On September 19, 2018, the Los Angeles City Fire Department responded to a fire in a commercial structure. Within minutes of arrival, the department experienced a significant near miss event involving serious injury to one of its newest members. Rather than take the incident in stride as “part of the job,” LAFD Fire Chief Ralph Terrazas reviewed the incident and within ten days ordered a top to bottom cultural shift in the department’s response to structural fires. The cultural shift preserved the LAFD tradition of aggressive fire attack, while injecting new practices designed to improve firefighter safety and avoid a repeat event that could lead to an irreversible tragedy. This article tells the tale of how one fire chief and a major metropolitan department recognized a threat and responded by taking bold corrective action before the threat became a tragedy. The story is a model of courageous leadership.