On February 20, 2009, a 45-year-old male volunteer fire fighter (FF) assisted in fighting an 800-acre wildland (grass) fire. After fighting the fire for approximately 10 hours, the FF was asked to assist with "mop up." While backing up a brush truck to provide water to crew members, the FF collapsed. A crew member yelled for help and moved the gearshift to the park position. The FF was pulled from the brush truck and found to be unresponsive, not breathing, with a weak pulse. Shortly thereafter, his pulse stopped, and an oral airway was placed while cardiopulmonary resuscitation (CPR) was begun. An automated external defibrillator (AED) was retrieved, a shock was delivered, and a pulse returned. An ambulance arrived and began advanced life support treatment. About 30 minutes after he collapsed, a Life Flight helicopter arrived and took over patient care. The FF went into cardiac arrest again and CPR continued for another 32 minutes. Medical Control was contacted and informed of the FF's condition. Medical Control advised the flight crew to pronounce the FF dead, approximately 67 minutes after his collapse. The death certificate and the autopsy, completed by the medical examiner, listed "atherosclerotic and hypertrophic cardiovascular disease" as the cause of death. NIOSH investigators conclude that the physical stress of performing fire extinguishing activities, coupled with the FF's severe underlying atherosclerotic coronary artery disease (CAD), probably triggered a heart attack and his subsequent sudden cardiac death. The NIOSH investigator offers the following recommendations to address general safety and health issues. Had these recommended measures been in place prior to the FF's collapse, his sudden cardiac death may have been prevented. 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. 2. Incorporate exercise stress tests following standard medical guidelines into a fire department medical evaluation program. 3. Phase in a comprehensive wellness and fitness program for fire fighters consistent with National Fire Protection Association (NFPA) 1583, Standard on Health-Related Fitness Programs For Fire Fighters. 4. Perform an annual physical performance (physical ability) evaluation consistent with NFPA 1500, Standard on Fire Department Occupational Safety and Health Program. 5. Provide fire fighters with medical clearance to wear self-contained breathing apparatus (SCBA) as part of the fire department's medical evaluation program.