Beyond Safety: Expanding the Boundaries of ICAM Investigations

For decades, the ICAM (Incident Cause Analysis Method) model has stood as a gold standard in the investigation of safety-related incidents. Developed with the aim of identifying systemic, organisational, and human factors behind workplace accidents, ICAM has empowered investigators to look beyond blame and uncover deeper causal pathways. But while ICAM is widely associated with traditional safety incidents—falls from heights, equipment failures, vehicle accidents—it is far from a one-trick pony.

At Safety Wise, we’ve spent years pushing the envelope on what ICAM can be used for. We have successfully applied ICAM—without modifying the methodology—to a wide range of non-safety incidents, including:

• Workplace bullying and harassment

• Grooming and inappropriate conduct in youth-focused environments

• Mechanical failures not involving injury

• IT system outages and cybersecurity breaches

• Business process failures and operational deviations

This article explores how ICAM maintains its integrity and effectiveness across these domains, and why more organisations should consider broadening their understanding of what a “critical incident” really is.

Understanding ICAM at Its Core

ICAM (Incident Cause Analysis Method) is grounded in the principles of human factors, systems thinking, and a commitment to organisational learning. It provides a structured, evidence-based approach to investigating incidents by identifying the various systemic, task-level, and individual contributions that lead to an undesired outcome.

Rather than assigning blame to individuals, ICAM focuses on understanding how and why defences failed, and what underlying conditions within the organisation may have contributed. This allows for deeper insight into the causes of incidents and more meaningful, sustainable improvements.

The ICAM methodology comprises several key analytical components:

• Event and Condition Analysis: Establishes a clear, factual timeline of the incident, identifying what happened and the conditions present at the time.

• Failed and Missing Defences: Assesses the effectiveness of existing controls and barriers, determining where they failed or were absent.

• Individual and Task Analysis: Explores the actions and decisions of individuals involved, in the context of the work environment, task demands, and system influences.

• Workplace and Organisational Factors: Examines broader influences such as leadership, culture, communication, training, resourcing, and procedures that may have shaped the conditions for failure.

• Learning Outcomes and Recommendations: Identifies opportunities for improvement, focusing on systemic change and preventative action rather than punitive measures.

Crucially, ICAM is methodology-neutral—it is not confined to any specific incident type. Whether the event involves safety, conduct, process reliability, or operational failure, ICAM offers a consistent, robust framework for understanding and learning from what occurred. This adaptability is what enables organisations like Safety Wise to successfully apply ICAM across a diverse range of incident types.

Workplace Bullying: A Complex Human Factors Issue

Traditionally, bullying and harassment complaints are handled through HR investigations, often reliant on individual testimonies, policies, and interpersonal conflict resolution. These processes, while important, often fail to explore the deeper organisational enablers of such behaviours.

ICAM allows us to go further.

Case in Point: A Toxic Culture Unveiled

In one instance, Safety Wise was brought in to investigate a pattern of bullying within a regional operations team. A traditional investigation had already led to disciplinary action against one employee, but incidents continued. Using ICAM, we identified:

• Latent Conditions: A performance-driven culture that rewarded results over collaboration

• Organisational Factors: Inadequate training for team leaders in conflict management

• Failed Barriers: A grievance procedure that employees feared would backfire on them

• Contributing Actions: Poorly moderated team meetings that escalated tensions

The outcome wasn’t just accountability—it was transformation. New cultural values were embedded, leaders were upskilled, and safe reporting channels were created. None of this would have emerged from a simple HR file review.

Child Grooming in the Workplace: Sensitive, Serious, Systemic

Investigating potential grooming or inappropriate relationships involving minors is among the most sensitive challenges any organisation can face. Legal and reputational risks are immense, and the emotional toll on affected individuals is profound.

ICAM brings structure to this otherwise chaotic space.

In a case involving a contractor at a youth sporting organisation, the ICAM approach uncovered:

• Latent Conditions: Lack of supervision protocols for one-on-one interactions

• Organisational Gaps: Inadequate vetting and screening of external contractors

• Barrier Failure: No formal training on recognising grooming behaviours

• Task Failures: Deviation from agreed supervision processes

What distinguished the ICAM approach here was its ability to shift the conversation from “who is at fault?” to “how did our systems allow this to happen?” That subtle shift created space for genuine improvement without interfering with the necessary legal processes.

Mechanical Failures: More Than a Broken Part

When a critical machine fails, the first question is often “what broke?” But the more valuable question is “why did it break?” ICAM steers investigations away from the simplistic root cause of a failed component and instead explores the full ecosystem that contributed to the breakdown.

Take the case of a production line robot that stopped working, leading to days of lost productivity. The ICAM investigation identified:

• Organisational Factors: A cost-cutting initiative that delayed routine servicing

• Latent Conditions: No remote monitoring for wear-and-tear on moving joints

• Task-Based Issues: Maintenance teams assigned unrealistic workloads

• Failed Barrier: A manual alert system that was ignored due to frequent false positives

Replacing the robot would have addressed the symptom. Addressing the contributing conditions fixed the system.

IT Failures and Cyber Incidents: An Organisational Story

In the digital age, information technology incidents—whether due to human error, system glitches, or cyberattacks—can cripple operations. Most post-incident reviews focus on logs, server status, and user behaviour. ICAM adds a human and organisational layer to that analysis.

Case Study: System Outage in a Finance Firm

An unexpected platform outage delayed invoicing by two weeks and cost the company significant revenue. An ICAM investigation revealed:

• Latent Conditions: An outdated risk register that didn’t reflect IT dependencies

• Organisational Factors: A siloed IT department with poor integration with operations

• Barrier Failure: Scheduled maintenance overlaps with critical business operations

• Task-Level Issues: Misinterpretation of system reboot instructions

Importantly, the investigation didn’t just stop at fixing the outage. It led to strategic changes in cross-departmental planning, improved vendor management, and the introduction of a real-time IT dashboard for senior leaders.

Process Deviations: When SOPs Don’t Deliver

Process deviations—where staff or systems stray from standard operating procedures—are often shrugged off as minor errors or addressed with retraining. But such deviations often signal deeper issues with how systems are designed, maintained, and understood.

Using ICAM, Safety Wise worked with a pharmaceutical manufacturer after repeated process deviations led to the scrapping of entire production batches. The findings included:

• Latent Conditions: Overly complex SOPs written in technical jargon

• Organisational Factors: High turnover in QA roles, leading to loss of institutional knowledge

• Failed Barriers: Poorly implemented digital checklist system

• Task Issues: Line workers creating “workarounds” due to inefficient procedures

The investigation triggered a full redesign of the SOP system using user-centred design principles. The result? Fewer deviations, better engagement, and higher product consistency.

Why It Works: ICAM’s Strengths Across Domains

So why does ICAM work so effectively outside of safety?

1. Focus on Systems, Not Blame In complex incidents, assigning blame rarely solves the root problem. ICAM encourages learning, not punishment.

2. Adaptable Without Alteration ICAM doesn’t need a “version for HR” or a “version for IT.” Its framework is broad enough to accommodate diverse incident types without compromising its structure.

3. Cross-Functional Language Its categorisation of causal factors—such as “organisational influences” and “task/environment”—resonates across departments and disciplines.

4. Visual Mapping and Storytelling Tools like the timeline and incident map allow diverse stakeholders to see cause and effect visually, creating shared understanding.

5. Data-Driven Recommendations The method guides the development of SMART (Specific, Measurable, Achievable, Relevant, Time-bound) recommendations that actually drive improvement.

How to Implement ICAM for Non-Safety Incidents

Organisations looking to expand their ICAM usage should follow a few practical steps:

1. Broaden the Definition of "Incident"

Encourage teams to report not just injuries or damage, but any significant deviation from what “should” happen—whether cultural, procedural, or technical.

2. Train Cross-Functional Teams

Train HR, IT, operations, and quality teams in ICAM—not just the safety department. The more diverse your facilitators, the better your investigations.

3. Integrate ICAM Into Incident Management Systems

Design your digital reporting systems to accommodate ICAM categories and outputs, not just generic checklists or compliance forms.

4. Respect Legal Boundaries

While ICAM is powerful, sensitive matters (e.g. grooming, bullying, fraud) may involve legal or criminal implications. Collaborate with legal advisors to ensure findings are handled appropriately.

5. Promote a Learning Culture

ICAM only works in organisations committed to change. Celebrate what investigations uncover. Avoid using them to justify discipline unless legal or regulatory obligations demand it.

Conclusion: A Tool for Organisational Maturity

ICAM has always been more than a tool for investigating injuries. It’s a structured lens through which any organisational failure—human, cultural, technical, or systemic—can be understood, learned from, and prevented.

At Safety Wise, we’ve seen firsthand how applying ICAM to bullying cases reshapes workplace culture, how it helps IT teams learn from outages, and how it uncovers the true cost of process complexity. As the pace of business accelerates and the definition of "risk" continues to expand, ICAM remains not only relevant—but essential.

The next time something goes wrong in your organisation, don’t ask “Was this a safety incident?” Ask, “Is there something here we can learn from?”

The answer is almost always yes—and ICAM is the method to get you there.