Abstract: At approximately 3:53 a.m. on February 3, 1989, Employee #1, a fire fighter acting as the outside ventman for the second ladder company to arrive, entered the floor above the fire floor alone. Employee #1 was wearing a Scott 4.5 air pack, full-face, positive pressure respirator with a 20 minute polar wrapped cylinder, a Handie Talkie radio, and a PASS alarm, which was off. At approximately 4:00 a.m., Employee #1 was overcome by flames. At approximately 4:12 a.m., Employee #1 was discovered unconscious with severe burns. Employee #1 was taken to the hospital, where he was pronounced dead at approximately 5:15 a.m. He died of smoke inhalation with carbon monoxide poisoning due to respirator failure.