Checklist

Scope

This category audits whether the department reports, triages, reviews and learns from events, and whether it meets its statutory reporting and committee duties. It covers Incident Investigation and Learning Program, Policy - Incident, Injury, Exposure and Near-Miss Reporting and Investigation and the learning-review parts of Policy - Right to Refuse Unsafe Work and Stop-Work Authority. It is audited internally every year and by the external review every three years (01 Audit Program).

The auditor samples: the last ten near-miss and good-catch reports; every statutory-list event in the period; the last three triage records above Tier 1; the last two Tier 2 reports and any Tier 3; every refusal and stop-work record; the Corrective Action Register entries from reviews; the last four bulletins and change notices; the JOHSC minutes for the period. The auditor also observes an After-Action Review and interviews members at two stations, one of them volunteer where the department has one.

Criteria

The criteria come from the applicable provincial or territorial OHS and workers’ compensation law (reporting, scene preservation, investigation, committee participation and response, refusals and reprisal; J05 Joint Committee and Health and Safety Representative; J07 Right to Refuse and Reprisal Protection; J08 Incident Reporting and Investigation); the responder safety standard (NFPA 1550, 2024, s. 4.7, s. 5.6, s. 5.7, ch. 6 and Annex G and H); the workplace incident investigation standard (CSA Z1005:21, cl. 4.4 to 7); the management-system standard on corrective action and management review (ISO 45001:2018, cl. 9.3, 10.2); the accreditation criteria on hazard reporting, documented risk reduction, near-miss reporting and investigation (CPSE, 2019, criteria 11A.2, 11A.3, 11A.6, 11A.7); and the package’s own requirements for the learning firewall, the 30-day decision rule and the closed loop (Incident Investigation and Learning Program; Corrective Action Register).

Scoring

0 not in place; 1 documented, not implemented; 2 implemented, not verified effective; 3 implemented and effective with evidence. The category score is the mean of the items applicable at the department’s stage; it is reported by category, never rolled into a single program number (02 Audit Checklist Master Index).

#	Item	Stage	Evidence expected
A. Policy and governance
1	A reporting and investigation policy is adopted at chief or council level, with the learning firewall and the triage rules inside the policy	S1	Signed policy; approval record; version
2	The policy was consulted with the JOHSC, the bargaining agents and the volunteer association, and a letter of understanding on the firewall exists	S1	JOHSC minutes; letter of understanding
3	Counsel reviewed the policy, and in particular the firewall clause, before adoption	S1	Counsel’s note or sign-off
4	The policy has been reviewed within 12 months of adoption and every three years, or after any Tier 3 or legislative change	S2	Review record; version history
5	One accountable owner is named for the program and holds the authority and time to run it	S1	01 Roles and Responsibilities mapping; interview
B. Reporting
6	A near-miss and good-catch route exists that takes a few minutes and needs no login: QR code, paper form in every apparatus, phone number, oral report to any officer	S1	Observed on apparatus and station walls; phone test
7	The event definitions, with fire-service examples, are posted in every station sampled and taught in recruit training	S1	Observed; training records
8	Injuries, exposures and equipment failures are reported on the injury and incident form before the end of the shift (24 hours for volunteers), with the supervisor’s section completed	S1	Sample of forms against incident records; timestamps
9	Crew exposure at working fires is logged for every fire in the sample	S1	Exposure log against incident records
10	Every report in the sample was acknowledged to the reporter within five working days and the reporter was told the outcome within 30 days	S2	Acknowledgement log; reporter interview
11	Near-miss and good-catch reports per 100 calls and per working fire are counted by station and segment, and the trend is reported quarterly	S2	Quarterly indicator worksheet
12	Reporting rates at volunteer and outlying stations are comparable to the career core, or the gap is known and being acted on	S2	Indicator by segment; register item if a gap
C. Statutory reporting
13	A written statutory reporting procedure exists with the regulator’s contact, the list of reportable events, the clocks and the call log	S1	Written procedure built from the department’s section of J08 Incident Reporting and Investigation; posted number
14	Every statutory-list event in the period was reported to the regulator within the statutory time, with the call logged	S1	Call log against event records; regulator correspondence
15	The JOHSC was notified of every statutory-list event	S1	Notification record; JOHSC minutes
16	Scenes of serious events were preserved until released, with any movement recorded	S1	Incident records; officer interview
17	Workers’ compensation reports were filed within the board’s deadline for every compensable injury	S1	Claim records against injury reports
D. Triage
18	A Triage Group is named by role with a JOHSC worker seat and backups for every seat, including a volunteer-side backup where applicable	S1	Policy; roster; interview
19	Every event above a clear Tier 1 in the sample was triaged within 24 hours or the next business day, with the trigger recorded	S1	Triage records; timestamps
20	Clear Tier 1 events are confirmed on a daily log	S1	Daily log
21	Any request for a higher tier was recorded with the outcome; any de-escalation was unanimous with reasons	S2	Triage records
22	The three closing checks (statutory reporting, support offered, preservation) were completed for every triage record sampled	S1	Triage records
E. Reviews
23	An After-Action Review was held within 72 hours for every working fire and Tier 1 trigger in the sample, on the four-question sheet	S1	AAR sheets against incident records
24	The AAR observed was led by the officer, had the junior member speak first, recorded conditions not people, and recorded what went well	S2	Observation
25	At least two members hold current investigator training to a recognized standard, each has facilitated a review in the last year, or a written arrangement with a neighbouring department exists	S1	Training records; review log; arrangement
26	Every Tier 2 in the period had signed terms of reference within 72 hours of triage, a facilitator not at the event, and a JOHSC worker member on the team	S1	Terms of reference
27	Tier 2 reports were released within 30 days, or within 60 with the reason recorded	S2	Report dates
28	Each Tier 2 report sampled has a complete timeline, local rationality for every decision point, contributing factors classified by work-system element, and what went well	S2	Reports against the quality check
29	Reports use the language rule: roles not names; conditions not character; no “failed to,” “should have,” “ignored,” “complacent”	S2	Reports
30	Participants were briefed before release and disagreements recorded	S2	Briefing record; participant interview
31	The sponsor’s quality check was completed before release	S2	Signed check
32	A Tier 3 arrangement (independent reviewer, joint oversight including labour) is in place before it is needed, and any Tier 3 in the period was engaged within five working days with a public summary issued	S2	Arrangement; Tier 3 records
F. Learning firewall and just culture
33	Every Tier 2 and Tier 3 participant received the firewall notice in writing before interview	S1	Signed notices
34	The JOHSC’s annual check found no discipline, performance action or personnel-file entry resting on learning information	S2	JOHSC minutes; HR confirmation
35	A separate accountability process for conduct concerns is written down, run by different people, and any referral in the period was decided and recorded by the fire chief without learning information passing across	S1	Conduct policy; referral records
36	Interview notes are destroyed when reports are accepted and are not held in any file	S2	Facilitator interview; records check
37	Peer support was offered to those involved in every Tier 2 and Tier 3 event independently of participation	S1	Triage closing check 2; peer team aggregate record
G. Recommendations and closure
38	Every recommendation from the reviews sampled is in the Corrective Action Register with a strength rating, owner and date	S1	Register against reports
39	Every recommendation was decided (accepted, modified, deferred with interim controls and revisit date, or rejected) within 30 days with the rationale recorded by the fire chief or delegate	S1	Decision records
40	Every JOHSC written recommendation arising from a review was answered in writing within the time the applicable statute sets (J05 Joint Committee and Health and Safety Representative)	S1	Recommendation and response register
41	Closed items in the sample have a verifier’s confirmation and an effectiveness check recorded; failed checks reopened the item	S2	Register
42	Overdue items were escalated on the schedule their priority sets, P1 (Imminent) to P4 (Improvement) (Corrective Action Register), and open-item age was an input to the last management review	S2	Register; management review minutes
43	The share of adopted recommendations rated stronger is reported annually, and reviews that could offer only weaker actions said so	S3	Annual learning report; reports
H. Sharing and evaluation
44	A change notice was issued within 15 days of every adopted change in the sample, and members at the stations visited can describe the change	S1	Notices; member interview
45	A de-identified learning bulletin followed every Tier 2 and Tier 3 within 30 days, after participants saw it, and included what went well	S1	Bulletins; dates
46	A quarterly near-miss and good-catch digest was issued with the department’s response to each item	S2	Digests
47	De-identified lessons were shared externally with the fire chief’s approval, and the department’s near-miss data is held so a provincial or national aggregator could take a feed	S3	Sharing record; database design
48	The program was evaluated annually before management review against the full indicator set, including the six learning-system construct bands from the culture baseline, and the evaluation changed something	S2	Annual learning report; management review minutes; register item
49	The external review examined this program in the last three years	S3	External review report
I. Refusals and stop-work
50	Every refusal and stop-work call in the period was recorded, triaged and reviewed for learning at the tier the policy sets, and the member heard the outcome within 30 days	S1	Refusal records; triage records; feedback dates
51	The JOHSC’s annual reprisal check found none, and any reprisal complaint was answered in writing within ten working days	S1	JOHSC minutes; complaint records
J. Accountability and closed feedback loop
52	The program’s accountability table is complete and true in practice: one accountable owner; doers who can describe their part; verifiers who have verified in the period; feedback routes that returned an answer to each member who raised a concern, with dates; a closure rule applied with escalation. The auditor runs the loop test from the program note with a real event from the period	S1	Program note section 11; register; acknowledgement and feedback logs; member interview tracing one concern to its answer

Effectiveness questions (observation or interview only)

These cannot be answered from documents. The auditor records the answers verbatim, by role, and scores them into items 10, 24 and 52.

To a firefighter at a volunteer or outlying station: “Tell me about the last time you or someone on your crew reported a near miss. What happened to it? Did you hear back? Would you report the next one?” Then ask their officer the same thing and compare.
To a company officer: “A member on your crew says ‘stop’ on the fireground and it turns out the hazard was not there. What do you do in the moment, and what happens afterward?” Compare the answer with policy clause 5.2.5 and the learning review requirement.
To a Tier 2 participant: “Before your interview, did anyone tell you in writing how what you said would be used? Did you see the report before anyone else? Did the report describe how it looked to you at the time?”

Reading the result

A high score on documents (items 1 to 5, 13, 18, 35) with a low score on the effectiveness questions and on items 10, 12, 24 and 52 is the characteristic pattern of a learning system on paper; report it as such. A rising near-miss count with a falling injury count is the expected pattern of a working one; a falling near-miss count is a finding whatever the injury count does (NZFS, 2016b; FENZ, 2023).

Jurisdiction requirements

This chapter relies on the following legal requirements, which differ by province and territory. Check your jurisdiction’s section on each topic page before adopting it.

Topic	What to check in your jurisdiction	Page
Joint Committee and Health and Safety Representative	The committee’s statutory role in incident investigation and the employer’s deadline to answer a committee recommendation in writing (items 26, 40)	J05 Joint Committee and Health and Safety Representative
Right to Refuse and Reprisal Protection	The worker’s right to refuse unsafe work, the steps after a refusal, any carve-out for firefighters, and protection from reprisal for exercising it (items 50, 51)	J07 Right to Refuse and Reprisal Protection
Incident Reporting and Investigation	Which deaths, serious injuries and no-injury events must be reported to the regulator and how fast, who else must be told, scene preservation and release, the employer’s deadline to report to the compensation board, and the duty to investigate (items 13 to 17)	J08 Incident Reporting and Investigation

References

Center for Public Safety Excellence [CPSE]. (2019). Fire and emergency service self-assessment manual (10th ed.). Commission on Fire Accreditation International. https://cpse.org/wp-content/uploads/2019/08/10th-Edition-FESSAM-Strikethrough-Underline-v.4.pdf

CSA Group. (2021). CSA Z1005:21 (R2026), Workplace incident investigation. https://www.csagroup.org/store/product/CSA%20Z1005:21/

Fire and Emergency New Zealand [FENZ]. (2023). Report 210: Safety, health and wellbeing evidence brief 2023. https://fireandemergency.nz/assets/Documents/Research-and-reports/Report-210-Safety-Health-and-Wellbeing-Evidence-Brief-2023.pdf

International Organization for Standardization. (2018). ISO 45001:2018, Occupational health and safety management systems: Requirements with guidance for use. https://www.iso.org/standard/63787.html

National Fire Protection Association. (2024). NFPA 1550, Standard for emergency responder health and safety (consolidates NFPA 1500, 1521 and 1561). https://www.nfpa.org/codes-and-standards/nfpa-1550-standard-development/1550

New Zealand Fire Service [NZFS]. (2016b). Report 158: Improving the safety culture and practices of rural fire personnel in relation to near-miss reporting (prepared by Heathrose Research). Hosted by Fire and Emergency New Zealand. https://www.fireandemergency.nz/assets/Documents/Research-and-reports/Report-158-Improving-the-safety-culture-and-practices-of-Rural-Fire-Personnel-in-relation-to-near-miss-reporting.pdf