On May 28, 2007, a 41-year-old male career fire fighter (the victim) died after becoming disoriented and falling down a set of stairs while searching for a missing male occupant at a residential structure fire. A fire captain also received second degree burns resulting in lost-time from work. Both the victim and the captain were members of the first-responding fast attack engine company. After becoming disoriented, they were trapped and missing for several minutes before being found. The fire was reported at approximately 0449 hours. The first arriving fire fighters, including the victim, arrived on the scene at 0459 hours and were on-scene 13 minutes when the first mayday was called. The male resident also perished in the fire. NIOSH investigators concluded that, in order to minimize the risk of similar occurrences, fire departments should: 1. ensure that their response to structure fires provides adequate numbers of staff and apparatus to immediately respond to emergency incidents and is in accordance with recommended guidelines; 2. ensure that the first arriving fire unit conducts an initial size-up that includes as much information as possible to develop a quick initial plan for rescue and fire fighting strategy and tactics; 3. ensure that fire fighters are trained in SCBA emergency procedures and fire fighter emergency communications; 4. ensure that interior conditions are communicated to the Incident Commander (IC) on a regular and timely basis; 5. ensure that an Incident Safety Officer (ISO) is established at structure fires; 6. ensure that a Rapid Intervention Team (RIT) is established and available; 7. ensure that the Incident Commander does not become directly involved in fire fighting efforts; 8. ensure that the Incident Commander maintains close accountability for all personnel operating on the fireground and that procedures and training for the use of a personnel accountability report (PAR) are in place; 9. ensure that all fire fighters wear a full array of turnout clothing and personal protective equipment (PPE) appropriate for the assigned task while participating in fire suppression and overhaul activities; 10. ensure that department policies and procedures for proper inspection, use, and maintenance of self-contained breathing apparatus (SCBA) are followed to ensure they function properly when needed. Additionally, manufacturers, equipment designers, and researchers should: 1. continue to develop and refine durable, easy-to-use systems to enhance verbal and radio communication in conjunction with properly worn SCBA; 2. continue to pursue emerging technologies for evaluating and monitoring the stability of buildings exposed to fireground conditions. Additionally, municipalities should take into consideration the impact community secession and annexation can have on emergency services response, and should ensure resources are provided to support an appropriate level of community service and responder safety.