Form - Post-Incident Analysis Report Outline (Tier 2)

The outline every Tier 2 Post-Incident Analysis report follows, so that reports are comparable, auditable and readable by a crew. The lead facilitator writes it; the sponsor checks it against the quality standard before release; participants see it before anyone else. The method behind each section is in Incident Investigation and Learning Program element 5.6 and follows the national incident investigation standard (CSA Z1005:21, cl. 6), the systems view of contributing factors (Holden et al., 2013)DOI and the principle of local rationality (Woods & Cook, 1999; Dekker, 2014). The outline also serves as the written post-incident analysis the responder safety standard asks of the incident safety officer (NFPA 1550, 2024, s. 5.7 and Annex G), with the safety officer’s observations entered under section 4.

Target: 30 days from triage, 60 at most. Length: as short as the event allows; most reports are eight to 15 pages plus appendices.

Cover. Report reference; event reference; date of event; date of report; sponsor (role); lead facilitator (role); team (roles); distribution and status (draft to participants / draft to sponsor / released).

Firewall statement. The learning firewall text from the policy, on the first page.

What happened, in three sentences, as the crew experienced it. The three to five conditions that shaped it. What went well. The recommendations, each with its strength rating and proposed owner. One line on what a crew can do tonight.

The signed terms of reference (toolkit 15.5 in the program note): tier and trigger, scope in and out, questions, team, access, timeline, statutory interfaces, support.

How the review was done: records collected (dispatch, radio, accountability, action plan, pre-plans, telematics, camera, weather, photographs, equipment set aside, training and inspection records, exposure log); number of learning interviews by role; site visit; subject matter advice; limits (what could not be obtained and why).

A narrative from the participants’ point of view, in order, without judgment: what each crew knew, saw, expected and did, and when. The incident safety officer’s observations from the scene are entered here. Roles, never names.

A single table: time; what happened; who knew it (by role); source. Checked with the participants.

The things the crews did, and the conditions that were present, that kept the event from being worse. Stated as specifically as the things that went wrong.

For each decision point: what the person knew; what they were trying to do; the cues they had; the pressures on them; why the action made sense at the time; what the system could have given them that it did not.

The classification table (toolkit 15.8 in the program note): each factor in one work-system row (person, task, tools and equipment, organization, internal environment, external environment), cross-referenced to any of the five recurring fireground factors (risk assessment, command, accountability, communications, procedures). No factor entered as “human error,” “complacency,” “failed to” or “lost situational awareness” without the condition that produced it.

A table: number; the contributing factor it addresses; the recommendation; where it sits on the hierarchy of controls; strength rating (stronger / moderate / weaker); proposed priority on the department’s one scale; proposed owner (role); proposed date; effectiveness check proposed. Where only weaker actions are available, the stronger action that could not be recommended and why. The priority sets the interim control and the dates once the item enters the Corrective Action Register. P1 (Imminent): interim control immediately, the same shift, with the fire chief and JOHSC co-chairs told within 24 hours; plan due in two working days; closed within seven days. P2 (Serious): interim control within 24 hours where practicable; plan due in seven days; closed within 30 days. P3 (Moderate): plan due in 30 days; closed within 90 days. P4 (Improvement): plan by the next quarterly program update; closed within 365 days or the next budget cycle. Extensions and escalation follow the register.

Any participant’s or team member’s disagreement with a finding or recommendation, recorded in their words.

Support offered and by whom (roles), independent of participation; no personal health information.

Participants briefed (date); sponsor’s quality check (date; result); JOHSC received (date); fire chief received (date); learning bulletin issued (date); register items opened (references); decisions recorded within 30 days (date).

Photographs and diagrams; equipment examination results; relevant procedure extracts; the interview guide used; the firewall notice given to participants.

Released reports are kept per 05 Document Control and Records. Interview notes are the facilitator’s working papers and are destroyed when the report is accepted. Reports are written for freedom-of-information disclosure.