Checklist - Leadership, Policy and Program Management | Fire Service Safety Management System

1. Scope

Category 1 audits whether the department’s leaders have built, resourced and visibly lead a safety management system, rather than delegated one to the safety division. It covers the OHS policy, the written program and organizational statement, the risk management plan, roles and accountabilities by rank, the appointment and authority of the health and safety officer, the budget line, the legal register and compliance evaluation, the department’s engagement with labour, the volunteer association and council, and the behaviour of leaders that makes it safe to speak up.

It does not score the committee itself (category 2, Checklist - Worker Participation and JOHSC), the hazard profile (category 3), training content (category 5), the audit function (category 19) or the management review meeting (category 20). Where leadership and those categories touch, this note scores the leadership half: did the chief decide, resource and follow through.

Fed by 01 Roles and Responsibilities, 06 Program Improvement Teams, the OHS Policy and the Internal Responsibility and Accountability policy (04 Policies).

2. Criteria

Source	What it requires	Items
Applicable provincial or territorial OHS statute: written policy and written program, prepared in consultation with the committee, with named content (J03 OHS Policy and Program; J06 Written Procedures and Committee Consultation)	A signed policy reviewed at the interval the statute sets, and at least annually in this package; a written program containing the statutory elements; a copy to the committee and to any employee on request where the statute requires it	1.1 to 1.6, 1.12 to 1.15
NFPA 1550 ch. 6, fire department administration (NFPA 1550, 2024)	Organizational statement; written risk management plan covering administration, facilities, training, vehicle operations, PPE, emergency and non-emergency operations and incident-related health hazards, with identification, evaluation, prioritization, control and monitoring; appointment of the HSO with authority to administer the program; additional safety officers as needed	1.7 to 1.11, 1.16 to 1.20
ISO 45001 cl. 5.1 leadership and commitment, 5.2 policy, 5.3 roles, 7.1 resources, 6.1.3 legal and other requirements, 9.1.2 evaluation of compliance (ISO 45001:2018)	Top management accountable; policy communicated; roles assigned and communicated; resources provided; legal register kept and compliance evaluated	1.1 to 1.6, 1.21 to 1.30
CSA Z45001 Canadian deviations: worker participation in decisions, right to refuse, employer provides PPE and training (CSA Z45001:19)	Leadership supports the right to refuse and participation without reprisal	1.37 to 1.42
COR elements 1 (policy) and 13 (legislation) (CFCSA, 2021)	Written policy with roles; current legislation available and understood	1.1, 1.21 to 1.24
CFAI criterion 1A governance and indicator 11A.1 responsibility assigned for the OHS and risk management programs (CPSE, 2019)	A person or persons assigned responsibility for implementing the program	1.16 to 1.18
Criminal Code s. 217.1 duty of those who direct work (Criminal Code [CA], 1985)	Reasonable steps to prevent bodily harm by anyone who directs work	1.12, 1.13
Psychological safety as an organizational condition created by leaders’ behaviour and the response to reports (Edmondson, 1999)DOI; culture ladder (Westrum, 2004)DOI; learning before blame (Conklin, 2012); work-as-done (Hollnagel, 2014)	The four house principles are lived, not posted	1.31 to 1.42

The CFAI crosswalk in this note and in the checklist table is to the 10th edition (CPSE, 2019); the 11th edition applies to agencies appearing before the Commission from 2027 (CPSE, 2024), and the category structure is unchanged.

3. How to score

Score each item on D, I and E (0 to 3) and derive the item score per 01 Audit Program section 5.
Items coded with a plus sign need both evidence types to score above 1 on implementation.
Weights: C3 critical (x3), K2 core (x2), S1 supporting (x1). L items must score at least 2 for the category to pass.
Category score = sum(weight x item score) / sum(weight x 3). Effectiveness index uses E.
Record a finding, owner, priority and due dates for every item below 3: a major nonconformity is P1 (Imminent) or P2 (Serious) by risk, a minor nonconformity P3 (Moderate) and an opportunity for improvement P4 (Improvement), with the clocks in 01 Audit Program section 6; majors go to the fire chief within 24 hours.

4. Checklist

#	Item	Stage	Wt	Evid	CFAI	Scoring anchors (1 / 2 / 3)
1.1 OHS policy
1.1	A written OHS policy exists, signed by the fire chief and by the chief administrative officer or equivalent, stating the department’s commitment, the internal responsibility system and the duties of each level (ISO 45001:2018, cl. 5.2; see J03 OHS Policy and Program)	S1	C3 L	D+O	-	1: draft or unsigned / 2: signed, posted at headquarters / 3: signed, posted in every station including volunteer stations, and members at sampled stations know where it is
1.2	The policy was reviewed within the last 12 months in consultation with the JOHSC, and the review is recorded in the minutes (J03 OHS Policy and Program)	S1	C3 L	D	-	1: review overdue / 2: reviewed on time, consultation recorded / 3: reviewed on time with JOHSC comments visibly incorporated
1.3	The policy commits to the four house principles in the department’s own words: people as the solution, procedures from work-as-done, learning before blame with no discipline from learning information, and psychological safety as a condition of safety	S1	K2	D+I	-	1: one or two principles present / 2: all four present / 3: all four present and officers interviewed can name what each one changes in their station
1.4	The policy names the fire chief as accountable for the system and states that the safety division advises and verifies and does not own operational risk	S1	K2	D	11A.1	1: accountability implied / 2: stated / 3: stated and the RACI in 1.12 matches it
1.5	The policy is communicated at hire, at promotion and after each revision, with a record	S1	S1	D+I	-	1: communicated at hire only / 2: at hire and on revision, recorded / 3: all three, and new members interviewed recall it
1.6	The policy is available to any member and to the public in the form the department chooses, and the copy in circulation is the current version	S1	S1	O	-	1: old versions found / 2: current version at every sampled station / 3: current version everywhere and on the member-facing system
1.2 Written program and organizational statement
1.7	A written OHS program exists that contains every element the applicable statute names and the elements of NFPA 1550 chapters 6 to 16 that the department has adopted (NFPA 1550, 2024; see J03 OHS Policy and Program)	S1	C3 L	D	11A.1	1: elements scattered across documents with no index / 2: a single program document or index with every statutory element / 3: the program document maps each element to its policy, program module and checklist category
1.8	The program was prepared and is revised in consultation with the JOHSC, with the consultation recorded	S1	C3 L	D	-	1: no record / 2: consultation minuted / 3: consultation minuted and the committee’s input traceable to changes
1.9	A copy of the program has been given to the committee and is available to any member on request (J03 OHS Policy and Program)	S1	K2 L	D+I	-	1: committee has an old copy / 2: committee has the current copy / 3: members interviewed know how to get it
1.10	An organizational statement defines the services the department provides, the organizational structure, the expected functions of members and the staffing and deployment standards it adopts (NFPA 1550, 2024, ch. 6)	S1	K2	D	1B.2	1: partial / 2: complete and approved / 3: complete, approved, consistent with the Program Profile Worksheet and reviewed within three years
1.11	Every specialty module switched off in 01 Program Profile Worksheet has a recorded reason, and dispatch data for the last year has been checked for responses to that hazard	S2	K2	D	-	1: modules switched off without reason / 2: reasons recorded / 3: reasons recorded and dispatch check done and minuted
1.3 Roles and accountabilities
1.12	A RACI or equivalent assigns one accountable role to every element of the system, from council to probationary member, and the accountable roles hold the authority, time and budget to deliver (see 01 Roles and Responsibilities) (ISO 45001:2018, cl. 5.3)	S1	C3	D+I	1B.2	1: roles listed without accountability / 2: one accountable role per element / 3: role-holders interviewed can describe their accountabilities and show the evidence
1.13	Every officer who directs work, career and volunteer, has been told in writing of the supervisory duties in law, including the duty under the Criminal Code to take reasonable steps to prevent bodily harm (Criminal Code [CA], 1985, s. 217.1)	S1	C3 L	D+I	1B.2	1: career officers only / 2: all officers, recorded / 3: all officers, recorded, and sampled officers can state three of their duties
1.14	Volunteer officers are named as supervisors under the department’s policies (whether volunteers are workers and supervisors in law depends on the jurisdiction, J11 Volunteer Firefighters) and carry the same safety duties, adapted for how and when they work	S1	C3 L	D+I	1B.2	1: not addressed / 2: addressed in the RACI / 3: addressed, and volunteer officers interviewed confirm they received training at times they could attend
1.15	The generic roles in the package are mapped to the department’s actual titles and positions, and every “A” lands on a position that exists	S1	K2	D	1B.2	1: mapping partial / 2: mapping complete / 3: mapping complete and reviewed after each organizational change
1.4 Health and safety officer and risk management plan
1.16	The fire chief has appointed a health and safety officer in writing with the authority to administer the program and report directly to the chief on safety matters (NFPA 1550, 2024, ch. 6; CPSE, 2019, criterion 11A.1)	S1	C3	D+I	11A.1	1: role filled informally / 2: appointed in writing with authority / 3: appointed, and the HSO and two officers interviewed confirm the direct reporting route has been used
1.17	The HSO meets the qualifications for the function and has time allocated to it that is proportionate to the department’s size and risk (NFPA 1550, 2024, ch. 4)	S1	K2	D+I	11A.1	1: no qualification record / 2: qualification recorded / 3: qualification current, time allocated and the HSO confirms the time is sufficient for the audit schedule
1.18	A pool of incident safety officers is qualified and rostered so that one is available for every incident meeting the deployment triggers, on every platoon and in every district	S1	C3	D+O	11A.1, 11A.11	1: ISOs exist on some platoons / 2: pool rostered on all platoons / 3: pool rostered, and incident records for the last quarter show an ISO at every triggering incident
1.19	A written risk management plan covers administration, facilities, training, vehicle operations, PPE, emergency operations, non-emergency activities and incident-related health hazards, with risk identification, evaluation, priorities, controls and monitoring (NFPA 1550, 2024, ch. 6)	S1	K2	D	11A.3	1: partial coverage / 2: all areas covered / 3: all areas covered and the plan reviewed annually against the hazard profile
1.20	The risk management plan names the senior officer responsible for health and safety as its custodian and the fire chief as its approver, and the latest approval is dated	S1	S1	D	11A.3	1: unapproved / 2: approved and dated / 3: approved within the last 12 months
1.5 Resources and budget
1.21	The department budget contains an identifiable line or lines for the safety management system (safety division, program team work, PPE life cycle, medicals, fit testing, training safety, audit) (ISO 45001:2018, cl. 7.1)	S1	K2	D	1B.1	1: safety costs buried in other lines / 2: identifiable lines / 3: identifiable lines built from the program teams’ budget worksheets
1.22	Program managers can submit budget lines for their programs, and the submissions are visible in the budget record	S2	K2	D+I	1B.1	1: no route / 2: route exists / 3: program managers interviewed have used it and can name a funded item
1.23	Safety-critical gaps that cannot be funded are escalated in writing to the chief administrative officer and council, with the risk stated	S2	C3	D	2D.9	1: gaps known but not escalated / 2: escalation recorded / 3: escalation recorded with a council or CAO decision minuted
1.24	The time members spend on committee duties, program team work and learning-team sessions is paid or credited on the same basis as training, including for volunteers	S1	K2 L	D+I	-	1: career only / 2: policy covers all members / 3: volunteer members interviewed confirm they were paid or credited
1.6 Legal register and compliance evaluation
1.25	A legal and other requirements register lists every statute, regulation, standard and agreement the department is bound by or has adopted, with the edition or consolidation date (ISO 45001:2018, cl. 6.1.3; CFCSA, 2021, element 13)	S1	C3 L	D	1A.2	1: list incomplete or undated / 2: complete and dated / 3: complete, dated and each entry mapped to the program module that discharges it (02 Standards and Law Master Map)
1.26	The register is reviewed at least annually and after any change in law or standard edition, and the review is recorded	S2	K2	D	1A.2	1: no review / 2: annual review recorded / 3: edition changes in the last year were picked up within three months
1.27	Compliance with legal requirements is evaluated on a schedule, the results recorded, and gaps entered in the register (ISO 45001:2018, cl. 9.1.2)	S2	C3	D	1A.2	1: evaluation ad hoc / 2: scheduled and recorded / 3: scheduled, recorded, gaps tracked to closure in the Corrective Action Register
1.28	Current copies of the applicable statute and regulations are available to members at every station in the form the regulator requires (J01 OHS Legislation, Regulator and Enforcement)	S1	K2 L	O	1A.2	1: at headquarters only / 2: at every sampled career station / 3: at every sampled station including volunteer stations
1.29	Regulator orders, directions and contacts in the last three years are logged with the response and closure evidence	S1	C3	D	1A.2	1: no log / 2: log complete / 3: log complete and every item closed with evidence
1.30	The department cites current editions of the standards it has adopted; superseded references (for example a standard consolidated into a newer one) have been updated in policies and programs	S2	S1	D	9C.3	1: several superseded references / 2: references updated in policies / 3: references current throughout the program set
1.7 Engagement and leadership behaviour
1.31	The fire chief or a deputy chief chairs or attends the monthly operations meeting at which safety indicators are reviewed, and the record shows decisions taken	S2	K2	D+O	-	1: indicators circulated, no meeting / 2: meeting held, attendance recorded / 3: meeting observed, decisions recorded and followed up
1.32	The fire chief responds in writing to every JOHSC recommendation within the period the applicable statute sets (J05 Joint Committee and Health and Safety Representative), and the responses address the hazard rather than governance or labour-relations arguments	S1	C3 L	D	11A.2	1: responses late or missing / 2: all responses on time / 3: all on time, and each states accept, reject or defer per item with reasons, interim controls and a revisit date
1.33	Labour and volunteer association representatives are engaged in the system as the package provides: nominated to the Equipment Standards team, consulted on safety-sensitive changes, and invited to the management review	S2	K2	D+I	-	1: engagement informal / 2: engagement recorded / 3: representatives interviewed confirm they were consulted before the last two safety-sensitive changes
1.34	The annual health and safety report has gone to council within the window set in 03 Accountability and Reporting, and council’s response or questions are recorded	S2	K2	D	2D.9	1: no report / 2: report delivered / 3: report delivered on time with council minutes recording its receipt
1.35	Chief officers are seen in stations and at incidents following the department’s own rules: PPE worn, procedures followed, decon done, and the record of leader visits exists	S1	K2	O+I	-	1: visits rare / 2: visits regular / 3: members at sampled stations describe a chief officer modelling the behaviour in the last quarter
1.36	Program Improvement Teams are chartered for every applicable program, or a named officer holds the duties in a small department, and the charters are approved by the fire chief (06 Program Improvement Teams)	S2	K2	D	11A.1	1: some teams chartered / 2: all applicable programs covered / 3: all covered, and the fire chief has decided on the last annual appraisals
1.8 Psychological safety and just culture
1.37	The department has a written just-culture commitment stating that errors, adaptations and workarounds are treated as learning information, that learning information is never used for discipline, and that conduct concerns go to a separate process run by different people (Conklin, 2012)	S1	C3	D+I	-	1: commitment implied / 2: written and approved / 3: written, and members interviewed can describe a case where it was honoured
1.38	Every member has the authority to stop an activity they believe presents an imminent danger, the authority is written, and stop-work calls are recorded and reviewed for learning without reprisal	S1	C3	D+I	-	1: authority assumed, not written / 2: written / 3: written, and stop-work calls in the last year are recorded with the review outcome and no reprisal
1.39	Members at sampled stations, career and volunteer, say they can raise a safety concern with their officer and get an answer, and can name the route if the officer does not act (Edmondson, 1999)DOI	S1	C3	I	-	1: fewer than half positive / 2: majority positive / 3: majority positive in every group sampled, with specific examples
1.40	The response to reports is visible: near-miss and good-catch reporters hear back, within a set time, what was done with the report	S2	K2	D+I	-	1: no feedback route / 2: route defined / 3: reporters interviewed confirm they heard back within the time set
1.41	Officers are trained in how to receive a concern, a challenge or a stop-work call, and what to say and do in reply, and the training is recorded (see 01 Roles and Responsibilities section 7)	S2	K2	D+I	-	1: not covered in officer training / 2: covered / 3: covered, and officers interviewed describe the expected reply
1.42	The culture baseline survey has been run, the results shared with members, and at least one leadership action taken from it (05 Safety Culture Baseline; Westrum, 2004)	S2	K2	D	-	1: survey run, results not shared / 2: shared / 3: shared, and an action traceable to the results
1.9 Accountability loop
1.43	The accountability and closed-feedback-loop table for governance is complete: owner (fire chief), doer (senior officer responsible for H&S), verifier (internal audit, JOHSC), feedback (management review, member communication) and closure (Corrective Action Register, with escalation on the schedule each item’s priority sets); and the loop test passes in practice	S1	K2	D+I	11A.3	1: table incomplete / 2: table complete / 3: table complete, and a real example from the last year shows the loop closing on the stated path

Loop test. A volunteer captain writes to the fire chief on Monday that volunteer officers have had no supervisory safety training. By Friday the gap is in the register as a P2, a legal duty not met, with the training division as owner, the captain has a reply, and the JOHSC has the item; within the 30-day closure date, sessions are scheduled on training nights and the RACI records who verifies attendance.

5. Effectiveness questions

Answer each from observation or interview only, and record the evidence.

Ask three members at different stations what the fire chief has done for safety in the last year that they noticed. Can they name something specific that changed their work, or only a document?
Pick the last two JOHSC recommendations and the last two regulator contacts. Did the department’s reply name the hazard, the control and the date, and did the control arrive?
Ask members, career and volunteer, whether they can raise a concern with their officer and get an answer, and whether they have done so. What proportion say yes with an example, and does the proportion differ between career and volunteer members?

6. Interview and observation prompts

(Fire chief) Which safety decision did you take in the last year that cost money or time, and what evidence did you take it on?
(Fire chief) When did you last hear directly from a firefighter about a hazard, and what happened?
(Deputy chief) Which corrective actions are overdue in your area right now, and why?
(Program manager) Can you put a budget line forward for your program? Show me one.
(Company officer, volunteer officer) What are your legal duties as a supervisor? When were you trained in them?
(Company officer) A firefighter tells you to stop a task. What do you say, in the moment and afterwards?
(Member) Who would you tell about an unsafe condition tomorrow, and what would happen next?
(Member) Have you reported a near miss or stopped a job this year? What came back to you?
(JOHSC co-chair) How long did the chief’s last written response take, and did it answer the hazard?
(Observation) At the operations meeting: are indicators discussed, and is a decision recorded?
(Observation) At a station: is the current signed policy posted, and are the statute and regulations available?
(Observation) At an incident or drill: do chief officers wear PPE and follow the accountability system?

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
OHS Legislation, Regulator and Enforcement	Which OHS statute and regulations govern the department, and what must be posted or made available to members at each workplace (item 1.28)	J01 OHS Legislation, Regulator and Enforcement
OHS Policy and Program	The employee counts at which a written OHS policy and a written OHS program are required, how the policy is prepared, posted and reviewed, the elements the program must contain, and who must receive a copy (items 1.1, 1.2, 1.7 to 1.9)	J03 OHS Policy and Program
Joint Committee and Health and Safety Representative	The employer’s deadline to answer a committee recommendation in writing (item 1.32)	J05 Joint Committee and Health and Safety Representative
Written Procedures and Committee Consultation	Whether the committee must be consulted when written policies, procedures, plans or codes of practice are established or reviewed (item 1.8)	J06 Written Procedures and Committee Consultation
Volunteer Firefighters	Whether volunteers are workers under the OHS statute, and whether a volunteer officer who directs work carries a supervisor’s duties	J11 Volunteer Firefighters

References

Canadian Federation of Construction Safety Associations [CFCSA]. (2021). National COR accreditation standard (final draft, 2021-06-11). https://cfcsa.ca/pdfs/CFCSA%20National%20COR%20Accreditation%20Standard%20-%20FINAL%20DRAFT,%202021.06.11.pdf

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

Center for Public Safety Excellence [CPSE]. (2024). Fire and emergency service self-assessment manual (11th ed.). Commission on Fire Accreditation International. https://www.cpse.org/accreditation/cfai10/

Conklin, T. (2012). Pre-accident investigations: An introduction to organizational safety. Ashgate.

Criminal Code, R.S.C. 1985, c. C-46 (Canada; consolidated to 2026-09-30; ss. 22.1, 22.2 and 217.1). https://laws-lois.justice.gc.ca/eng/acts/c-46/

CSA Group. (2019). CSA Z45001:19 (R2023), Occupational health and safety management systems: Requirements with guidance for use (adopts ISO 45001:2018 with Canadian deviations). https://www.csagroup.org/store/product/CSA%20Z45001:19/

Edmondson, A. C. (1999). Psychological safety and learning behavior in work teams. Administrative Science Quarterly, 44(2), 350–383. doi:10.2307/2666999

Hollnagel, E. (2014). Safety-I and Safety-II: The past and future of safety management. Ashgate.

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

Westrum, R. (2004). A typology of organisational cultures. Quality and Safety in Health Care, 13(Suppl. 2), ii22–ii27. doi:10.1136/qshc.2003.009522