7 Red Flags of a Poor ICAM Investigation

Incident investigations are powerful tools when conducted correctly, but when poorly executed, they not only fail to prevent future events but can also actively harm safety culture, trust, and decision-making. The ICAM (Incident Cause Analysis Method) is designed to deliver clarity and insight, but like any tool, its effectiveness depends on the user’s competence, objectivity, and process discipline.

If you’re reviewing a report or involved in an investigation, look for these seven red flags that may indicate a poor investigation.

1. It Focuses on Blame, Not Systems

Red Flag: The report singles out an individual’s action or inaction as the primary cause, without deeper analysis.

When an ICAM investigation ends with “the operator failed to...” or “the supervisor should have...”, it strongly signals that the investigation is stuck in a person-focused mindset. One of the core tenets of ICAM is to move beyond human error and identify why people made the decisions they did in the context of their systems, environment, and culture.

A quality investigation explores latent conditions, such as training gaps, unclear procedures, workload pressures, inadequate supervision, or conflicting goals. Blame-based outcomes undermine learning and discourage future reporting.2. There’s No Evidence of Interviewing or Triangulation

Red Flag: The report lacks direct quotes, witness perspectives, or diverse evidence sources.

Effective ICAM investigations rely on triangulation, combining interviews, document reviews, system data, and site observations to verify facts and build a comprehensive timeline. A poor investigation may rely on assumptions, anecdotal evidence, or a single source, leading to biased or incomplete conclusions.

If interviews were not conducted (or documented), or if key roles weren't consulted, it's a serious concern. Without triangulation, the “why” behind decisions remains guesswork, not analysis.

3. Contributing Factors Are Misclassified or Missing

Red Flag: The PEEPO and ICAM charts are inconsistent, oversimplified, or don’t align with the narrative.

ICAM classifies contributing factors into People, Environment, Equipment, Procedures, and Organisation (PEEPO). A solid investigation should identify how these factors contributed to the event.

Common issues in poor reports include:

• All causes are classified under “People”

• Charts that don’t align with the story in the report

• Missing linkages between systemic and active failures

If the ICAM chart looks too neat or doesn’t reflect complexity, it may indicate a checkbox investigation rather than fundamental analysis.

4. There’s No Timeline—or It’s Inaccurate

Red Flag: The investigation jumps to conclusions without clearly laying out what happened, when, and in what order.

A clear, validated timeline is the backbone of any investigation. It allows the team to identify trigger points, decisions made under pressure, and deviations from normal operations. Without it, you're relying on hunches.

Poor investigations either:

• Skip the timeline entirely

• Construct one after forming a hypothesis (confirmation bias)

• Fail to validate key moments with evidence

This leads to circular reasoning and conclusions that cannot be trusted. Always ask: How do we know the event unfolded this way?

5. Recommendations Don’t Address the Real Issues

Red Flag: Actions are superficial, generic, or focused only on procedural compliance.

Strong ICAM investigations end with recommendations that tackle root and systemic causes. Weak ones suggest token gestures—more training, disciplinary action (which shouldn't even be in the report!), or rewriting procedures—without addressing why those systems failed in the first place.

Watch for these vague or unhelpful recommendations:

• “Ensure all staff are trained on procedure X”

• “Remind staff of the importance of safety”

• “Discipline the employee involved”

These do nothing to strengthen systems or prevent recurrence. Effective recommendations may involve changes to design, supervision models, workload distribution, or leadership accountability.

6. The Investigation Team Lacked Independence or Expertise

Red Flag: The investigators were closely involved in the event or lacked investigation training.

Independence is essential to eliminating bias and conflict of interest. Someone in the direct line of reporting or who has a vested interest in avoiding scrutiny may conduct a poor investigation. In such cases, critical issues may be overlooked, downplayed, or ignored.

In addition, ICAM requires a skilled investigator who understands how to conduct interviews, analyse systemic failures, and apply the methodology correctly. A team lacking training or experience will default to intuitive or biased conclusions.

Red flags here include:

• Investigators were directly involved in the event or the approval chain

• No training or credentialing in ICAM or investigations

• Over-reliance on one person, without cross-functional input

7. There’s No Organisational Learning or Governance Oversight

Red Flag: The report is filed and forgotten—no tracking, communication, or leadership reflection.

The purpose of ICAM is not just to investigate an incident—it’s to learn and prevent recurrence. If there’s no evidence that recommendations were implemented, lessons shared, or systemic themes tracked across incidents, the process has failed.

Organisational learning requires:

• Executive engagement in findings

• Tracking of actions to closure

• Analysis of trends from multiple investigations

• Feedback loops to confirm effectiveness

If ICAM reports are treated as a compliance exercise rather than a catalyst for change, improvement will be slow or nonexistent.

Final Thoughts

ICAM is a robust framework, but it can be undermined by haste, bias, lack of training, or poor organisational support. These seven red flags don’t just signal a weak report; they point to deeper cultural or capability issues that must be addressed.

When reviewing investigations, use these red flags as a quality assurance checklist. Better yet, embed them into your governance and training frameworks to uplift standards across the board.

The goal of every investigation should be simple: learn deeply, act meaningfully, and prevent recurrence.

Are you interested in Investigation Report Writing or Investigation Governance training? Visit our website at https://www.safetywise.com/courses/icam, and let's chat.