On June 21, 2007, a 23-year-old male career fire fighter (the victim) died after falling from the roof at a four-story apartment building fire. When fire fighters arrived on scene, light smoke and fire was showing from a 4th floor window. The victim had just climbed the truck ladder to the roof bulkhead and was attempting to lower himself to the main roof when he fell. The roof saw (slung on the victim's back) shifted causing the victim to lose his balance and fall to the ground. Fire fighters had been on scene less than 3 minutes when the victim fell. The victim was transported to a metropolitan hospital where he succumbed to his injuries. Key contributing factors to this incident include: judgment of the fire fighter in deciding on a riskier means of moving from the roof bulkhead to the main roof, the placement of the ladder against the roof bulkhead rather than the main roof which introduced additional fall risks for fire fighters, the hazardous task of climbing a ladder while laden with tools and equipment, and the method in which the saw was carried which allowed the shifting saw to put the fire fighter off balance. NIOSH has concluded that, to minimize the risk of similar occurrences, fire departments should: 1. stress to fire fighters the importance of exercising caution when working at elevation; 2. consider the location and placement of aerial ladders to prevent fire fighters from climbing from different elevations during fireground operations; 3. consider the use of portable scissor ladders to facilitate access from an aerial ladder to the roof; 4. ensure that fire fighters communicate any potential hazards to one another and ensure that team continuity is maintained during roof operations; 5. evaluate the manner in which equipment is harnessed or carried by fire fighters to prevent loss of balance; 6. consider reducing the amount of equipment that fire fighters must carry while climbing ladders. Manufacturers of fire service saws should: 1. consider ergonomic design principles to reduce the weight of ventilation saws; 2. consider developing improved carrying slings.