Are We Too Focused on Root Cause and Not Enough on Learning?

Reimagining Investigations Through the ICAM Lens

In the world of incident investigations, ICAM has become the gold standard for structured, systems-based analysis. It helps organisations move beyond blaming individuals by identifying organisational, task, environmental, and individual factors that contribute to an incident.

But even with ICAM — and perhaps because of its structured nature — there's a growing tension we need to acknowledge:

Are we using ICAM to truly learn? Or are we still chasing the illusion of a singular root cause?

1. The Misunderstood Mission of ICAM

ICAM was designed to guide investigators beyond linear thinking. Unlike traditional root cause analysis, which aims to pinpoint a single failure, ICAM acknowledges that incidents stem from multiple interrelated factors. It highlights conditions, systems, and culture that shape human performance.

But in practice, many investigations still end with a tidy "root cause" — sometimes even naming a task or an individual's decision — and a set of corrective actions that close the case. The deeper intent of ICAM gets lost.

Instead of using the method as a gateway to organisational learning, we risk reducing it to a compliance tool. Diagrams are completed. Reports are signed off. Boxes are ticked. But what have we actually learned?

2. Learning: The True Endgame

If the goal of ICAM is insight, then the goal of investigation must be learning, not just explanation.

Learning is messy, contextual, and often uncomfortable. It requires us to:

• Step back from the timeline and look at system dynamics.

• Understand what made sense to people at the time.

• Explore the difference between work-as-imagined and work-as-done.

• Ask how our systems create both safety and risk.

ICAM gives us a structure to do this, but structure without reflection is just process. It’s up to us to bring curiosity to the table.

3. The Problem with “Root Cause Thinking”

Despite ICAM’s emphasis on systemic causes, the term "root cause" still appears in many reports. Why?

Because organisations crave certainty. Leaders want a headline. Regulators want answers. Boards want assurance. Root cause feels like closure.

But this mindset creates several problems:

• It narrows the investigation too early.

• It oversimplifies complexity, reducing multi-factor events into linear narratives.

• It stifles organisational learning by focusing on "the fix" rather than systemic improvement.

Even when ICAM is used, if the output is boiled down to “Procedure wasn’t followed,” “Training inadequate,” or “Human error,” then we haven’t used the method — we’ve just populated the form.

4. ICAM Is a Framework, Not a Formula

What makes ICAM powerful is that it’s a learning framework, not a checkbox exercise. It invites us to look across four key domains:

• Absent/failed defences

• Individual/Team actions

• Task/environmental conditions

• Organisational influences

But it’s not about filling in boxes. It’s about exploring how these layers interact. It’s about revealing tensions, trade-offs, misalignments, and assumptions.

For example:

• Why was a risky decision reasonable at the time?

• What systemic pressures shaped that decision?

• Were the controls imagined by the organisation present in the moment?

• How did normal work drift over time?

These are learning questions, not judgment questions. And ICAM can help ask them if we let it.

5. Case Example: Beyond the Obvious

Let’s take a hypothetical incident where a maintenance worker receives an electric shock while servicing equipment.

A surface-level ICAM might identify:

• Individual: The Worker didn’t follow the isolation procedure.

• Task/Environment: Procedure unclear or not visible at point-of-use.

• Team: Supervisors are unaware of procedural drift.

• Organisation: Pressure to reduce downtime.

• Defences: No physical lockout system in place.

Now stop.

You’ve captured a lot — but have you learned?

A learning-focused ICAM would go further:

• What shaped the worker’s perception of risk?

• How had the team adapted the task over time?

• What was valued more — compliance or output?

• How were these conditions created and sustained?

And — crucially — how does success normally occur in this environment? Because that’s where resilience lives.

ICAM gives us the scaffolding for this kind of inquiry. But we have to move beyond cause-finding and lean into meaning-making.

6. The Role of Psychological Safety in Investigations

True learning only happens when people feel safe to speak up.

If the ICAM process is seen as a prelude to disciplinary action or reputation damage, people will withhold the very insights we need. You'll get surface compliance, not real truth.

Learning-focused ICAM investigations require:

• Trust in the process.

• Separation of discipline and learning.

• Frontline involvement in the analysis.

• Transparency in sharing findings.

The investigation team must signal intent from the start: "We’re not here to assign blame — we’re here to understand, together."

That’s when ICAM becomes a conversation, not a verdict.

7. Recommendations vs. Insights

ICAM investigations typically conclude with recommendations. But not all recommendations are created equal.

Ask yourself:

• Are we recommending training because it's easy or because it’s meaningful?

• Are we updating a procedure that no one followed because it was impractical?

• Are we adding another layer of control to compensate for a deeper system flaw?

Strong recommendations are based on insight, not just cause. They:

• Reflect the lived experience of the people doing the work.

• Align with what the system actually allows and supports.

• Address cultural and systemic levers — not just symptoms.

Sometimes, the most powerful recommendation isn’t to add a new rule. It’s to create more feedback loops, involve workers in procedure design, or rethink performance metrics that drive unsafe shortcuts.

8. From Fixing to Evolving

ICAM isn’t just about preventing recurrence. It’s about building smarter systems.

That means we must shift from a "fix the problem" mindset to a "grow the system" mindset:

Every ICAM investigation is a learning opportunity — not just for the team involved, but for the entire organisation.

Are we capturing that? Or are we just closing files?

9. ICAM and Resilience

ICAM is often used reactively — after an incident. But the same thinking can be applied proactively:

• Where are we seeing near misses or weak signals?

• Where is performance drifting from procedure, and why?

• What does “successful work” look like under pressure?

• What do workers know that the system doesn’t?

Resilience isn’t about stopping things from going wrong — it’s about increasing the capacity to adapt, anticipate, and recover. ICAM can be a lens for studying work-as-done, not just work-as-failed.

10. A Call to (Learning) Action

If you use ICAM in your organisation — as an investigator, leader, or facilitator — here’s a challenge:

• Use ICAM as a launchpad for conversations, not conclusions.

• Don’t stop at the analysis — go deep into reflection.

• Involve the people closest to the work — their story is your richest data.

• Resist the pressure to simplify. Complexity is where truth lives.

• Turn every investigation into an opportunity for growth, not just a fix-it list.

ICAM is more than a model. It’s a mindset.

Let’s not just trace what went wrong. Let’s explore how to be stronger, smarter, and more resilient next time.

Conclusion: ICAM as a Tool for Learning, Not Just Compliance

The strength of ICAM lies not in its structure, but in how we use that structure to enable insight, conversation, and change.

If we treat ICAM as a pathway to learning, it becomes one of the most powerful tools we have. But if we reduce it to a root cause formality, we miss its full potential.

Don’t just close the loop. Open minds.