01 Program Architecture

The package is a management system, not a checklist. Its frame is Plan, Do, Check, Act on the ISO 45001 and CSA Z45001 pattern (ISO 45001:2018; CSA Z45001:19), keyed to the written occupational health and safety program that the applicable provincial or territorial statute requires of an employer of the department’s size (J03 OHS Policy and Program). NFPA 1550 and the specialty standards supply the content inside the frame; they are never the frame itself (NFPA 1550, 2024). The reason is historical: a voluntary checklist standard for fire service safety has existed since 1987 and the one compliance survey found that most departments had not adopted it and most adopters were not compliant, because a list tells a department what to have and not how to keep it alive (Fire Engineering, 1991; NFPA 1550, 2024, annex H).

flowchart LR
    subgraph PLAN["PLAN  (ISO 45001 cl. 4 to 6)"]
        P1[Program Profile Worksheet]
        P2[Gap Assessment]
        P3[Hazard Profile and Risk Register]
        P4[Baseline Metrics]
        P5[Policies and objectives]
    end
    subgraph DO["DO  (cl. 7 and 8)"]
        D1[Program modules]
        D2[Safe work procedures]
        D3[Training and competency]
        D4[Program Improvement Teams]
    end
    subgraph CHECK["CHECK  (cl. 9)"]
        C1[Inspections and indicators]
        C2[JOHSC inspection and review]
        C3[Internal audit, annual]
        C4[External review, triennial]
        C5[Learning: AAR, PIA, Learning Review]
    end
    subgraph ACT["ACT  (cl. 10)"]
        A1[Corrective Action Register]
        A2[Management Review]
        A3[Objectives, budget, roadmap]
    end
    P1 --> P2 --> P3 --> P4 --> P5 --> D1
    D1 --> D2 --> D3 --> D4
    D4 --> C1 --> C2 --> C3 --> C4
    D4 --> C5
    C1 & C2 & C3 & C4 & C5 --> A1 --> A2 --> A3
    A3 -.->|next cycle| P2
    A1 -.->|change notice to every member| D2

The loop runs once a year as a whole (the annual cycle in 04 Annual Program Cycle and Calendar) and continuously in parts: every inspection, every near miss and every learning review enters the Act stage through the Corrective Action Register without waiting for the year to end.

These are not a chapter of the package. They are the method every module is built with, and the reader will find the same five ideas in every program note under the heading “Safety Differently in this program”, in every policy’s principles, and in every safe work procedure’s speak-up callout.

The After the Call link. The learning engine of the package is the three-tier model from The Human Factor’s After the Call manual: Tier 1 After-Action Review (the crew, after every qualifying call, short and templated), Tier 2 Post-Incident Analysis (the department, for working fires, maydays, RIT deployments, injuries and high-potential near misses, led by trained people with a systems method), and Tier 3 Independent Learning Review (serious events, non-punitive, externally facilitated, under the learning firewall) (The Human Factor, 2026a). Every program note names which tier its triggers feed and the two or three AAR questions a crew asks after its task. The program-level description is Incident Investigation and Learning Program; the full method and triage rules are in Manual 02 - The Three Tiers and Event Triage.

Three rules hold the parts together.

1. One taxonomy. The 20 categories in 02 Gap Assessment Tool are the audit categories in 02 Audit Checklist Master Index; a department compares its first gap assessment with its third audit without translation.
2. One register. Every deficiency from an inspection, an audit, an investigation, a JOHSC recommendation, a near-miss report or a gap assessment lands in the Corrective Action Register with an owner, a date, a verifier and an escalation rule.
3. One owner per element. Every program has one accountable line owner through its Program Improvement Team; the health and safety officer coordinates and verifies; the JOHSC participates and challenges; none of them replaces the line (01 Roles and Responsibilities).

A department can be honestly at Stage 1 and still be safe. The stages describe what is in place, not how good the firefighters are. Every policy, program element and checklist item carries its stage tag.

The maturity bands (Reacting, Complying, Building, Learning, Generative) describe how the department relates to its own system and map to the stages in 02 Gap Assessment Tool section 4 (Westrum, 2004DOI; Hudson, 2003).

Safety programs usually fail in the same place: the document is fine, nobody in the line owns it, nobody who does the work helped design it, nobody checks whether it changed anything, and the person who understood it retires. Program Improvement Teams close all four gaps at once (06 Program Improvement Teams). A standing team per program or specialty, led by a line officer as program manager with a front-line team lead and members, a JOHSC standing consultant, an assigned training officer and a clinician where needed, runs a six-step cycle: define, assess from work-as-done, plan, implement with JOHSC consultation, evaluate quarterly, revise and communicate. It reports quarterly, appraises annually into the budget, and builds succession through a named capability list, an understudy for every lead and a rotation rule. A department too small for standing teams names one officer per program with the same duties and cycle.

Every program carries a five-row accountability table that cannot be left blank: owner, doer, verifier, feedback, closure, followed by a loop test (“a member reports X on Monday; by when and through whom does the fix reach the whole department?”). Every accountability table also names how a concern raised by a member gets an answer back to that member. The audit scores the table as its own item. A program with no named owner or no closure rule is not finished, whatever else it contains. The Corrective Action Register’s open-item age is a standing management review input (ISO 45001:2018, cl. 10.2, 9.3).

A lower level never contradicts a higher one; where it would, the higher one is wrong or out of date and the management of change procedure applies (05 Document Control and Records).

1. Profile. Complete 01 Program Profile Worksheet with the chief, the senior officer responsible for health and safety and both JOHSC co-chairs: switch every module on or off with a reason, set the jurisdiction, collect the baseline facts.
2. Gap assessment. Run 02 Gap Assessment Tool with the team of three; get the category profile, the band, the top ten gaps, the Stage 1 critical items and the 90-day actions.
3. Hazard profile. Build the register from the seed inventory in 03 Hazard Profile and Risk Register Method, switched to the Profile; hold learning-team sessions on the ten highest-risk tasks.
4. Stage 1 policies and programs. Adopt the OHS policy and the Stage 1 policy set; stand up the Stage 1 programs with their procedures, training and records; open the Corrective Action Register and load the critical items.
5. Teams. Charter two or three Program Improvement Teams, prove the cycle for two quarters, then extend to every Required module.
6. Measure. Declare the baseline from 04 Baseline Metrics and Indicator Set and run 05 Safety Culture Baseline; start the monthly page to the chief and the JOHSC.
7. Audit. Run the first internal audit at month 12 against the same taxonomy; plan the external review for year three.
8. Review. Hold the management review; set objectives, resource them, tell every member; re-run the gap assessment annually and move through the stages on evidence (01 Implementation Roadmap 0-36 Months).

• Not a substitute for the standards themselves. It tells the department which editions apply and what they require at the level needed to build a program; the department buys or reads the standards it adopts and cites them in its own documents (02 Standards and Law Master Map).
• Not legal advice. The chapters state statutory duties generically; each province’s, territory’s and the federal version is set out in Part 10 (00 Jurisdiction Index). Every section number must be confirmed against the current official text before adoption, and the collective agreement governs where it conflicts.
• Not an accreditation. It crosswalks to the CFAI criteria and can supply the Category 11 evidence and the annual appraisals, but accreditation is granted by the Commission on a peer team’s site visit, not by using this package (CPSE, 2019).
• Not a culture. The package builds the conditions (line ownership, work-as-done procedures, a just culture in writing, a measured loop) in which a safety culture can grow; the culture itself is made by what leaders do when someone speaks up.

Every program module with its policy, its safe work procedures, its forms, its audit checklist and the CFAI criteria it evidences (CPSE, 2019; CC marks a core competency). The policy column gives each policy’s title in 04 Policies without the “Policy -” prefix; the forms column describes each record, and the forms themselves are in Part 9 (09 Forms and Templates). The checklist column names the dedicated checklist; 02 Audit Checklist Master Index shows the category each one belongs to.

Cross-cutting policies with no single program: Occupational Health and Safety (the OHS policy); Internal Responsibility and Accountability; Risk Management and Hazard Assessment (delivered by 03 Hazard Profile and Risk Register Method); Right to Refuse Unsafe Work and Stop-Work Authority; Fatigue and Hours of Work (delivered through Medical, Fitness and Wellness and the specialty programs); Volunteer Members; Records, Privacy and Health Information; Program Review and Continuous Improvement (delivered by Management Review and 06 Program Improvement Teams).

Concern-to-answer route. Any member can propose a change to the package through their officer, their JOHSC member or a Program Improvement Team; the senior officer responsible for health and safety answers within 30 days with what was decided and why.

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.