On August 9, 2008, a 47-year-old male volunteer Captain led an attack team during live fire training. After finishing the 30-minute interior attack, the Captain rotated to an exterior, standby hose crew position. When the second interior crew finished its 30-minute fire attack exercise, all personnel reported to the rehabilitation (rehab) area. Medical personnel triaged all fire fighters. The Captain mentioned that he was "a little tired" but had no other complaints. Although the Captain's pulse and respiratory rates were elevated, this was expected from anyone just completing a live fire exercise. After relaxing and drinking some water, the Captain related that he felt better. He left the rehab area, walked to his personal vehicle, and lay down on the grass. A short time later, two students walking nearby thought they heard the Captain snoring. They went over to investigate and heard a gurgling noise. They summoned the rehab emergency medical technician (EMT), instructors, and other students for help. A second ambulance was requested, cardiopulmonary resuscitation (CPR) was begun, and an automated external defibrillator (AED) delivered four shocks. The ambulance arrived, and paramedics began advanced life support. The Captain was transported to the hospital's emergency department, where CPR and advanced life support treatment continued. Approximately 65 minutes after his collapse, despite CPR and advanced life support, the Captain died. The death certificate, completed by the Coroner, and the autopsy, completed by the Forensic Pathologist, listed "arteriosclerotic cardiovascular disease" as the cause of death and "stress at the live burn exercises" as the underlying cause. The results of the NIOSH investigation support this determination. The NIOSH investigator offers the following recommendations to address general safety and health issues. Had these recommended measures been in place prior to the Captain's collapse, his sudden cardiac death may have been prevented at this time. 1. Provide preplacement and annual medical evaluations to fire fighters consistent with National Fire Protection Association (NFPA) 1582, Standard on Comprehensive Occupational Medical Program for Fire Departments, 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 return to duty by a physician knowledgeable about the physical demands of fire fighting, the personal protective equipment used by fire fighters, and the various components of NFPA 1582. 3. Phase in a comprehensive wellness and fitness program for fire fighters to reduce risk factors for cardiovascular disease and improve cardiovascular capacity. 4. Provide fire fighters with medical clearance to wear a self-contained breathing apparatus (SCBA) as part of the Fire Department's medical evaluation program. 5. Use a secondary (technological) test to confirm appropriate placement of the endotracheal tube. 6. Recheck vital signs of fire fighters prior to leaving rehab.