ICAM Incident Investigation: A Summary for Newbies
Ever wondered why ICAM Investigation has established itself as the cutting-edge incident investigation process in Australia? This article will cover the basics of ICAM Investigation and give you an understanding of why this method should be the go-to methodology for investigations of incidents in your organisation.
What is ICAM?
ICAM stands for:
Based on the work of psychologist James Reason, ICAM Investigation is a process that aims to identify the contributing factors, underlying (root) causes, and organizational failures that led to an incident. Rather than simply identifying the immediate cause, ICAM attempts to look deeper and detect the underlying (root) cause/s that led to an incident.
An example could be:
- Immediate Cause = Faulty Equipment, and
- Underlying (Root) Cause = Lack of Maintenance due to Inadequate Resourcing
Sometimes the underlying cause may be uncomfortable for the organization to acknowledge, but it is vital these are identified and addressed to prevent reoccurrence and improve WHS performance outcomes.
What is the ICAM Process?
The ICAM Investigation process has 6 steps:
- Gathering and Preparing Evidence
- Identify Absent / Failed Defenses (last-minute measures that should have stopped the incident)
- Identify Individual / Team Actions (errors or violations made by personnel)
- Identify Task / Environmental Factors (conditions that existed at time of the incident)
- Identify Organizational Factors (underlying organizational factors)
- Develop Recommendations
The first step in an ICAM Investigation is to gather and prepare evidence. This can be quite a long process, especially for a serious incident. The duration of this step depends on geographic location of the workplace incident, how many people were involved and the complexity of the incident. For example, following an aviation crash, it may take the investigation team years to simply find and assemble all of the physical evidence. For most workplace accidents, the evidence gathering should take no more than a few days to a few weeks depending on severity of incident.
Download a copy of our simplified ICAM Incident Report and Investigation form.
The ICAM Investigation Data Analysis Process
The information and evidence are then categorized into 5 groups using the PEEPO acronym:
- People – e.g., witness statements
- Environment – e.g., weather
- Equipment – e.g., inspections of plant
- Procedures – e.g., work instructions
- Organization – e.g., training records
Once evidence and information have been collected, it’s time to present and analyze the data. This can be done with a variety of tools including Timelines, 5 Why’s Analysis, Incident Trees, or Ishikawa (Fishbone) Diagrams.
These tools help us to visualize all the gathered data and allow for easier analysis. Below is an example of an Ishikawa (or Fishbone) Diagram. This helps visualize how a number of contributing causes can lead to an incident (or “effect”):
Identifying Failed Defenses Using ICAM Investigation
Through the data analysis process, the Lead Investigator (or team) will begin to identify contributing factors and underlying (or root) causes. The factors that either caused (or failed to prevent) an incident are sometimes called “Failed Defenses”.
It is important to think critically and look deeper than the surface when examining these failed defenses. For example, identifying “human error in activating emergency system” as a failed defense may only be a symptom of a deeper and more systematic problem of “poor organizational training“ or other root causes.
Failed defenses are generally categorized into 4 groups:
Using ICAM to Guide Organizational Improvements
Once the data has been analyzed, the investigation team will have developed a list of contributing factors and underlying causes. Corrective actions and preventative measures should be developed to address each of these contributing and underlying factors (and there may be several or more recommendations for each factor).
Investigation findings should aim to improve safety management ideally will follow the SMARTER rule:
What are the Benefits of ICAM?
ICAM incident investigations are open source and can be accessed and used by anyone. Also, the ICAM training (or ICAM Lead Investigator Course) can be delivered by any organization (or RTO) and is not “proprietary” or owned by any one company or entity (assuming applicants meet the required literacy requirements). The ICAM Investigation process or further information can be researched freely on the internet meaning anyone with a laptop can teach themselves the ICAM investigation process.
Due to its open-source nature, the process has been developed and fine-tuned by many organizations and has established itself as one of the most used and effective incident investigation techniques globally. The ICAM Investigation process is known for providing results in a short time span, which is crucial when handling incidents, especially those involving safety and human life. They also help standardize the process used to investigate WHS incidents and promote consistency across organisations.
They can be used to find out the root cause of an incident, or to identify factors that can cause similar incidents in future. They are also useful for conducting training sessions for your employees and creating awareness about safety across your company as well as improving communication amongst stakeholders by providing accurate and detailed information about incidents. If you’re looking to boost safety measures in your organization, conducting ICAM investigations is a must.
If you need assistance with an incident investigation or other WHS issue, contact us.
For more information on incident notifications and investigations please visit the WHSQ Incident and Notifications page.