Policy - Internal Responsibility and Accountability

Format. Adopt as a department policy. It can also be issued as a directive from the fire chief; keep the numbering either way, because the audit checklist for leadership and governance scores clauses by number.

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 sit in callouts and are removed before adoption.

Keep intact. Section 5.3 (the closed loop as a duty), section 5.4 (just culture and the distinction between learning information and conduct), section 5.6 (stop-work authority), and the four house principles. Adapt. Role titles, who receives escalations where the department’s structure has fewer levels, the recognition mechanisms, and the disciplinary process references to match the collective agreement.

1.1 To state how responsibility for health and safety flows through {{Department}}, what each level owes, how the department proves due diligence, how it closes the loop on every hazard and concern, how it treats people when things go wrong, and who can stop work.

1.2 To give Policy - Occupational Health and Safety section 5.2 its working content.

2.1 Applies to every member, every officer, the fire chief, and the municipality’s officials in their dealings with the department. Applies to contractors and mutual aid partners while under department command.

2.2 Applies to all work: emergency operations, training, station duties, maintenance, administration, travel on department business, and volunteer response from home.

2.3 Does not replace the disciplinary provisions of a collective agreement or the municipality’s human resources policies. Where this policy touches discipline, it sets the gate (section 5.4) through which safety-related conduct concerns pass before those provisions apply.

Accountable. Answerable for an outcome; one role per outcome.

Adaptation. A departure from a procedure made to get the job done under the conditions present. Adaptations are expected in emergency work and are the raw material of learning, not evidence of misconduct.

Closed loop. A hazard, concern, deficiency or recommendation is logged, assigned an owner and a due date, acted on, verified closed, and the result reported back to the person who raised it and to the people affected.

Conduct concern. Intentional harm, working while impaired, reckless disregard of a known and understood risk, a criminal act, or repeated refusal to follow a procedure the member has been trained in and has the means to follow, where the member has been told and the conditions allow it.

Due diligence. Taking every precaution reasonable in the circumstances, and being able to show it with records; the defence to a strict liability offence under occupational health and safety law (R. v. Sault Ste. Marie, 1978).

Learning firewall. The rule that learning information is used for learning and is not the basis for discipline, and that conduct concerns go to a separate process run by different people (Dekker, 2016; Reason, 1997).

Learning information. Anything produced in a debrief, after-action review, post-incident analysis, learning team, near-miss report, good-catch report or independent learning review for the purpose of learning.

Responsible. Does the work or ensures it is done.

Stop-work authority. The authority and duty of any member to halt an activity they believe presents an imminent danger.

1. People are the solution we build around, not the problem to fix. When a procedure fails in practice, the department asks what made the member’s action make sense at the time, and fixes the conditions.

2. Procedures describe work as done, written with the people who do it. A member who departs from a procedure to get the job done safely has told the department something about the procedure.

3. Learning comes before blame, and learning information is never used for discipline. The department wants to know, and it cannot know if reporting is punished.

4. Psychological safety is a condition of safety, so speaking up is expected and protected. An officer who makes it hard to speak up has failed a safety duty (Edmondson, 1999)DOI.

5. Responsibility is shared; accountability is not. Every element of the safety management system has one accountable role (ISO 45001:2018, cl. 5.3).

6. Authority matches accountability. No role is accountable for an outcome it has no authority, time or budget to deliver. Where that happens, the department fixes the organization, not the paper.

7. Decisions are judged by their quality, not by their outcome. An officer who makes a sound risk decision with the information available is supported whatever happens next; an outcome that happened to be good does not validate a poor decision (NFCC, n.d.-b, decision principle 4).

8. Heroism is narrowly defined. The department will not act against a member who takes a risk on their own initiative to protect life, without endangering others (HSE, 2010); it will not reward or celebrate the violation of a safety rule (USFA & IAFC, 2015).

5.1.1 {{Municipality}}, as employer of record, carries the employer’s statutory duties (J02 Duties of Employers, Supervisors, Workers and Contractors) and exercises them through the chief administrative officer and the fire chief. Accountable: CAO.

5.1.2 The fire chief is accountable for the safety management system as a whole and for every outcome in it, and discharges that accountability through the chain of command. Accountable: {{Fire Chief}}.

5.1.3 Each officer who directs work carries the employer’s duties for that work: knowing the hazards, telling the crew, ensuring training, competence and fitness, ensuring procedures are followed and protective equipment used, accounting for the crew, responding to concerns and refusals, and reporting. OHS statutes differ on whether supervisors are separate duty-holders with duties of their own or are reached through the employer’s duties (J02 Duties of Employers, Supervisors, Workers and Contractors); either way, this policy assigns these duties to every officer for the work they direct. Accountable: each officer, at each level, for the work they direct.

5.1.4 Each program is owned by a line program manager through a Program Improvement Team or a named officer under 06 Program Improvement Teams. Accountable: {{Deputy Chief}} for the assignment; the program manager for the program.

5.1.5 Each member is responsible for their own safety and that of others to the extent of their authority and ability to act, and for reporting what they see, as the worker’s statutory duties require (J02 Duties of Employers, Supervisors, Workers and Contractors). Accountable: each member.

5.1.6 The safety division advises, coordinates, verifies and audits. The JOHSC participates, inspects, recommends and challenges. Neither owns an operational risk. Accountable: {{Fire Chief}} for keeping it so.

5.1.7 The RACI matrix in 01 Roles and Responsibilities section 4 forms part of this policy. Every “A” shall sit on a role with the authority to deliver it, checked at each annual review. Accountable: {{Fire Chief}}.

5.2.1 The department shall take every precaution reasonable in the circumstances for the health and safety of its members, as the employer’s general duty requires (J02 Duties of Employers, Supervisors, Workers and Contractors), and shall be able to show it (R. v. Sault Ste. Marie, 1978). Accountable: {{Fire Chief}}.

5.2.2 Due diligence is shown by records that exist as a by-product of running the programs: hazard assessments, written procedures, training and competency records, supervision records, inspection records, enforcement of procedures, corrective action to closure, and the review of all of these. Canadian regulators consistently frame their findings after a firefighter death or injury as a missing procedure, training, supervision, inspection or plan (WorkSafeBC, 2025; see 05 Design Principles and Lessons Learned), so a system built on those records is also the department’s defence. The department shall keep those records under Policy - Records, Privacy and Health Information and 05 Document Control and Records. Accountable: program managers; {{Division Chief, Safety}} for the system.

5.2.3 Every officer and senior officer shall know that a person who undertakes, or has the authority, to direct how another person does work is under a legal duty to take reasonable steps to prevent bodily harm to that person arising from that work (Criminal Code [CA], 1985, s. 217.1), and that the department, as an organization, can be held criminally liable for the conduct of its senior officers (Criminal Code [CA], 1985, ss. 22.1 and 22.2). The department shall train this. Accountable: {{Deputy Chief}}.

5.2.4 Where a precaution is reasonable and the department cannot resource it, the fire chief shall escalate in writing to the chief administrative officer and council, with the risk, the control and the cost, and shall record the interim control in place while the gap stands. Accountable: {{Fire Chief}}.

5.3.1 Every hazard, concern, deficiency, near miss, inspection finding, audit finding, investigation recommendation, JOHSC recommendation and learning review recommendation shall be logged in the Corrective Action Register within five working days of identification, with an owner and a due date (ISO 45001:2018, cl. 10.2); this is also how the department meets the hazard follow-up element of a statutory OHS program where one is required (J03 OHS Policy and Program). Accountable: the receiving officer for logging; the program manager for the item.

5.3.2 Every item shall be acted on, verified closed with evidence by someone other than the person who did the work, and reported to the JOHSC and the fire chief. Accountable: the program manager; {{Health and Safety Officer}} for verification.

5.3.3 The person who raised the item shall hear back: an acknowledgement within two working days, and the outcome when the item closes or when a decision is made not to act, with reasons. Accountable: the receiving officer.

5.3.4 Every item carries a priority on the department’s one scale, P1 (Imminent), P2 (Serious), P3 (Moderate) or P4 (Improvement), with the interim control, plan and closure dates that priority sets. Overdue items escalate as the scale provides: a P1 to the fire chief at once; a P2 to the deputy chief at its due date and to the fire chief at 30 days overdue; a P3 to the deputy chief at 30 days overdue and to the fire chief at 60 days; a P4 is cancelled only with a written reason. Open-item age is a standing input to the monthly operations meeting and the annual management review. Accountable: {{Deputy Chief}}; {{Fire Chief}}.

5.3.5 A hazard or concern that an officer cannot resolve within their authority shall be escalated the same day to the next level, and the member told where it has gone. Accountable: each officer.

5.3.6 Failing to log, failing to act, or failing to tell the person who raised the item is a failure of a safety duty under this policy, handled under section 5.4. Accountable: {{Fire Chief}}.

5.4.1 The department operates a learning firewall. Learning information is used for learning and is never the basis for discipline (Dekker, 2016; Marx, 2001). An investigation run for prevention is kept separate from any enforcement or disciplinary process (CSA Z1005:21). Accountable: {{Fire Chief}}.

5.4.2 For clarity, the following are learning information and shall not be used as evidence in any disciplinary process: what is said in a hot debrief, an after-action review or a learning team; a near-miss or good-catch report and the identity of the reporter; interview notes, timelines and analyses from a post-incident analysis or independent learning review; a member’s own account of an error, adaptation or workaround given for the purpose of learning. Accountable: {{Fire Chief}}; {{Division Chief, Safety}}.

5.4.3 Conduct concerns are different. Where any process surfaces a conduct concern as defined in section 3, the facilitator shall stop, note the concern without analysis, and refer it to the fire chief or designate, who decides whether to open a separate conduct process. That process is run by different people, gathers its own evidence, follows the collective agreement and the municipality’s policies, and does not have access to the learning record. Accountable: {{Fire Chief}}.

5.4.4 In deciding whether a safety-related act is a conduct concern, the decision-maker shall apply the following test and record the answer: Was the member trained and competent in the procedure? Was the procedure available, current and workable under the conditions? Did the member have the equipment, staffing and time the procedure assumes? Would a peer with the same training, in the same conditions, likely have done the same? Did the member intend harm, act while impaired, or disregard a known and understood risk with reckless indifference? A “yes” to any of the first four, or a “no” to the fifth, points to a system issue, and the response is to fix the system. Accountable: {{Fire Chief}} or designate.

5.4.5 Where a conduct concern is substantiated, the response shall be proportionate, consistent, and recorded, and shall follow the collective agreement. Where the same act by the same member recurs after the system has been fixed and the member has been told, the department may treat it as a conduct concern on the second occurrence. Accountable: {{Fire Chief}}.

5.4.6 No member shall be subject to reprisal for reporting a hazard, injury, exposure, near miss or error; for refusing unsafe work in good faith; for exercising stop-work authority in good faith; for raising a concern with the JOHSC or the regulator; or for taking part in a learning process. The applicable statute also prohibits reprisal for exercising a statutory right (J07 Right to Refuse and Reprisal Protection). Accountable: {{Fire Chief}}.

5.4.7 The department shall tell every member in writing, at orientation and annually, what the learning firewall covers and what it does not. Accountable: training division.

5.5.1 The department shall recognize safety behaviour that the program depends on: reporting a near miss or good catch; stopping work; making a sound risk decision whatever the outcome; withdrawing from a position that became untenable; designing a better procedure with a learning team; mentoring a new member in safe practice. Accountable: {{Fire Chief}}.

5.5.2 Recognition shall be prompt, specific and public where the member agrees, and shall never name a member’s error. Accountable: each officer.

5.5.3 Awards and commendations shall not be given for acts that violated a safety rule, and the criteria for every award shall say so. Accountable: {{Fire Chief}}.

5.5.4 Team service, learning-team participation and completed safety development shall be recorded and count in promotional and assignment processes as the collective agreement permits. Accountable: {{Deputy Chief}}.

5.6.1 Every member has the authority and the duty to stop an activity they believe presents an imminent danger to themselves or any other person, and to tell the officer in charge right away. Accountable: each member.

5.6.2 The incident safety officer, the health and safety officer and the training safety officer have express authority to alter, suspend or terminate any activity, including training, that presents an imminent hazard, and shall tell the incident commander or officer in charge immediately. Accountable: those roles.

5.6.3 When a member stops work, the officer shall acknowledge it, make the area safe, address the hazard or confirm the activity can proceed, and tell the member why. The stop and the response are recorded and reviewed later for learning. Accountable: the officer in charge.

5.6.4 A stop-work call made in good faith is never the subject of reprisal, whatever the outcome. Accountable: {{Fire Chief}}.

5.6.5 Stop-work authority is separate from, and in addition to, the statutory right to refuse unsafe work. The right to refuse follows Policy - Right to Refuse and Work Stoppage. Accountable: {{Division Chief, Safety}}.

5.7.1 The department shall measure, by station and overall, at least: corrective actions opened and closed and the median days to closure; items overdue and escalated; reports acknowledged within two working days; near-miss and good-catch reports per 100 calls; stop-work events and their outcomes; the psychological safety items of the culture survey. Accountable: {{Health and Safety Officer}}.

5.7.2 A rising near-miss count after adoption is the expected sign of success, not of decline; services that promoted reporting and showed members what happened as a result saw reports increase (NZFS, 2016a). Accountable: {{Fire Chief}} to say so to council.

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

6.1 Fire chief. Owns the learning firewall; is the decision-maker, or names the designate, for conduct referrals under 5.4.3; signs the escalation letters under 5.2.4; ensures award criteria comply with 5.5.3.

6.2 Designate for conduct referrals. A senior officer who does not facilitate learning processes. In a small department, this may be the CAO’s human resources function.

6.3 Facilitators of learning processes. Stop and refer under 5.4.3; never carry a conduct concern into a conduct process themselves.

6.4 Officers. Log within five days; acknowledge within two; escalate the same day what they cannot resolve; close the loop with the reporter.

6.5 Human resources. Runs conduct processes under the collective agreement without access to learning records; keeps the two record sets apart.

6.6 JOHSC. Receives the register summary monthly; may ask for any item’s status; is consulted on this policy.

Incident Investigation and Learning Program (the three tiers, triage and the firewall in full); Corrective Action Register; 03 Accountability and Reporting; 06 Program Improvement Teams; Policy - Right to Refuse and Work Stoppage; Policy - Incident, Injury, Exposure and Near-Miss Reporting and Investigation.

8.1 Records: the Corrective Action Register; acknowledgement and closure notices; escalation letters; stop-work records; conduct referral decisions (held by human resources, separate from learning records); the 5.4.4 test records; recognition records.

8.2 Learning records and conduct records are kept in separate systems with separate access. No learning record is filed in a personnel file. Governed by Policy - Records, Privacy and Health Information.

8.3 All records are written for disclosure under municipal freedom-of-information law, identify people by role where possible, and contain no personal health information.

• The applicable OHS statute: employer, supervisor and worker duties, and the internal responsibility system, which some statutes state in their purpose clause (J02 Duties of Employers, Supervisors, Workers and Contractors); reprisal protection and the right to refuse (J07 Right to Refuse and Reprisal Protection); the written OHS program and its hazard follow-up element (J03 OHS Policy and Program); hazard identification and the handling of reported hazards (J04 Hazard Assessment and Workplace Inspections); the committee’s role in receiving reports and making recommendations (J05 Joint Committee and Health and Safety Representative); and the duty to keep written procedures adequate, implemented, trained and followed (J06 Written Procedures and Committee Consultation).
• The duty of persons directing work and organizational criminal liability (Criminal Code [CA], 1985, ss. 22.1, 22.2, 217.1).
• The due diligence defence (R. v. Sault Ste. Marie, 1978).
• Leadership, roles, consultation, and incident, nonconformity and corrective action (ISO 45001:2018, cl. 5.1, 5.3, 5.4, 10.2; CSA Z45001:19).
• Workplace incident investigation kept separate from enforcement (CSA Z1005:21).
• Roles and accountability in the fire service health and safety standard (NFPA 1550, 2024, ch. 6).
• Just culture and the separation of learning from blame (Dekker, 2016; Marx, 2001; Reason, 1997).
• The CPSE/CFAI accreditation path: responsibility for the health, safety and risk management programs assigned to specific persons (CPSE, 2019, criterion 11A.1); a corrective actions system that ensures accountability (CPSE, 2019, criterion 7C.3); a member recognition program (CPSE, 2019, criterion 7B.7); a succession plan that incorporates mentoring (CPSE, 2019, criterion 7D.6). Sections 5.3, 5.5 and 06 Program Improvement Teams are written as the evidence for these.

12.1 Reviewed 12 months after adoption, then every three years; after any Tier 3 learning review or any conduct referral that tests section 5.4; after any change in the statute, the Criminal Code provisions or the collective agreement; and on JOHSC request.

12.2 Each review checks every “A” in the RACI against a real position with the authority to deliver it, and records what was changed.

Put the consultation in writing. Record disagreement, adopt what can be adopted, revisit at 12 months.

Closing disclaimer. This model policy is general information prepared by The Human Factor for licensed use by {{Department}}. It is not legal advice. Confirm every statutory reference with counsel before adoption.

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.

R. v. Sault Ste. Marie (City), [1978] 2 S.C.R. 1299 (Supreme Court of Canada).

National Fire Chiefs Council [NFCC]. (n.d.-b). National Operational Guidance: Incident command (login required). https://nfcc.org.uk/nog/incident-command/