On June 12, 2007, a 42-year-old paid on-call Fire Fighter (FF) participated in mandatory Fire Department training. The training involved hose drills consisting of making a hydrant connection, advancing an attack hose line, and utilizing the nozzle. The FF participated in two drills, each lasting about 5 to 10 minutes. There was a 15 minute "cool-down" period between drills during which time the FF removed his personal protective equipment, drank cool fluids, and helped reload the hose. Following a 15-20 minute break to discuss the goals of the training, the FF collapsed. Despite on scene cardiopulmonary resuscitation (CPR) and defibrillation, continued CPR in the ambulance, and advanced cardiac life support in the hospital Emergency Department, the FF could not be revived. The death certificate listed "acute, premature death" as the immediate cause of death and severe atherosclerotic disease and congenital hypoplasia of the right coronary artery as underlying causes, with multi-focal myocardial scarring and cardiomegaly as significant conditions contributing to the death. The autopsy was conducted by a faculty member at the nearby University School of Medicine and Public Health. The autopsy report concluded, "the comprehensive autopsy findings in conjunction with the clinical history support acute, premature cardiac death during work related strenuous physical activity." The NIOSH investigator considered that the physical effort associated with the hose drills performed during training in full personal protective equipment triggered a probable heart attack and the subsequent sudden cardiac death of this FF. It is unclear if any of the following recommendations could have prevented the death of this FF at this time. Nonetheless, the NIOSH investigator offers the following recommendations to reduce the risk of on-the-job heart attacks and sudden cardiac arrest among fire fighters at this, and other, fire departments across the country. 1. Provide mandatory pre-placement and period medical evaluations to all fire fighters consistent with the National Fire Protection Association (NFPA) Standard 1582, Standard on Comprehensive Occupational Medical Program for Fire Departments. 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. Develop a comprehensive wellness/fitness program for fire fighters to reduce risk factors for cardiovascular (CVD) and improve cardiovascular capacity. 4. Ensure that incident scene rehabilitation is established for working fires and training evolutions.