OBJECTIVE: To report the leading cause of death in National Collegiate Athletic Association (NCAA) athletes. DESIGN: Retrospective analysis from January 2004 to December 2008. SETTING: NCAA institutions. PARTICIPANTS: Collegiate athletes. ASSESSMENT OF RISK FACTORS: NCAA divisions, sport, gender, and race. MAIN OUTCOME MEASURES: Mortality. RESULTS: During the 5-year period, there were 273 deaths and a total of 1 969 663 athlete participation-years. Of these 273 deaths, 145 (53%) were due to accidents or unintentional injury, 45 (16%) from cardiac arrest, 25 (9%) suicides, and 18 (6%) homicides. The rate of death due to accidents was 7.36/100 000 participants per year. Motor vehicle accidents accounted for 100 accidents (69%). There was no significant difference in accident rates between NCAA divisions. Accidents were twice as likely in men compared with women (P < 0.0001). There was no significant difference in the accident rates in white versus black athletes. Although accidents usually occurred more frequently in the general population (5-fold) compared with NCAA athletes, certain athlete subgroups (Division I wrestling, Divisions I and II basketball, and Divisions I and II football) seem to be high-risk populations with death rates that were no different than the general population. This suggests that these athletes may engage in higher risk behaviors compared with other sporting subgroups. CONCLUSIONS: Motor vehicle accidents are the most common cause of sudden death in athletes across NCAA divisions, gender, race, and sport. Medical teams and institutions should design (1) effective safety prevention programs, and (2) catastrophic incident plans that can be implemented in the event of such tragedies. Copyright © 2013 by Lippincott Williams & Wilkins.