02 Gap Assessment Tool

The Gap Assessment Tool measures the distance between the department’s safety management system as it exists today and the system this package describes. It produces a scored profile across 20 categories, a maturity band, a ranked list of gaps, the Stage 1 critical items, and a 90-day action list. Everything in 01 Implementation Roadmap 0-36 Months starts from this result, every entry it generates lands in the Corrective Action Register, and the annual Management Review re-reads it.

It is not a compliance inspection and it is not the internal audit. The audit (01 Audit Program) verifies that programs run as written, category by category, once they exist. The gap assessment asks a prior question: which programs exist, how far they are implemented, and whether any of them can be shown to work. The two instruments share one taxonomy and one scoring scale so a department can compare its first gap assessment with its third audit without translation. The taxonomy follows the ISO 45001 clause order (ISO 45001:2018), the technical content follows NFPA 1550 (NFPA 1550, 2024), the evidence and threshold rules follow the Canadian COR model (CFCSA, 2021; IHSA, 2017), and the answer template follows the accreditation model (CPSE, 2019).

The Profile Worksheet must be complete before the assessment starts. A module marked Not applicable is scored “N/A” and removed from the denominator; a module marked Conditional is scored against the awareness-level and stand-off elements only.

The assessment team of three. The health and safety officer ({{Health and Safety Officer}}), one line officer from outside the safety division (a company officer or district chief who has not written the programs being scored), and one worker member of the {{JOHSC}}. In a composite department one of the three is a volunteer officer or member. An external facilitator is optional at Stage 1 and expected at Stage 3, where the external reviewer uses this instrument as the baseline.

Independence rules. Nobody scores an element they are accountable for. The HSO scores no element in categories 18, 19 or 20; the line officer and the JOHSC member score those. A consultant who wrote the department’s program does not score it.

Time required. Figures are for the full instrument including document review, station visits, observations and interviews.

Interview sampling. One-on-one, confidential, notes destroyed after scoring, on the COR audit pattern (CFCSA, 2021; IHSA, 2017). Stratify by rank (firefighter, company officer, chief officer) and by career and volunteer status in proportion to headcount, with volunteers never below 30 percent of the sample in a composite department. An element that carries an interview code scores on the majority of positive responses.

Observation sampling. At least one apparatus and SCBA check, one PPE routine inspection, one decontamination cycle after a fire or a drill, one JOHSC meeting, one station inspection, one training evolution, and one live incident or a drill where command, accountability and PAR can be watched. All career stations and at least half the volunteer stations are visited; the rest are visited the following year.

Five bands, after the Westrum typology and the Hudson culture ladder (Westrum, 2004DOI; Hudson, 2003DOI) as used in the NextCall Readiness Index (The Human Factor, 2026h). The band describes how the department relates to its own safety system, not how good its firefighters are.

The weakest-category rule. The department’s band is capped at one band above its weakest category. A department scoring 78 percent overall with a Reacting score in Emergency Operations is Complying, not Learning. Programs die in the category nobody looks at (Vaughan, 1996).

How the three stages map to the bands.

A department can be honestly at Stage 1 and still safe. The point of the bands is to describe, not to shame.

Every element is scored on three dimensions. The maximum per element is nine. The three-dimension design answers the known limits of the NFPA 1550 Annex H worksheet, which is binary, unweighted and carries no evidence or effectiveness requirement (NFPA 1550, 2024, Annex H).

Effectiveness cannot score above Implementation. An element with I = 1 has E capped at 1.

Elements flagged L discharge a duty that occupational health and safety law places on employers across Canada, with thresholds and details that vary by jurisdiction. Each L element names, in its Jurisdiction topic column, the Part 10 page that sets out the duty for every province and territory and for federal workplaces; check your jurisdiction’s section there before scoring. Where your jurisdiction imposes no such duty on the department (a headcount below a threshold, for example), the element keeps the floor as a department standard and the Appraisal field records why. The floor: every L element must score D ≥ 2 and I ≥ 2. A category with any L element below the floor is reported as “not passing: legislated floor”, whatever its percentage, and every such element is automatically a Stage 1 critical item. This is the Ontario COR “100 percent on legislated items” rule (IHSA, 2017), softened to two-thirds so that a department can pass while still improving.

• Element points = (D + I + E) × weight. Element possible = 9 × weight.
• Category score (percent) = sum of element points ÷ sum of element possible, N/A elements excluded.
• Overall score (percent) = sum of all element points ÷ sum of all element possible. Never report the overall score without the category profile beside it.
• Effectiveness index (percent) = sum of E scores ÷ (3 × number of scored elements), by category and overall, unweighted. This is the number that tells a department it is compliant but not yet effective.
• Pass thresholds (COR pattern, CFCSA, 2021): 80 percent overall and 50 percent in every category, with every L element at the floor.
• Band: from the overall score and effectiveness index per section 4, then capped by the weakest-category rule.

The audit checklists in 02 Audit Checklist Master Index use one 0 to 3 scale. The two are reconciled by rule so the gap assessment and the audit compare directly:

A small department may score the whole instrument on the single scale at Stage 1 and move to three dimensions at Stage 2.

Each scored element carries four short fields, the CFAI pattern (CPSE, 2019): Description (what the department does), Appraisal (how well, with the data and the evidence seen), Plan (what will change, with owner and date), References (the exhibits). The Plan field is what flows to the Corrective Action Register.

Legend. Stage: the stage at which the element becomes required (S1, S2, S3). Wt: C Critical ×3, K Core ×2, S Supporting ×1; L marks a legislated item subject to the floor (section 5.4). Evid: D, O, I codes per section 5.2. Crosswalk abbreviations double as the in-text citations for each row: 1550 NFPA 1550 chapter (NFPA 1550, 2024; chapter numbers follow the 2024 consolidation, and any clause-level citation is until confirmed in 02 Standards and Law Master Map); ISO ISO 45001:2018 and CSA Z45001:19 clause; CFAI Fire and Emergency Service Self-Assessment Manual 10th edition criterion or performance indicator (CPSE, 2019), CC marks a core competency, 11th edition noted where the research gives it (CPSE, 2025; 11th edition numbers); COR CFCSA national element number (CFCSA, 2021: 1 Policy; 2 Hazard assessment; 3 Safe work practices; 4 Safe job procedures; 5 Rules; 6 PPE; 7 Preventive maintenance; 8 Training and communication; 9 Inspections; 10 Investigation; 11 Emergency preparedness; 12 Records; 13 Legislation; 14 Procurement and contractors), ON marks an Ontario IHSA additional element (IHSA, 2017); Section 21 Ontario Firefighter Guidance Notes, cited by note number (MLITSD, n.d.); Lavender Ribbon and Yellow Ribbon (IAFC VCOS & NVFC, 2018; IAFC VCOS, 2021); NIOSH 5 the five contributing factors that recur in NIOSH structural-fire fatality reports, numbered as the fire service lists them (Fire Engineering, 2023); NIOSH top ten the ten most frequent recommendation categories in NIOSH fatality investigations, in rank order (Hard et al., 2019)DOI; NFFF FLSI the Firefighter Life Safety Initiatives (NFFF, n.d.); IAFF/IAFC WFI the joint wellness-fitness initiative (IAFF & IAFC, 2018); CARs the Canadian Aviation Regulations (Canadian Aviation Regulations [CA], 2026); Design principle the numbered principles, with their evidence, in section 8 of 05 Design Principles and Lessons Learned. Other standards named by designation in the elements or the crosswalk are cited at these editions: NFPA 470 (2022), NFPA 1006 (2021), NFPA 1010 (2024), NFPA 1020 (2025), NFPA 1091 (2024), NFPA 1140 (2022), NFPA 1400 (2026), NFPA 1580 (2025), NFPA 1585 (2025), NFPA 1750 (2026), NFPA 1850 (2026), NFPA 1900 (2024), NFPA 1910 (2024), NFPA 1930 (2024), NFPA 1950 (2025), NFPA 1990 (2022), NFPA 2500 (2022), CSA Z94.4-18, CSA Z180.1:19, CSA Z1002:12, CSA Z1003-13, CSA Z1004:24, CSA Z1005:21, CSA Z1008:21, CSA Z1010:18, CSA Z1600:17 and ISO 19011:2026. Jurisdiction topic, the last column, names the Part 10 page that sets out the legal requirement behind the element for every province and territory and for federal workplaces; every L element has one, and a few unflagged elements have one where the law shapes how the element is met. Jurisdiction requirements at the end of this note says what to confirm on each page. Each category also carries a fabric element (N.F) that scores the Safety Differently and psychological-safety fabric of that category: whether procedures were written with the crews from work-as-done, whether the learning firewall is in force, how a member’s speak-up is answered, and whether a concern gets an answer back (Edmondson, 1999DOI; Hollnagel, 2014; Dekker, 2014; Conklin, 2017).

Desired outcome: the fire chief and the municipality own the system, have written down what the department does and does not do, and have resourced it.

Desired outcome: the committee is inside the system, meeting on the statutory cycle, consulted before changes, and able to show that its recommendations get answered.

Desired outcome: the department knows its hazards, has ranked them, has applied the hierarchy of controls, and reviews the result on a cycle.

Desired outcome: a current, consulted, version-controlled library of safe work procedures that describe the work as it is actually done safely.

Desired outcome: nobody does work they are not trained for, training is safe, and records prove it.

Desired outcome: the right document is the current one, records are kept and protected, and every member gets the same information at the same time.

Desired outcome: every member has the right PPE, it is clean, inspected, fit tested where it must be, and worn when it must be.

Desired outcome: apparatus is maintained and tested by qualified people, driven by trained people wearing seat belts, and nothing goes on the truck without the Equipment Standards gate.

Desired outcome: stations and shops are inspected on a cycle, exhaust is captured, contaminated gear stays out of living areas, and deficiencies get fixed.

Desired outcome: at every incident there is command, accountability, a way to call for help, air to get out, and someone watching for danger.

Desired outcome: for every hazard the department declares it will face, there is a program, a procedure, trained people, and a go and no-go rule.

Desired outcome: contaminants are reduced at the scene, kept out of the cab and the station, washed off within the hour, and every exposure is written down for life.

Desired outcome: every member is medically fit for the work, knows their cardiac risk, and can get back to duty safely after injury.

Desired outcome: members can get help fast and quietly, supervisors know how to start the conversation, and nobody is bullied or assaulted at work without the department acting.

Desired outcome: everything that hurts or nearly hurts someone gets reported quickly, looked at honestly, and turned into a change that the whole department hears about.

Desired outcome: when the emergency happens to the department, in a station, at a scene or to a member, the plan already exists.

Desired outcome: nobody working in the department’s workplaces, and nobody the department works beside, is outside the system.

Desired outcome: the department knows, in numbers, whether its controls are in place and whether they work.

Desired outcome: somebody independent checks the system every year, somebody outside checks it every three, and the findings get fixed.

Desired outcome: once a year the chief sits down with the evidence, decides what changes, puts money and names against it, and tells the department.

Element count: 208: 188 core elements (11, 10, 11, 8, 12, 8, 12, 9, 9, 12, 10, 10, 9, 9, 10, 7, 7, 9, 7, 8) plus one fabric element per category.

A department pursuing or holding accreditation through the Commission on Fire Accreditation International answers every performance indicator in four parts: description, appraisal, plan and references, and must meet every core competency to be accredited (CPSE, 2019). This instrument is built so that the Category 11 answers fall out of it without a second exercise.

• Category 11 self-assessment evidence. Each of the 18 Category 11 indicators maps to a small set of elements (table below). The department’s answer to an indicator is the Description, Appraisal, Plan and References fields of those elements, with the D, I and E scores as the appraisal data and the exhibits in the References field as the peer assessors’ document trail. Only three Category 11 indicators are core competencies (CC 11A.5 training, CC 11B.1 medical and fitness evaluations, and CC 11B.6 the annual appraisal of the wellness and fitness program); this package treats all 18 as mandatory, so a department that passes the Stage 1 gate will have evidence for every one of them, not only the three it must meet (CPSE, 2019).
• Annual program appraisal input. The roll-up worksheet and the category profile are the data behind the formal, documented annual appraisal the manual requires for wellness and fitness (CC 11B.6) and for each operational program (CC 5E.3, CC 5F.9, CC 5G.2, CC 5H.3, CC 5I.2, CC 5J.2, CC 5K.3), and for training (CC 8B.6). Each Program Improvement Team’s annual appraisal (06 Program Improvement Teams section 10) quotes its category and element scores and its indicator results in the appraisal’s outcomes section.
• Annual compliance reports. An accredited agency files an annual compliance report between site visits (CPSE, 2019); the year-over-year movement on the roll-up worksheet and the closed register entries are the safety content of that report.
• Edition change. Agencies appearing before the Commission from spring 2027 are assessed under the 11th edition, which expands the indicators on member mental health and wellness, labour-management interaction and PPE policy, and adds criteria for emergency medical transport and the public information function (CPSE, 2025). The 10th edition numbers in this instrument remain the crosswalk for current documents; the 11th edition’s category structure and numbers are until the department holds the manual, and the elements already cover the expanded topics (categories 1, 7 and 14).
• Peer assessment as the external review. The triennial external review in element 19.4 may be delivered by a CFAI peer team site visit where the department is in the accreditation cycle; the gap assessment scored by the internal team is then the baseline the peer team reality-tests at stations (CPSE, 2019).

Complete one row per category. N/A elements are removed from both numerator and denominator.

Band determination, in order.

1. Overall score and effectiveness index against section 4.
2. Weakest category band (same thresholds applied to the category score and category E index).
3. Department band = the lower of (1) and (weakest category band + 1).
4. If any legislated element is below the floor, the band cannot exceed Reacting until it is fixed, whatever the arithmetic. Report “Reacting (legislated floor)” with the elements listed.

Stage gate check. Beneath the roll-up, list every Critical element with I < 2 (Stage 1 gate), every category below 50 percent (Stage 2 gate), and the E index against 40 and 60 percent (Stage 2 and 3 gates).

The report is 10 to 15 pages. It goes to the fire chief, the senior team, the JOHSC co-chairs, the union and volunteer association representatives, the CAO, and (summary) council. Roles, never names.

GAP ASSESSMENT REPORT                                   {{Department}}  {{Province}}
Assessment date(s):                 Team: HSO; line officer (role); JOHSC worker member; facilitator (if any)
Scope: modules per Profile Worksheet dated ____ ; stations visited ____ of ____ ; interviews ____ ; observations ____

1. SUMMARY (one page)
   Overall score ____ %    Effectiveness index ____ %    Band: ____ (capped by category ____ )
   Legislated floor: met / not met (elements: ____ )
   Stage gate position: Stage 1 criteria met? ____   Stage 2? ____   Stage 3? ____
   Three sentences on what the department does well.
   Three sentences on what must change first.

2. CATEGORY PROFILE
   Bar chart or table: 20 categories, score %, E index %, pass/fail, band; previous year beside it where it exists.
   Career and volunteer columns where practice differs.

3. TOP TEN GAPS, ranked by risk and legal exposure
   Rank order rule: (a) legislated elements below floor, by severity of the duty; (b) Critical elements with I < 2,
   ordered by the hazard register risk band they control; (c) Critical elements with E < 2; (d) categories below 50 %.
   For each: element #, what was found (evidence), what it controls (hazard register IDs), legal exposure (duty, confirmed on
   the Jurisdiction topic page), priority (P1 to P4, section 9), recommended action, owner (role), closure date on the
   priority's clock, cost class (none / member time / under $10k / over $10k).

4. STAGE 1 CRITICAL ITEMS
   Every L element below floor and every Critical element with I < 2, as a checklist with priority, owner and date. These are the
   first entries in the Corrective Action Register and the first 90 days of the Roadmap.

5. RECOMMENDED 90-DAY ACTIONS (no more than 12)
   Action | Why (gap #) | Owner | By | Evidence of completion | Cost class

6. RESOURCING
   People: HSO time, program team hours, training days, backfill.
   Money: by cost class and by category, with the three items that need a budget decision.
   Decisions the chief must make: list.

7. METHOD AND LIMITS
   Sampling achieved vs planned; stations not visited; elements scored N/A and why; interview response counts;
   disagreements within the team and how resolved; what the team could not verify.

8. APPENDICES
   A. Completed instrument (208 rows with D/I/E, evidence and the four answer fields)
   B. Roll-up worksheet
   C. Interview and observation schedules (no names)
   D. Documents reviewed (register)

Into the Implementation Roadmap. Section 4 of the report (Stage 1 critical items) is the first 90 days of 01 Implementation Roadmap 0-36 Months without further argument. The category profile sets the order of program builds: the lowest-scoring category with a Required module goes first unless a legislated floor item sits elsewhere. The stage gate check tells the roadmap which stage the department is actually at, which is often not the stage it believed.

Into the Corrective Action Register. Every element scoring D < 2 or I < 2 becomes one register entry, carrying the element number as its source, the Plan field as its action and the accountable role from the RACI as its owner, rated on the package’s one priority scale (Corrective Action Register): P1 where a Critical control is absent or has failed and the work it protects goes on; P2 where an L element is below the floor or a Critical control is weakened; P3 for any other Stage 1 element below 2; P4 for a Stage 2 or Stage 3 element the department has not yet reached, dated to its roadmap stage. Each entry takes the scale’s interim control, plan and closure clocks and its extension and escalation rules. Where the full fix cannot be finished inside the closure clock because it needs capital work or a budget decision (a capital item, a medical program), the action that brings the element to the floor or puts the control in place is the interim control and does not close the entry: the permanent fix keeps its priority, flagged Capital, with a dated plan tied to the roadmap and the budget cycle, approved by the fire chief and reviewed quarterly by the JOHSC, and the interim control is re-verified monthly until the fix is in (Corrective Action Register section 4). Elements scoring E < 2 with I ≥ 2 become P4 register entries of type “effectiveness”, owned by the program team, with the plan due at the next quarterly update. The register’s open-item age for gap assessment entries is reported at every management review until the next assessment.

Into the management review. The report is an input under “audit results” and “OHS performance trends”. The review minutes record which top-ten gaps were accepted, deferred with reasons, or resourced. The next year’s assessment reports movement on every accepted item.

Into the Program Improvement Teams. Each team receives the rows for the categories and elements its programs own, as the first item on its next agenda, and reports progress in the quarterly update.

Into the audit. The audit uses the same taxonomy. Categories scoring above 60 percent move to the audit’s verification sampling; categories below stay on the gap assessment’s fuller treatment until they cross.

A composite department: about 180 members (60 career on four platoons, 120 volunteers), nine stations (three career, six volunteer), full-time fire chief and two deputies, one HSO who is also the training division captain, a JOHSC that meets most months, medical first response, structural and interface fire, hazmat operations level, surface water and ice rescue, rope rescue at operations level, no confined space or trench (Conditional), no marine, airport or RPAS (Not applicable). First assessment, Stage 1, six team days, 20 interviews (12 volunteer), five stations visited.

Reading it. The department is better than its band. PPE and apparatus are genuinely run by people who care (Building); emergency operations are sound on the career platoons and uneven at volunteer stations (Implementation 1 on 10.2 and 10.4 because two volunteer stations had not drilled mayday in three years). What drags it to Reacting is the assurance loop: no register, no indicators, no audit, no management review, and the JOHSC recommendation process stalled at 61 percent with two recommendations unanswered for 14 months. The effectiveness index of 21 percent says almost nothing is measured.

Top ten gaps (abridged).

1. 15.6 No single Corrective Action Register; deficiencies live in four places. Legislated. P2. Owner: senior officer H&S. Closure 30 days. Cost: none.
2. 3.1 and 3.6 No hazard register; hazard reports go to whoever is on duty. Legislated. P2. Owner: senior officer H&S with program teams. Closure 30 days for the reporting route and the register with its first entries; the deputy chief extends the full seed inventory once, to 90 days. Cost: member time.
3. 12.4 Exposure reports filed for 11 of 47 working fires last year. Legislated (records). P2. Owner: deputy chief operations. Closure 30 days for the form and the rule; the deputy chief extends once, to 90 days, for the filing rate. Cost: none.
4. 2.4 and 2.9 Two JOHSC recommendations unanswered beyond the statutory time; four volunteer stations have no representative. Legislated. P2. Owner: fire chief. Closure 30 days. Cost: none.
5. 9.1 Station inspections done at career stations only; three volunteer stations never inspected. Legislated. P2. Owner: district chiefs. Closure 30 days. Cost: member time.
6. 20.1 No management review has ever been held. Legislated (program effectiveness). P2. Owner: fire chief. Closure 30 days, extended once to 90 days so the first review has its input pack. Cost: none.
7. 18.3 and 18.4 No indicators collected; injury data exists only as compensation letters. Legislated (records). P2. Owner: HSO. Closure 30 days, extended once to 90 days for the baseline worksheet. Cost: none.
8. 10.4 Mayday not drilled at two volunteer stations in three years. Critical, weakened rather than absent: P2. Owner: training division with volunteer officers. Closure 30 days. Cost: training time.
9. 13.1 Volunteer medical tier undefined; 40 percent of volunteers have no record of any medical. Critical. P2, flagged Capital: the tier, written with the physician and approved within 30 days (extended once to 90), is the interim control and is re-verified monthly; completing the medicals keeps the P2 priority, with a dated plan to the next budget cycle (12 months) approved by the fire chief and reviewed quarterly by the JOHSC. Owner: fire chief with physician. Cost: over $10k.
10. 19.1 No audit program. Legislated (program evaluation). P2: a Stage 2 element, but below the floor, so a Stage 1 critical item (section 5.4). Owner: senior officer H&S. Closure 30 days for the written audit program, extended once to 90 days; the first internal audit follows at month 12 of the roadmap. Cost: auditor training for two people.

90-day actions. Charter the Corrective Action Register and load the 11 floor items as P2 entries (week 1). Answer the two JOHSC recommendations in writing and appoint volunteer station representatives (week 2). Issue the exposure report rule and form; officer signs every working fire report with the exposure report attached (week 3). Stand up three Program Improvement Teams: Respiratory Protection, Protective Clothing and Decontamination, Emergency Operations (month 1). Start the hazard register with the seed inventory switched to the Profile (month 1 to 3). Monthly inspections at every station with a volunteer worker member (month 1). Mayday drill at the two volunteer stations (month 1) and at every station (month 3). First dashboard, six indicators, to the chief and JOHSC (month 3). First management review held (month 3).

Resourcing. HSO at 0.5 FTE for 90 days (currently 0.2); backfill the training captain’s hours. Volunteer honoraria for inspections and team sessions, about 240 hours in the quarter. Budget decision for the chief: the volunteer medical program (the one item over $10k) goes to the next budget cycle with the business case from 02 Business Case and Cost Model.

A year later. The same department re-scored at 63 percent overall, effectiveness index 38 percent, all floors met, two categories below 50 percent (19 and 20, both Stage 2 items in progress). Band: Building, capped from Learning by category 19. Stage 1 gate passed; Stage 2 gate not yet. That is a normal, good year.

Loop test. A volunteer captain tells the interviewer on a Tuesday that the SCBA at her station have not been flow tested in two years. By the report date, element 7.6 scores Implementation 1 with that evidence, the item is in the top ten, and it is in the Corrective Action Register as a P2 with the Respiratory Protection program manager as owner and a 30-day closure date. Within the month the units are tested or tagged out, the captain has been told, and the quarterly update from the Respiratory Protection team shows flow-test currency at 100 percent for the first time.

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.

National Fallen Firefighters Foundation [NFFF]. (n.d.). Until everyone goes home: Firefighter life safety initiatives [Web page]. https://www.firehero.org/fire-service-resources/until-everyone-goes-home/

Ontario Ministry of Labour, Immigration, Training and Skills Development [MLITSD]. (n.d.). Firefighter guidance notes (Section 21 Advisory Committee; individual notes revised to 2026). https://www.ontario.ca/document/firefighter-guidance-notes