Between 1992 and 2005, 431 confined space incidents that met the case definition claimed 530 lives, or about 0.63% of the 84,446 all-cause U.S. occupational fatal injuries that occurred during this period. 87 (20%) incidents resulted in multiple fatalities. Twelve (57%) of 21 surveyed companies reported that they relied on the fire department for permit-required confined space emergency response. The median fire department arrival time was about 5 minutes for engines and 7 minutes for technical rescue units. Fire department confined space rescue time estimates ranged from 48 to 123 minutes and increased to 70 and 173 minutes when hazardous materials were present. Our work illustrates that: (i) confined space incidents represent a small but continuing source of fatal occupational injuries in the U.S.; (ii) a sizeable portion of employers may be relying on public fire departments for permit-required confined space emergency response; and (iii) in the event of a life-threatening emergency, fire departments usually are not able to effect a confined space rescue in a timely manner. We propose that the appropriate role for the fire department is to support a properly trained and equipped on-site rescue team, and to provide advanced life support intervention following extrication and during ambulance transportation.