Corrective Action Register

The register is the one place where every deficiency the system finds is tracked from the day it is found to the day someone checks that the fix held. Inspections, audits, investigations, JOHSC recommendations, near-miss reports, program team actions and regulator orders all land here. A deficiency that is not in the register does not exist as far as the management review is concerned, and a register that nobody reads at the JOHSC meeting is a list, not a control.

ISO 45001 requires the organization to react to nonconformities, evaluate the need for action to eliminate the cause, implement the action, review its effectiveness, and retain documented information on the nonconformity, the action and its results (ISO 45001:2018, cl. 10.2). The applicable OHS law sets its own version of this duty, typically prompt follow-up and control of identified hazards and records of inspections and investigations (J04 Hazard Assessment and Workplace Inspections; J09 Records Retention). The register is how both are evidenced: it is the follow-up system and the record.

• One register. Not one per division, not one for audits and one for inspections. A single register with a source field. A department that runs several will lose the one that matters.
• One owner per item. A role, with a name behind it in the live system. Shared ownership is no ownership.
• Closure needs evidence and a second pair of eyes. The owner says it is done; the verifier confirms it with evidence; for majors the verifier is not the person who found it.
• The fix is checked later. A closed item gets an effectiveness check after a set interval. Many fixes work for a month.
• The person who raised it hears back. Every item records who raised it (by role or station, never by name in the register itself) and the date they were told the outcome. Psychological safety is built one answered report at a time (Edmondson, 1999)DOI.
• Overdue is visible. The overdue list is read at every JOHSC meeting and every operations meeting. Nobody is surprised at the management review.

Priority is set on intake by the HSO or delegate and confirmed by the owner within two working days. Every source uses this one scale. Inspection ratings map directly: Immediate, High, Medium and Low are P1, P2, P3 and P4. Audit grades map as major nonconformity P1 or P2 by risk, minor nonconformity P3, and opportunity for improvement P4 (01 Audit Program section 6).

Critical controls include accountability, two-in/two-out and rapid intervention, air management, SCBA, fall protection, the confined space atmosphere, and apparatus brakes and seat belts. A cluster of P3 items showing that a category has failed is rated P2.

Due dates count from the date identified, not the date logged. The one extension the table allows is recorded with its reason and its approver; a second extension is an escalation (section 8). A regulator order is logged as P1 or P2, and the compliance date in the order becomes the closure due date when it is earlier than the table’s (J01 OHS Legislation, Regulator and Enforcement). An accepted JOHSC recommendation is logged at the priority its hazard warrants and follows the table; the employer’s written response to the committee must also meet the deadline the applicable statute sets (J05 Joint Committee and Health and Safety Representative), and the response date is recorded in the register.

Capital work. Where the permanent fix needs capital work that cannot be finished inside the closure clock, the interim control does not close the item. The permanent fix keeps its priority, flagged Capital, with a dated plan approved by the fire chief and reviewed quarterly by the JOHSC; the interim control is re-verified monthly until the fix is in.

The owner accepts the item within two working days or sends it back with a proposed owner. An item with no accepted owner after five working days is assigned by the deputy chief. The HSO never owns an item merely because the safety division found it; the HSO administers the register and owns only safety division items.

An item closes only when all of these are in the record:

1. The planned action is done and described in the past tense with dates.
2. Verification evidence is attached or referenced: a record, a photograph, an observation note, a test certificate, a training record, an interview note. “Confirmed by owner” is not evidence.
3. The verifier is independent to the degree the priority requires (section 4): for P1 and P2, not the person who found the item and not the owner.
4. The root cause field is complete and condition-based.
5. The raised-by role or station has been told the outcome, with the date.
6. The effectiveness check date is set.

An item whose action was to write a document closes on approval of the document; an item whose action was to change a practice closes on observation or records showing the changed practice, not on the memo announcing it.

Cancellation is permitted only with a written reason approved by the deputy chief (P2 to P4) or fire chief (P1), and the raised-by party informed. Typical valid reasons: the hazard no longer exists; a different item supersedes it (cross-referenced); the finding was wrong on the evidence.

Every closed P1, P2 and P3 item is checked after closure to confirm the fix held. The check asks: is the condition still absent; is the control still in place and in use; has the indicator moved; has the same deficiency reappeared anywhere else?

Result “held”: status becomes verified effective. “Partly held” or “not held”: the item is reopened with a new sequence suffix (CAR-2026-041-R1), the root cause is revisited, and the reopening is reported to the JOHSC and the owner’s deputy chief.

Escalation is not punishment. In most departments an item is overdue because the owner lacks a resource or a decision, and escalation is the route to the person who can supply it. The register records the decision so that the pattern of resource gaps is visible at the management review.

Indicators drawn from the register. Open-item age (median days open); on-time closure rate by priority; reopen rate after effectiveness check; proportion of items with “raised-by informed” dated before closure (target 100 per cent; this is a psychological-safety measure); source mix (a register fed only by audits means inspections and near-miss reports are not producing actions).

A composite department, fiscal year starting April; the register as it stood on 2026-11-20. All roles generic; no names.

What the example shows: the raised-by column holds a role or station; every P1 and P2 has an interim control within the time the scale sets; every plan and closure date follows the scale from the date identified; the P1 regulator order was extended once by the fire chief while the platform stayed locked out; the JOHSC recommendation item carries its one approved extension with the reason and, when that date was missed too, the fire chief’s recorded decision, rather than a silent slip; the closed items name the evidence and an independent verifier; the first effectiveness check has been done and held.

Loop test. A volunteer firefighter reports on a Tuesday training night that the bay door’s safety edge does not reverse. By Monday it is in the register as P2 with the door locked open and a cone across the track (interim control), the facilities liaison as owner, a 7-day plan date and a 30-day closure date. The firefighter has heard from the station officer that it is logged and what the number is. The repair is done in three weeks, the station officer photographs the reversing test, the HSO verifies and closes it, and the firefighter is told. Six months later the HSO checks the door still reverses and the monthly inspection form has a line for it.

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.