Checklist - Procedures and Document Control | Fire Service Safety Management System

1. Scope

Category 4 audits whether the department’s written procedures describe the work as it is actually done safely, are controlled so that only the current version is in use, were built with the people who do the work and consulted with the committee, are reviewed on a cycle, reach every member including volunteers, and are known in practice. It covers the document hierarchy and numbering; safe work procedure and operating guideline development; approval and consultation; the review cycle; distribution and acknowledgement; availability on apparatus and devices; and member familiarity verified by interview and drill.

It does not score the content of any specific procedure (categories 7 to 15 score their own procedures), records retention (category 6) or training delivery (category 5). It scores the system that produces, controls and refreshes procedures.

Fed by 05 Document Control and Records and the safe work procedure shells in 06 Safe Work Procedures.

2. Criteria

Source	What it requires	Items
Applicable OHS statute and regulations: when written work procedures are required, including those that specific regulations require (commonly respiratory protection, confined space, fall protection, WHMIS and lockout); whether the written program must provide for them; and any duty to consult the committee on written policies, procedures, plans or codes of practice (J03 OHS Policy and Program; J06 Written Procedures and Committee Consultation)	Written procedures exist for the practices the law and the hazard profile require; consultation recorded	4.8 to 4.11, 4.16 to 4.21
Emergency-services relief in the applicable OHS regulations, where it exists: an equivalent trained procedure in place of a written fall protection plan, and for work at temporary highway scenes (J16 Fall Protection and Rope Access; J31 Roadway Incident Scenes)	The equivalent procedure is still written and trained; scored in categories 12 and 14	4.8
ISO 45001 cl. 7.5 documented information (creation, update, identification, format, review, approval, control of distribution, access, retrieval, storage, change control, retention, obsolete documents); 8.1.1 operational planning and control with criteria for processes; 5.4 consultation (ISO 45001:2018)	Controlled documents; procedures as operational controls; worker consultation on their content	4.1 to 4.7, 4.22 to 4.30
COR elements 3 safe work practices, 4 safe job procedures and 5 company rules (CFCSA, 2021)	Written practices and procedures for hazardous tasks with worker input, communicated, trained, enforced and reviewed	4.8 to 4.15, 4.31 to 4.38
NFPA 1550 ch. 6, written procedures and standard operating guidelines for the program and for emergency operations (NFPA 1550, 2024)	Written SOGs for the safety program elements and operations	4.8 to 4.11
CFAI CC 9C.3 organizational documents, procedures and manuals reviewed at least every three years; 11A.2 policies and procedures for hazards and unsafe practices; 8A.3 training consistent with legal mandatory training; CC 5E.2 standardized incident command supported by policy (CPSE, 2019)	Three-year review; hazard procedures; legally required procedures trained; command system in policy	4.19 to 4.21, 4.10, 4.13, 4.34
Work-as-done and the learning-team method (Hollnagel, 2014; Conklin, 2012)	Procedures written from how the task is really done, with the people who do it	4.12 to 4.15

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.
Sample at least eight procedures across three programs, check the version in use at three stations against the master, and watch at least one task done against its procedure, before scoring.

4. Checklist

#	Item	Stage	Wt	Evid	CFAI	Scoring anchors (1 / 2 / 3)
4.1 Document hierarchy and numbering
4.1	A written document hierarchy defines policy, procedure, operating guideline, safe work procedure, job aid and form, with what each is for and who approves each level (05 Document Control and Records) (ISO 45001:2018, cl. 7.5)	S1	K2	D	-	1: hierarchy informal / 2: written / 3: written and every sampled document fits one level
4.2	Every controlled document carries a unique number, a version, an effective date, a review date, an owner role and an approver role	S1	K2	D+O	-	1: some fields on some documents / 2: all fields on the master set / 3: all fields on every copy found at sampled stations
4.3	A master list or register of controlled documents exists, shows the current version of each, and is maintained by a named role	S1	K2	D	-	1: list incomplete / 2: complete / 3: complete and matches the versions found in use
4.4	Obsolete versions are withdrawn from stations, apparatus and electronic systems when a new version issues, and the withdrawal is recorded	S1	C3	D+O	-	1: old versions found at several sites / 2: withdrawal procedure exists / 3: no obsolete version found at any sampled site
4.5	Documents are legible, identifiable and in a format members can use where the task is done (apparatus-sized job aids, electronic copies on devices)	S1	S1	O	-	1: desk-format only / 2: field format for critical tasks / 3: field format for all SWPs, found on apparatus
4.6	External documents the department relies on (standards, manufacturer instructions, regulator guidance) are listed with the edition in use and controlled the same way	S2	S1	D	-	1: not listed / 2: listed / 3: listed with editions and reviewed annually
4.7	Changes to a document record what changed, why and who authorized it, so a reader can see the history	S2	S1	D	-	1: no change history / 2: history on recent changes / 3: history on every sampled document
4.2 Procedure development from work-as-done
4.8	A written safe work procedure exists for every task the hazard profile ranks as high risk and for every practice the applicable statute or regulations require a written procedure for (J06 Written Procedures and Committee Consultation)	S1	C3 L	D	11A.2	1: gaps for several high-risk tasks / 2: all high-risk tasks and legal requirements covered / 3: as 2 and the set is mapped to the hazard profile
4.9	Each safe work procedure follows the package structure: task and when it applies, hazards, controls in hierarchy order, PPE and equipment, staffing and competencies, numbered steps with decision points and stop-work triggers, emergency and contingency, documentation, training and review	S1	K2	D	-	1: structure varies / 2: structure consistent / 3: consistent and every sampled SWP has stop-work triggers and a contingency
4.10	Operating guidelines exist for emergency operations elements (incident management, accountability, rapid intervention, mayday, air management, rehabilitation, roadway operations) and are consistent with the standards adopted (NFPA 1550, 2024, ch. 10 and 17 to 21; CPSE, 2019, criterion 5E.2)	S1	C3	D	5E.2	1: some elements / 2: all elements / 3: all elements, consistent with the standards and cross-referenced
4.11	Department rules (for example turnout gear kept out of living areas; only approved PPE and equipment used; seat belts) are written, posted and consistent with the procedures	S1	K2	D+O	11A.2	1: rules unwritten / 2: written / 3: written, posted at sampled stations and consistent
4.12	Every new or revised procedure was developed through a learning-team session or equivalent with the members who do the task, and the record names the roles who took part (06 Program Improvement Teams section 5) (Hollnagel, 2014)	S2	K2	D+I	-	1: written without the crew / 2: participation recorded / 3: members interviewed recognize the procedure as how they do the task
4.13	Procedures required by law were checked against the regulation’s wording by the HSO and the check is recorded (CPSE, 2019, criterion 8A.3)	S1	C3 L	D	8A.3	1: not checked / 2: checked / 3: checked and re-checked after each regulatory change
4.14	Where observation shows the practice differs from the procedure, the department’s first response is to review the procedure with the crew, not to enforce it, and the record shows this happening	S2	K2	D+I	-	1: deviations treated as violations / 2: policy says review first / 3: a documented case in the year where the procedure changed because of a deviation
4.15	Each procedure names the conditions under which it does not apply or must be adapted, and what the crew does then	S2	S1	D	-	1: absent / 2: present in critical procedures / 3: present in all sampled
4.3 Approval and JOHSC consultation
4.16	Approval authority for each document level is set in the hierarchy and every sampled document was approved by the right role	S1	K2	D	-	1: approvals inconsistent / 2: authority set / 3: authority set and every sampled document approved by it
4.17	The committee was consulted before adoption of every policy, procedure, plan or code of practice with safety content, and the consultation is recorded with the committee’s comments (ISO 45001:2018, cl. 5.4) (J06 Written Procedures and Committee Consultation)	S1	C3 L	D	-	1: consultation missed on several / 2: on all / 3: on all, with comments traceable to the adopted text
4.18	Safety-sensitive changes pass through the relevant Program Improvement Team and, for equipment and PPE, the Equipment Standards team, before approval	S2	K2	D	-	1: bypassed in sampled changes / 2: all pass through / 3: all pass through and the team’s evidence is filed with the change
4.4 Review cycle
4.19	Policies and procedures are reviewed 12 months after first adoption and then at least every three years, and the review is recorded whether or not a change results (CPSE, 2019, criterion 9C.3)	S1	K2	D	9C.3	1: reviews overdue for many / 2: review dates set / 3: no sampled document past its review date
4.20	Procedures are reviewed outside the cycle after a serious event, a learning review recommendation, a legislative or standard edition change, or a committee request, and the trigger is recorded	S1	K2	D	9C.3	1: no out-of-cycle reviews / 2: triggers written / 3: a triggered review in the year is traceable from trigger to revised document
4.21	Procedures scheduled for review are listed in the annual program cycle and the list is managed by a named role	S2	S1	D	9C.3	1: no list / 2: list / 3: list on the calendar and met
4.5 Distribution and acknowledgement
4.22	New and revised procedures are distributed to every station and every member, including volunteers, by a defined route within a set time of approval	S1	K2	D+I	-	1: distribution informal / 2: route and time set / 3: volunteer members interviewed received the last revision within the time
4.23	Members acknowledge receipt and reading of procedures that apply to their role, and the acknowledgement is recorded	S1	K2	D	-	1: no acknowledgement / 2: recorded for career members / 3: recorded for all members
4.24	A change notice accompanies each revision stating what changed, why, and what the member must do differently, in plain language	S2	K2	D+I	-	1: revisions issued without notice / 2: notices issued / 3: members interviewed can describe the last change
4.25	Safety bulletins and interim directives are controlled: numbered, dated, time-limited, and either withdrawn or folded into a procedure by their expiry	S2	S1	D	-	1: bulletins uncontrolled / 2: controlled / 3: no expired bulletin still in circulation
4.26	Members on leave, new hires and members changing role receive the procedures that apply to them before resuming or starting the duty	S2	K2	D	-	1: not addressed / 2: addressed in orientation / 3: records show it for sampled members
4.6 Availability on apparatus and devices
4.27	The current procedure set is available at every station in a form members can use, and the version matches the master list	S1	K2	O	-	1: available at headquarters / 2: at every career station / 3: at every station, current version
4.28	Critical safe work procedures and job aids are available on apparatus, by printed aid or device, and crews can retrieve one on request	S1	K2	O	-	1: not on apparatus / 2: on some / 3: retrieved on request at every sampled apparatus
4.29	Electronic access does not depend on a single person or a device that is not on the apparatus, and works at volunteer stations	S2	S1	O+I	-	1: depends on one person / 2: shared access / 3: works at sampled volunteer stations
4.30	Forms referenced by procedures exist, are current, and are available where the procedure is done	S1	S1	O	-	1: forms missing / 2: forms exist / 3: forms current and found where needed
4.7 Member familiarity verified
4.31	Members at sampled stations can describe the key steps, the stop-work triggers and the contingency of a critical procedure for their role	S1	C3	I	-	1: fewer than half / 2: majority / 3: majority in every group, including volunteers
4.32	A task observed in a drill or at an incident is done as its procedure describes, or the crew can explain the adaptation and it is consistent with the procedure’s stated conditions	S1	C3	O+I	-	1: major unexplained deviations / 2: done as written / 3: done as written or adapted within the stated conditions, and the crew explains why
4.33	Procedures are rehearsed in training on a cycle set by the program, and training records show the rehearsal	S1	K2	D	-	1: no cycle / 2: cycle set / 3: cycle met for sampled procedures
4.34	Officers enforce procedures consistently and correct deviations in the moment, and the correction is treated as learning, not as discipline unless conduct is involved	S1	K2	I	-	1: enforcement inconsistent / 2: consistent / 3: consistent, and members describe correction as learning
4.35	Members report that they can question a procedure, propose a change and get an answer, and that the route exists	S1	C3	I	-	1: fewer than half / 2: majority / 3: majority with an example of a change made
4.36	Procedure familiarity is tested in performance-based evaluations rather than by signature only, for critical tasks	S2	K2	D	-	1: signature only / 2: performance tests for some / 3: performance tests for all critical tasks
4.37	Mutual aid partners and contractors who work under the department’s command receive the procedures that apply to them before they do the work	S2	S1	D	-	1: not provided / 2: provided / 3: provided and acknowledged
4.8 Accountability loop
4.38	The accountability and closed-feedback-loop table for document control is complete: owner (senior officer responsible for H&S for the system; program managers for their procedures), doer (document controller role; program teams), verifier (internal audit; committee consultation record), feedback (change notices; reply to whoever proposed a change), closure (Corrective Action Register with escalation on its priority scale); and the loop test passes in practice	S1	K2	D+I	-	1: table incomplete / 2: complete / 3: complete and a real example from the year shows the loop closing on the stated path

Loop test. A volunteer firefighter tells her captain on Monday that the ice rescue procedure’s tether step cannot be done with the new harness. By Friday the program team has the item, the firefighter has heard back, and the procedure is flagged for review; within the quarter a learning-team session has rewritten the step, the committee has been consulted, the revision has reached every station with a change notice, and the register shows closure.

5. Effectiveness questions

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

Pick one critical task and watch it done. Does the procedure in use at that station match the master, and does the crew do what it says or adapt within the conditions it names?
Ask three members, including a volunteer, to describe the last procedure change that reached them. Can they say what changed and why, and did they get it within the time the system sets?
Ask members whether they can question a procedure or propose a change and get an answer, and whether they have done so. What proportion say yes with an example?

6. Interview and observation prompts

(Document controller) Show me the master list. Which document is next due for review, and who owns it?
(Program manager) Who was in the room when your last procedure was written or revised?
(HSO) Which procedures does the law require in writing, and when did you last check them against the regulation?
(JOHSC co-chair) When were you last consulted on a procedure, and did your comments change it?
(Company officer) A crew member does a task differently from the procedure. What do you do?
(Member) Walk me through the stop-work triggers in a procedure you use often.
(Member, volunteer) How did the last procedure change reach you? Did you acknowledge it?
(Member) Have you ever proposed a change to a procedure? What happened?
(Observation) At a station: compare three procedures in the binder or system with the master list versions.
(Observation) On apparatus: ask the crew to retrieve the job aid for a critical task.
(Observation) In a drill: note each step done, each adaptation and the crew’s explanation.

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 Policy and Program	Whether the law requires a written OHS program at the department’s size, and whether that program must provide for written work procedures (items 4.8, 4.13)	J03 OHS Policy and Program
Written Procedures and Committee Consultation	When written safe work procedures are required, including by specific regulations, the rules for their adequacy, availability and review, and any duty to consult the committee before adopting or revising them (items 4.8, 4.13, 4.17)	J06 Written Procedures and Committee Consultation
Fall Protection and Rope Access	Whether emergency services have relief from the written fall protection plan, and the conditions the equivalent procedure must meet (item 4.8; scored in category 14)	J16 Fall Protection and Rope Access
Roadway Incident Scenes	Whether temporary highway work rules apply at emergency scenes or are relieved for emergency services, and what the equivalent procedure must cover (item 4.8; scored in category 12)	J31 Roadway Incident Scenes

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.

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