stairs. The two fire fighters assumed the victim was nearby. Both fire fighters ended up exiting the structure, within minutes of each other, when their low air alarms went off. Other fire fighters heard a personnel alert safety system (PASS) alarm when they were on a landing just below the top of the stairs. The Rapid Intervention Team (RIT) was activated but the fire fighters who had reported the PASS alarm also took the initiative to find the victim. They located the victim underneath a mattress and pulled him to the doorway near the top of the stairs. The RIT progressed to the top of the stairs and extricated the victim to the yard where cardiopulmonary resuscitation (CPR) was performed. The hospitalized victim succumbed to his injuries on May 21, 2006. NIOSH investigators concluded that, to minimize the risk of similar occurrences, fire departments should: 1. ensure that team continuity is maintained; and, 2. ensure that officers and fire fighters follow established standard operating guidelines regarding SCBA donning on the fireground. Although there is no evidence that the following recommendations could have specifically prevented this fatality, NIOSH investigators recommend that fire departments: 1. ensure that all fire fighters are trained on proper radio discipline and operation to communicate with the Incident Commander (IC); and, 2. ensure that the Incident Commander receives pertinent information (i.e., location of stairs, number of occupants in the structure, etc.) from occupants on scene and information is relayed to crews during size-up.