Five Worst Phrases to Avoid in ICAM Reports

Introduction: Why Words Matter in ICAM Reports

An ICAM investigation report is more than a record of events- it’s a mirror of an organisation’s culture, learning capacity, and credibility. Every word shapes how stakeholders interpret the findings, how teams respond to recommendations, and whether meaningful change follows.

Poorly chosen language can sabotage even the most thorough analysis. Certain phrases, though common, reveal unconscious bias, diminish trust, and undermine ICAM’s core purpose: learning, not blaming.

This article explores five of the most damaging phrases found in ICAM reports and why they must be avoided. For each, we’ll unpack the risks, show real examples, and suggest powerful alternatives that uphold ICAM’s intent.

Phrase 1: “Human Error”

Why It’s Damaging

“Human error” is perhaps the most overused- and least helpful phrase in investigation history. 

It’s often dropped into reports as a convenient conclusion, implying the cause lies solely in individual failure. But ICAM was built to look beyond the error- to uncover why that action made sense at the time.

In the ICAM framework, Individual/Team Actions are only one part of the puzzle. They’re shaped by Task/Environmental Conditions, Organisational Factors, and Absent/Failed Defences. Simply stating “human error” shuts down curiosity and invites blame.

Worse, it gives leaders a false sense of resolution. They think the cause is identified when, in truth, the real system contributors remain hidden.

How It Shows Up

• “The incident occurred due to human error.”

• “The operator made a mistake.”

• “Failure was caused by the worker's inattention.”

The Impact

• Destroys psychological safety – workers feel blamed.

• Blocks systemic learning – no deeper conditions are explored.

• Fails the ICAM test – no organisational factor is identified.

• Damages credibility – reviewers see it as lazy analysis.

Better Alternatives

Replace “human error” with a descriptive and causal statement:

• “The operator misread the gauge due to poor lighting and similar dial design.”

• “The technician selected the wrong file because the digital interface lacked visual cues.”

• “The team deviated from procedure because it was outdated and impractical.”

These reframe the error as a symptom, not a root cause- aligning perfectly with ICAM’s learning philosophy.

Phrase 2: “Root Cause”

Why It’s Damaging

ICAM deliberately rejects the “root cause” concept. Why? Because incidents rarely have a single cause. They’re multi-factorial, arising from interactions across people, systems, and conditions (We do, however, reference "Basic Cause", which is different to Root Cause).

The phrase “root cause” promotes a linear mindset- the old “find the one cause, fix it, move on” approach. It contradicts ICAM’s systemic model, which acknowledges multiple contributing factors across four quadrants.

Using “root cause” in a report signals a methodological misunderstanding. It suggests the investigator sought a single answer rather than mapping the system influences.

How It Shows Up

• “The root cause was a failure to follow procedure.”

• “Root cause analysis identified inadequate training.”

• “The root cause has been addressed with retraining.”

The Impact

• Oversimplifies complex interactions.

• Misleads leaders into thinking the issue is solved.

• Neglects contributing conditions (e.g. workload, supervision, design).

• Reduces the investigation’s learning value.

Better Alternatives

Use ICAM-aligned language:

• “Contributing factors included inadequate supervision, unclear procedures, and absence of visual checks.”

• “The investigation identified several interacting conditions that influenced the team’s decision.”

This phrasing reflects the multi-causal nature of incidents and invites broader corrective actions.

Phrase 3: “Failure to Follow Procedure”

Why It’s Damaging

This phrase is a classic blame statement masquerading as analysis. It implies non-compliance is the root of the problem, without asking why the procedure wasn’t followed.

In ICAM, non-compliance is a starting point, not a conclusion. Investigators must explore:

• Was the procedure available, usable, or up to date?

• Did workers have competing demands?

• Was there pressure to meet production goals?

• Did the culture reward shortcuts?

“Failure to follow procedure” is lazy shorthand that shifts attention from system design to individual behaviour.

How It Shows Up

• “The technician failed to follow the isolation procedure.”

• “The operator did not adhere to the SOP.”

• “Non-compliance with company policy caused the incident.”

The Impact

• Invites punishment, not learning.

• Masks latent conditions – poor documentation, ambiguous steps, or conflicting priorities.

• Misses leadership accountability – unclear expectations, inadequate oversight.

Better Alternatives

• “The isolation procedure was bypassed due to time pressure and unclear supervisory expectations.”

• “The SOP was outdated and did not reflect current work practices.”

• “Operators relied on informal knowledge because the documented process was impractical.”

These reframe behaviour within its context, enabling systemic learning and fair accountability.

Phrase 4: “At Risk Behaviour”

Why It’s Damaging

“At risk behaviour” is often used in Behaviour-Based Safety (BBS) language, but it’s problematic in ICAM reports. It subtly blames workers for exposing themselves to risk, implying choice or recklessness, rather than recognising system design flaws.

In ICAM, the focus is on why the behaviour made sense within the conditions. Workers often act rationally, given pressures, norms, and available tools.

Describing actions as “at risk” invites subjective judgment and undermines trust in the process. It also fails to identify organisational controls that allowed or encouraged that behaviour.

How It Shows Up

• “The team engaged in at-risk behaviour by not using PPE.”

• “An at-risk decision was made to bypass the guard.”

• “Unsafe acts contributed to the incident.”

The Impact

• Shifts focus from system to individual.

• Reduces engagement – people fear being labelled “unsafe.”

• Fails to explore why risk-taking seemed reasonable.

• Contradicts ICAM’s just culture principles.

Better Alternatives

• “The decision to bypass the guard was influenced by poor equipment accessibility and production pressure.”

• “Workers perceived the risk as low due to previous successful outcomes and lack of recent incidents.”

• “The PPE requirement was not enforced and lacked managerial reinforcement.”

This approach builds empathy, exposes latent conditions, and drives systemic improvements.

Phrase 5: “Training Issue”

Why It’s Damaging

Labelling something as a “training issue” is a common investigative shortcut. It suggests the problem lies in worker knowledge, when often, the issue is systemic: poor design, unclear procedures, or cultural norms.

ICAM investigators must test whether training truly addresses the gap:

• Was the task covered in training?

• Was the training retained, reinforced, and evaluated?

• Was the task achievable even with perfect training?

• Were tools, environment, and supervision adequate?

Saying “training issue” is often a catch-all phrase that ends inquiry prematurely.

How It Shows Up

• “The incident resulted from inadequate training.”

• “Refresher training will prevent recurrence.”

• “A training issue was identified and corrected.”

The Impact

• Blames workers for organisational design flaws.

• Leads to weak recommendations (“retrain staff”) that don’t fix root systems.

• Fails to examine job design, supervision, or usability.

Better Alternatives

• “The task was not addressed in the current training program.”

• “Although trained, staff lacked practice and reinforcement under field conditions.”

• “The procedure required untrained decision-making beyond its scope.”

These statements clarify why training failed, helping leaders choose the right corrective control (e.g., redesigning tasks, simplifying steps, improving supervision).

Language Shapes Culture

These five phrases- “human error,” “root cause,” “failure to follow procedure,” “at risk behaviour,” and “training issue”- share a dangerous trait: they end thinking.

They simplify complex interactions into comfortable narratives, reinforce blame, and undermine ICAM’s learning intent. Every time we use them, we signal to readers- leaders, regulators, and workers- that we haven’t looked deep enough.

By contrast, precise, neutral, and descriptive language:

• Builds trust among stakeholders

• Promotes systemic thinking

• Encourages leadership accountability

• Drives meaningful change

How to Replace Weak Language with Strong ICAM Writing

1. Be Descriptive, Not Judgmental

Avoid labels. Describe what happened in observable terms.

❌ “Operator was careless.”

✅ “Operator omitted step three due to missing checklist.”

2. Use Evidence-Based Statements

Support every conclusion with data, witness accounts, or records.

❌ “Inadequate supervision caused the error.”

✅ “No supervisor was present during task execution, as confirmed by shift roster.”

3. Reflect the ICAM Structure

Organise findings across the four quadrants:

• Individual/Team Actions

• Task/Environmental Conditions

• Organisational Factors

• Absent/Failed Defences

This keeps focus on systemic learning rather than isolated blame.

4. Align Recommendations with Controls

Recommendations should address organisational factors and defences, not just individuals.

❌ “Provide refresher training.”

✅ “Redesign control panel layout to eliminate similar switch confusion.”

5. Check for Bias Triggers

Ask: Does this phrase imply blame? End inquiry? Suggest a single cause? If yes, rewrite.

Case Example: How Language Changed the Outcome

Scenario A – Poor Language

“The incident was caused by human error. The worker failed to follow procedure due to lack of training. Refresher training has been scheduled.”

Impact:

• Blames the worker

• Offers a weak fix

• Hides systemic contributors

Scenario B – ICAM-Aligned Language

“The operator omitted step three because the procedure was outdated and not visible at the workstation. Training covered the old version. Production pressure and unclear supervision reinforced shortcutting. The defence- peer check- was absent.”

Impact:

• Exposes multiple contributing factors

• Guides systemic improvements (procedure review, visibility, supervision)

• Strengthens recommendations

Common Review Checklist: Spotting Dangerous Phrases

Before submitting any ICAM report, run this language audit:

This checklist reinforces critical thinking and supports high-quality investigations.

The Role of Leadership Review

Leaders must also be trained to spot these phrases during report review. A governance process that challenges simplistic statements signals a learning culture.

When executives ask, “What made that action seem reasonable?” or “Why was that condition tolerated?”, they transform reports into strategic tools for continuous improvement.

Conclusion: Words That Drive Learning

ICAM is not just a methodology- it’s a mindset. It assumes people do not come to work to fail. When incidents happen, they reveal system weaknesses, not “bad workers.”

Language is the bridge between data and learning. The five phrases we’ve explored are warning signs- they reveal shallow thinking and invite blame. Eliminating them strengthens:

• Report credibility

• Stakeholder trust

• Organisational maturity

Next time you draft or review an ICAM report, pause before writing:

“human error,” “root cause,” “failure to follow procedure,” “at risk behaviour,” or “training issue.”

Ask yourself: 🔹 Have I explained why this made sense? 🔹 Have I identified system conditions? 🔹 Will this wording help the organisation learn- or assign blame?

When you choose precise, curious, and neutral language, you transform reports from compliance documents into learning blueprints, exactly what ICAM was designed for.