Policy - Incident, Injury, Exposure and Near-Miss Reporting and Investigation

Format. Adopt as a policy approved by the fire chief or council, as a standard operating guideline, or as a directive. Keep the section numbering whatever the format, because the forms, the program and the audit checklist refer to it. Where the department adopts it as an SOG, keep the learning firewall (section 8) and the triage rules (clause 5.3) in a policy approved by council or the fire chief, so they carry authority over any later SOG.

Drafting conventions. Shall means mandatory. Should means expected unless a documented reason exists. May means permitted. Placeholders in double curly braces, such as {{Department}}, are completed by the department. Drafting notes appear in callouts and are removed before adoption.

What to keep intact. The reporting duty for every event type (5.1); triage within 24 hours by a group that includes a JOHSC worker member (5.3); the three tiers and their triggers (5.4); the learning firewall and the separate accountability process (section 8); the 30-day decision rule with recorded rationale (5.8); JOHSC participation (5.7). These are the elements the program depends on and the audit scores.

What to adapt. Role titles; the records system; the Triage Group seats and backups; who sponsors reviews; the Tier 3 arrangement; the reporting clocks for volunteers; the forms’ layout.

1.1 This policy sets out how {{Department}} reports, triages, reviews and learns from injuries, exposures, near misses, good catches, equipment failures and work refusals, and how it meets its statutory duties to report serious events, preserve scenes, involve the joint occupational health and safety committee and respond to its recommendations.

1.2 Its purpose is that every event becomes knowledge that changes how the work is done, that members report because reporting is safe and something happens, and that nobody is blamed for an honest account of how the work really went.

2.1 This policy applies to every member of {{Department}}: career, volunteer, paid-on-call, probationary, civilian and student, and to contractors and mutual-aid partners while operating within the department’s incident management system or workplaces.

2.2 It applies to every event arising from the department’s work: emergency operations, training, station and facility work, apparatus and vehicle operation, medical response, public education, administration and travel on duty.

2.3 It applies to events involving more than one agency; the department’s review runs for the department’s own learning and coordinates with partners through the joint review clause in mutual-aid agreements.

2.4 Exclusions. Conduct concerns are handled under {{Conduct policy}} and the collective agreement, through the separate accountability process in section 8. Statutory investigations by the regulator, the workers’ compensation board, the coroner, the fire marshal or the police run under their own authority; this policy does not delay or replace them. Harassment and violence complaints are handled under {{Workplace Violence and Harassment policy}}; a violence injury is still reported and reviewed under this policy for the hazard it reveals.

• Accountability process: the separate route, run by different people under {{Conduct policy}} and the collective agreement, for conduct concerns.
• After-Action Review (Tier 1): a short, structured crew review within 72 hours using four questions.
• Conduct concern: intentional harm, impairment on duty, reckless disregard for a known rule that put others at risk, or a criminal act.
• Event: an injury, exposure, near miss, good catch, equipment failure, work refusal or stop-work call, exercise, or a response that went well and should be studied.
• Event triage: sorting a reported event into a review tier within 24 hours against written triggers, by the Triage Group.
• Exposure: contact with products of combustion, a hazardous substance, a biological agent, excessive noise, heat or cold, or a traumatic event, whether or not harm is apparent.
• Good catch: a hazard, defect or error noticed and corrected before it became an event.
• Independent Learning Review (Tier 3): a review led by a reviewer independent of the department, under joint oversight that includes labour, with a public summary; it runs alongside statutory processes and is not an investigation.
• Learning firewall: the commitment in section 8 that learning information is not used for discipline.
• Learning information: near-miss and good-catch reports, learning-team write-ups, after-action review sheets, learning interview notes, and the reports of Tier 2 and Tier 3 reviews.
• Near miss: an event that did not cause harm but could have under slightly different conditions.
• Post-Incident Analysis (Tier 2): a facilitated review by trained people who were not at the event, with terms of reference, a timeline, learning interviews, systems analysis and rated recommendations.
• Serious event: any event on the statutory reporting list of the applicable OHS statute (J08 Incident Reporting and Investigation).
• Statutory process: an investigation or proceeding under the authority of the regulator, the workers’ compensation board, the coroner or medical examiner, the fire marshal, or the police.
• Triage Group: the senior officer on duty, the health and safety officer, and the JOHSC worker co-chair or designate, with named backups.

1. People are the solution we build around, not the problem to fix. Our members are the reason most calls go right. When something goes wrong, we ask what the work asked of them and what we gave them, not who to blame.

2. Procedures describe work as done, written with the people who do it. When a review finds a gap between a procedure and practice, the first question is whether the procedure is right.

3. Learning comes before blame, and learning information is never used for discipline. The learning firewall in section 8 is the department’s promise and the condition on which reporting rests.

4. Psychological safety is a condition of safety, so speaking up is expected and protected. Every member is expected to report, to question and to stop unsafe work, and every officer is expected to welcome it.

5. Care for people first. Support is offered before any interview and does not depend on taking part.

6. Reviews look for how the situation made sense at the time before asking what should have been done, and they record what went well as well as what went wrong.

7. Fix the system at the strongest level available. Stronger, system-level actions are favoured over reminders and retraining, and leaders record why when they choose otherwise.

8. Close the loop. Every report is acknowledged, every recommendation is decided with reasons, every closed action is checked for effect, and the person who reported hears what happened.

9. Statutory duties come first and are never delayed by a review.

5.1.1 Every member shall report to their supervisor, before the end of the shift or, for a member who has left the station, within 24 hours, any injury, exposure, near miss, good catch, equipment failure, work refusal or stop-work call arising from the department’s work. Accountable: company officer.

5.1.2 Any member may report any event, including a response that went well, by any route in 5.1.3, orally or in writing, with or without their name. Accountable: senior officer responsible for health and safety.

5.1.3 The department shall provide a reporting route that takes no more than a few minutes and needs no login: a code on every apparatus and station wall, a paper form in every apparatus, a telephone number answered by the on-duty district chief, and any officer, who shall record an oral report. Accountable: senior officer responsible for health and safety.

5.1.4 Injuries, exposures and equipment failures shall be reported on Form - Injury and Incident Report; near misses and good catches on Form - Near-Miss and Good-Catch Report; work refusals and stop-work calls on Form - Work Refusal Record. Exposure to products of combustion at a working fire shall be recorded for the crew by the company officer on the exposure log. Accountable: company officer.

5.1.5 The supervisor shall send every report to the health and safety officer and the district chief the same shift. Accountable: company officer.

5.1.6 The health and safety officer shall acknowledge every report to the person who made it within five working days and shall tell that person what was done with it within 30 days. Accountable: health and safety officer.

5.1.7 The department’s definition of each event type, with fire-service examples, shall be posted in every station and taught to every member. Accountable: health and safety officer.

5.2.1 The department shall report to the regulator, within the times the applicable OHS statute sets, every death, every prescribed serious injury and every prescribed event whether or not anyone was hurt, and shall notify the JOHSC (J08 Incident Reporting and Investigation). Accountable: senior officer responsible for health and safety.

5.2.2 Any officer who becomes aware of a death, an injury likely to prove fatal, or an event on the statutory list shall call the senior officer responsible for health and safety immediately, at any hour. The senior officer shall make the regulator notification and record the time, the person spoken to and what was said. Accountable: senior officer responsible for health and safety.

5.2.3 The incident commander shall preserve the scene of a serious event until released by the regulator, except to the extent needed to rescue, treat, or prevent further harm, and shall record anything moved. Accountable: incident commander.

5.2.4 The department shall report compensable injuries and occupational disease claims to the workers’ compensation board within its deadline and shall file a copy of the notice with the regulator call log where the statute allows it to serve as notice. Accountable: health and safety officer with human resources.

5.3.1 Every reported event shall be triaged within 24 hours or by the next business day by the Triage Group, against the triggers in 5.4, and the decision recorded on Form - Event Triage Record. Clear Tier 1 events may be confirmed on a shared daily log. Accountable: senior officer responsible for health and safety.

5.3.2 The highest trigger met sets the tier. Any member may request a higher tier and the request shall be recorded with the decision. De-escalation below the indicated tier requires the agreement of the whole Triage Group with reasons recorded. Where the group disagrees, the higher tier stands. Accountable: Triage Group.

5.3.3 Before closing, triage shall confirm that statutory reporting has been made, that the people involved have been offered support, and that the scene and records have been preserved where a higher tier or a statutory process may need them. Accountable: Triage Group.

5.3.4 For a Tier 2 event, the sponsor and lead facilitator shall be named within 72 hours of triage. For a Tier 3 event, the fire chief shall be informed immediately and the independent reviewer engaged within five working days. Accountable: fire chief.

5.3.5 Each Triage Group seat shall have a named backup so that triage happens on every day of the year, including at volunteer stations. Accountable: senior officer responsible for health and safety.

5.4.1 Tier 1, After-Action Review. The company officer or incident commander shall hold a hot debrief before the crew leaves the scene or within the shift, and an After-Action Review within 72 hours using Form - After-Action Review (Tier 1), for: (a) significant calls; (b) every working fire; (c) multi-unit or multi-agency responses; (d) exercises and live-fire training; (e) good catches; (f) any event where anyone asks for one. Accountable: company officer.

5.4.2 Tier 2, Post-Incident Analysis. A trained facilitator who was not at the event shall conduct a Post-Incident Analysis, under terms of reference signed by a sponsor at deputy chief level, with a JOHSC worker member on the team, reporting within 30 days and no later than 60, for: (a) a near miss with the potential for death or critical injury, including a mayday, a collapse close call, a lost member, a fall arrested or an out-of-air event; (b) a lost-time injury; (c) any serious event on the statutory list; (d) an emergency vehicle collision with injury or significant damage; (e) a significant operational failure, including accountability lost, water supply failed, command not established or rapid intervention not in place at a working fire; (f) patient harm during medical response; (g) a workplace violence injury; (h) a work refusal or stop-work call not resolved at the scene; (i) a repeated Tier 1 issue. Accountable: deputy chief (sponsor).

5.4.3 Tier 3, Independent Learning Review. The fire chief shall arrange an Independent Learning Review, led by a reviewer independent of the department under joint oversight that includes {{Union}} and {{Volunteer Association}}, with a public summary, for: (a) a death or critical injury; (b) an event in which senior leaders’ decisions are within scope; (c) low labour-management trust, or a request for independence from either side; (d) multiple agencies with shared responsibility; (e) major external scrutiny expected; (f) recurrence after earlier recommendations; (g) no independent Tier 2 capacity in the department. The Tier 3 arrangement shall be in place before it is needed. Accountable: fire chief.

5.4.4 Every review shall: offer support before any interview; look for how the work made sense to the people doing it before asking what should have been done; record what went well; identify people by role, not by name; produce recommendations, never findings about an individual; and brief participants on the findings before anyone else. Accountable: sponsor.

5.4.5 The method for Tier 2 and Tier 3 reviews is the one in Incident Investigation and Learning Program element 5.6: trained people, terms of reference, preservation, timeline, learning interviews, local rationality, systems analysis, no-blame language, rated recommendations, quality check. Accountable: senior officer responsible for health and safety.

5.6.1 The department shall maintain at least two members trained in incident investigation to a recognized standard, each of whom facilitates at least one review a year and refreshes training every three years. A volunteer department may meet this by a written arrangement with a neighbouring department. Accountable: senior officer responsible for health and safety.

5.7.1 A JOHSC worker member shall participate in the investigation of every serious event and every Tier 2 and Tier 3 review, as a member of the team. Accountable: senior officer responsible for health and safety.

5.7.2 The JOHSC shall receive the triage log at each meeting, every Tier 2 and Tier 3 report when released, and the status of the Corrective Action Register quarterly. Accountable: health and safety officer.

5.7.3 The department shall respond in writing to every written JOHSC recommendation within the time the applicable OHS statute sets (J05 Joint Committee and Health and Safety Representative), stating what is accepted, rejected or deferred and why, with interim controls and a revisit date for anything deferred. Accountable: fire chief.

5.8.1 Every recommendation from any tier, every JOHSC recommendation arising from a review, and every regulator order shall be entered in the Corrective Action Register with a priority on the department’s one scale, from P1 (Imminent) to P4 (Improvement), a strength rating, a proposed owner and a proposed date. Accountable: health and safety officer.

5.8.2 Within 30 days of a report’s release, the fire chief or the deputy chief delegated shall record for each recommendation that it is accepted (owner, date), accepted with modification (modification, reason), deferred (reason, interim controls, revisit date) or rejected (reason). No recommendation shall remain undecided. Where the statutory JOHSC response time is shorter, it governs. Accountable: fire chief.

5.8.3 An action shall be closed only when the work is done, a verifier has confirmed it, and an effectiveness check is recorded. Actions that fail the check reopen. Accountable: program manager of the affected program.

5.8.4 Each action carries the interim control, plan and closure dates its priority sets, and overdue actions escalate as the scale provides: a P1 to the fire chief at once; a P2 (Serious) to the deputy chief at its due date and the fire chief at 30 days overdue; a P3 (Moderate) to the deputy chief at 30 days overdue and the fire chief at 60 days; a P4 is cancelled only with a written reason. The age of open actions is a standing input to management review. Accountable: senior officer responsible for health and safety.

5.9.1 The department shall issue a change notice with every adopted change within 15 days of the decision, a de-identified learning bulletin within 30 days of every Tier 2 and Tier 3 report after participants have seen it, and a quarterly digest of near misses and good catches with the department’s response to each. Accountable: health and safety officer.

5.9.2 De-identified lessons may be shared with mutual-aid partners, the provincial fire service association, the fire school and any provincial or national near-miss system, with the fire chief’s approval. Accountable: senior officer responsible for health and safety.

5.10.1 The senior officer responsible for health and safety shall evaluate this policy and the program annually before management review, and the external review shall examine it every three years. Accountable: fire chief.

5.11.1 Nothing in this policy delays, replaces or conditions any statutory process. Statutory reporting, scene preservation, co-operation with the regulator’s officers, the workers’ compensation board, the coroner or medical examiner, the fire marshal and the police, and the JOHSC’s statutory role in investigation proceed on their own timelines whatever tier a review is at. Accountable: senior officer responsible for health and safety.

5.11.2 Where a statutory process and a department review run at the same time, the department review does not interfere with it: the scene is not disturbed, physical evidence is not examined before the regulator releases it, and members are not asked for a department account before any interview the regulator requires, unless the regulator agrees. The review may proceed on records and on the systems questions meanwhile. Accountable: sponsor.

5.11.3 The senior officer responsible for health and safety is the department’s liaison with the regulator and the workers’ compensation board; the department’s legal counsel is the liaison with the coroner or medical examiner, the fire marshal’s investigator and the police, and advises on any demand for records. A JOHSC worker member participates in the statutory investigation of a serious event as the applicable OHS statute provides (J05 Joint Committee and Health and Safety Representative). Accountable: fire chief.

5.11.4 Records demanded under a statutory power are disclosed as the law requires; the member concerned is told, and counsel is consulted before privilege is claimed over anything. Accountable: senior officer responsible for health and safety.

Only the differences from 01 Roles and Responsibilities are recorded here.

6.1 Fire chief. Decides every Tier 2 and Tier 3 recommendation within 30 days with recorded rationale; engages the Tier 3 reviewer; decides any referral to the accountability process and records it; receives the annual evaluation.

6.2 Senior officer responsible for health and safety (policy owner). Makes statutory notifications; chairs or delegates the Triage Group; maintains facilitator capacity; keeps the register; evaluates the program annually.

6.3 Health and safety officer. Acknowledges and feeds back on every report; maintains the reporting routes and posted definitions; drafts bulletins and change notices; keeps the triage log; supplies the JOHSC.

6.4 Deputy chiefs (sponsors). Sign terms of reference; apply the quality check; decide recommendations when delegated; receive escalations of overdue actions as 5.8.4 sets.

6.5 Incident commanders and incident safety officers. Preserve the scene; begin the on-scene part of the investigation within the incident area; hold the hot debrief; provide the post-incident analysis observations the standard requires of the incident safety officer.

6.6 Company officers. Ensure every event is reported before the end of the shift; complete the supervisor’s section; hold the hot debrief and the After-Action Review; respond to a request for a higher tier by passing it on and telling the member what happened.

6.7 Members. Report; take part in reviews on paid time with accompaniment if they wish; may request a higher tier; may decline to be interviewed without consequence.

6.8 Triage Group. Triages within 24 hours; records the decision; checks the three closing items.

6.9 Tier 2 facilitators. Run reviews by the method; hold interview notes; apply the language rule; brief participants first.

6.10 JOHSC. Worker member on every serious-event and Tier 2 and Tier 3 team; receives the logs and reports; checks annually that no discipline has rested on learning information; makes written recommendations and receives written responses. Its statutory functions are preserved in full.

6.11 Bargaining agents and volunteer association. Consulted on this policy and the firewall; sit on Tier 3 oversight; may accompany members at interviews.

6.12 Peer support team. Offers support to everyone involved in an event, independent of any review; reports aggregate activity only.

6.13 Human resources. Receives referrals to the accountability process; never receives learning information; handles workers’ compensation claims.

• Incident Investigation and Learning Program
• SWP - Exposure Reporting
• The statutory reporting procedure and call log, built from your jurisdiction’s section of J08 Incident Reporting and Investigation
• Corrective Action Register
• Form - Near-Miss and Good-Catch Report; Form - Injury and Incident Report; Form - Event Triage Record; Form - After-Action Review (Tier 1); Form - Post-Incident Analysis Report Outline (Tier 2); Form - Work Refusal Record
• Where the department wants the full method: Manual 02 - The Three Tiers and Event Triage and Manual 08 - Model Policy

8.5 Records. The records this policy creates are: event reports; the triage log and triage records; After-Action Review sheets; terms of reference and reports for Tier 2 and Tier 3 reviews; register entries, decisions and effectiveness checks; change notices and bulletins; statutory notices and the call log. Interview notes are the facilitator’s working papers and are destroyed when the report is accepted. Retention follows 05 Document Control and Records and any period the applicable law sets (J09 Records Retention).

8.6 Access. Event reports and review reports are available to the fire chief, the policy owner, the sponsor, the JOHSC and the participants. Register status is available to every member. Learning interview notes are available to no one but the facilitator.

8.7 Disclosure. Every record is written expecting disclosure under freedom-of-information law: people are identified by role, not by name; conditions are described, not character. Personal health information is never requested by a review; where a member volunteers it, it is not recorded. Privilege is claimed only on counsel’s advice. De-identified reports and bulletins may be shared as 5.9.2 provides.

8.8 Support for people. Peer support and psychological first aid are offered to everyone involved in an event whether or not they take part in a review. A review is not a psychological debriefing and is kept separate from one. Interviews are on paid time with accompaniment if the member wishes. Workers’ compensation rights, including any presumptive coverage, are unaffected by anything in this policy.

9.1 To the fire chief: every serious event immediately; the triage log weekly; every Tier 2 and Tier 3 report on release; register age monthly; the annual evaluation.

9.2 To the JOHSC: the triage log at each meeting; every Tier 2 and Tier 3 report; register status quarterly; the annual evaluation; the firewall check result.

9.3 To council or the board: an annual summary of events, lessons and actions, aggregated and de-identified, within the annual health and safety report (03 Accountability and Reporting); the public summary of any Tier 3 review.

9.4 To members: acknowledgement within five working days and feedback within 30 days of a report; change notices; bulletins; the quarterly digest. Participants are briefed before any wider release.

11.1 The applicable occupational health and safety statute and regulations: duties of employers, supervisors and employees (J02 Duties of Employers, Supervisors, Workers and Contractors); reporting of serious events and scene preservation (J08 Incident Reporting and Investigation); JOHSC participation in investigation and the written response to recommendations (J05 Joint Committee and Health and Safety Representative); written procedures (J06 Written Procedures and Committee Consultation); and record retention (J09 Records Retention).

11.2 The applicable workers’ compensation statute (J32 Workers' Compensation and Firefighter Presumptions): the employer’s injury report to the board (J08 Incident Reporting and Investigation) and return-to-work duties (J33 Return to Work, Accommodation and Hours of Work).

11.3 Responder health and safety standard: health and safety officer accident investigation duties; incident safety officer accident investigation and post-incident analysis duties; investigation of accidents, injuries, illnesses, deaths and near misses with corrective action; program evaluation (NFPA 1550, 2024, s. 4.7, s. 5.6, s. 5.7, ch. 6 and Annex G and H).

11.4 Workplace incident investigation standard: program planning, incident response, investigation method, action plan and validation (CSA Z1005:21, cl. 4.4, 5, 6, 7).

11.5 Management-system standard: incident, nonconformity and corrective action; management review; consultation and participation of workers (ISO 45001:2018, cl. 5.4, 9.3, 10.2); the Canadian adoption (CSA Z45001:19).

11.6 Accreditation criteria: hazard reporting policies and procedures; documented steps to address identified hazards; near-miss reporting used to teach and share lessons; a process to investigate and document accidents, injuries and legal actions to determine root cause (CPSE, 2019, criteria 11A.2, 11A.3, 11A.6, 11A.7).

11.7 The learning firewall and just-culture clauses draw on the published literature on reporting cultures and just culture (Dekker, 2016; Marx, 2001; Reason, 1997) and on the After the Call model policy (The Human Factor, 2026b).

12.1 This policy shall be reviewed 12 months after adoption and every three years thereafter, and after any Tier 3 review, any change in the applicable statute or standards, or on request of the JOHSC.

12.2 Review is led by the policy owner with the JOHSC, {{Union}} and {{Volunteer Association}}, and the revised policy is approved by {{Fire Chief}} or {{Council or CAO}}.

Consult early, before the text is settled. The committee and the bargaining agents will ask the questions below; honest answers are given here.

Put the agreement in writing in a letter of understanding. Volunteers and non-union staff need a voice: the volunteer association sits in the consultation and on Tier 3 oversight. Where the parties disagree, record the disagreement, adopt what can be agreed, and review at 12 months.

Disclaimer. This model policy is general information prepared by The Human Factor for adaptation by the adopting department. It is not legal advice. The department is responsible for confirming every statutory and standards citation, for counsel and collective-agreement review, and for the policy as adopted.

End of model policy.

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.