Understanding ICAM: A New Lens on Workplace Incidents

In the wake of any workplace incident, one of the first questions asked is: “Who made the mistake?” This immediate response reflects a natural human instinct for accountability. Yet, this rush to judgment often points to “human error” without considering the deeper systemic issues that allowed the error to occur.

The ICAM (Incident Cause Analysis Method) challenges this blame-first mindset by asking a different question: Why did it make sense for the person to do what they did at the time? This shift redirects the focus from individual mistakes to the underlying organizational factors that influence behavior. Through structured analysis, ICAM helps investigators determine whether an incident was the result of human error, a system failure, or commonly—both.

Let’s explore how ICAM supports this distinction and why understanding the difference is crucial for genuine improvement.

The False Divide: Human vs. System Error

Before diving into ICAM’s approach, it's vital to grasp the false dichotomy between human and system error. Many workplaces tend to isolate causes into neat categories—either someone made a mistake (human error) or the system was flawed (system error). This black-and-white thinking is simplistic and dangerous.

In reality, most incidents arise from complex interactions between people, processes, equipment, and organizational systems. People don’t operate in a vacuum. Their decisions are shaped by training, procedures, supervision, work culture, resources, and even time pressure.

Examples of Complex Interactions

Consider the following scenarios to illustrate this complexity:

• A forklift driver hits a pedestrian in a warehouse. Was it because he wasn’t paying attention? Or because the pedestrian walkway was poorly marked and the driver had just completed a 12-hour shift?

• A maintenance technician incorrectly reinstalls a component. Was it a lack of attention? Or were the procedures unclear, with no peer check required before signing off?

  
  

Blaming the individual is easy. However, fixing the system is harder—but far more effective.

Enter ICAM: A Systems-Focused Framework

ICAM provides a structured approach to incident investigation that helps identify why an error occurred rather than who made it. Based on James Reason’s Swiss Cheese Model, ICAM assumes that accidents are rarely the result of a single act or failure. Instead, they are due to multiple layers of defense failing at once.

ICAM categorizes contributing factors into five areas, represented by the acronym PEEPO:

1. People – human actions or decisions directly involved in the incident.

2. Environment – the physical and operational circumstances influencing behavior.

3. Equipment – the machinery, tools, or systems involved.

4. Procedures – rules, work instructions, and training materials.

5. Organisation – aspects related to leadership, culture, resources, supervision, and risk management.

   
   

By exploring each of these layers, ICAM assists investigators in tracing the chain of events. It also helps identify latent conditions—the hidden weaknesses in the system that may have enabled the incident.

From “Who” to “Why”: The Power of Structured Thinking

Consider the following case to highlight this perspective shift:

Incident: A worker falls from height while performing a routine inspection.

Initial Reaction: “The worker didn’t clip on. Human error.”

An ICAM investigation might uncover that:

• The anchor points were removed due to roof repairs and had not been reinstalled.

• No hazard identification was conducted prior to the job.

• The team was reassured it was a “low-risk” activity and experienced time pressure due to a maintenance backlog.

• Procedures for working at height were ambiguous and not enforced by supervisors.

  
  

This reveals a very different narrative. The fall wasn’t simply due to human error. It was the end result of multiple system failures: poor planning, weak supervision, inadequate risk assessment, and inadequate communication regarding changing site conditions.

In this case, disciplining the worker would do little to prevent recurrence. On the other hand, addressing systemic issues tackles the root causes.

The Illusion of Control: Why Blaming Humans Feels Comfortable

Blaming individuals creates the illusion of problem resolution. One might think that removing the “bad apple,” conducting refresher training, and issuing a safety alert are enough. But unless the system is addressed, the conditions that led to the error remain unchanged.

ICAM dismantles this illusion by asserting that most human errors are predictable and manageable—if the organization is willing to self-examine. Indeed, labeling something as “human error” without further investigation often signifies a lack of insight. ICAM introduces a structured approach to what would otherwise be vague intuition.

When Human Error Is a Factor

None of this implies that people are never at fault. At times, despite effective systems, individuals may make poor choices—due to complacency, recklessness, or deliberate non-compliance. ICAM assists in differentiating between innocent mistakes, at-risk behavior, and reckless actions.

The key is to understand the context:

• Was the error foreseeable?

• Was the system designed to catch it?

• Were expectations clear?

• Was it an isolated incident or part of a pattern?

  
  

By answering these questions, organizations can respond appropriately. This may involve coaching, redesigning systems, or, in rare cases, taking disciplinary action.

ICAM in Action: Lessons from the Field

Organizations that routinely implement ICAM observe several benefits:

• Reduced blame culture: Investigations focus on learning rather than punishment.

• Stronger prevention strategies: Root causes are addressed, not just symptoms.

• Improved trust and reporting: Employees are more inclined to share concerns.

• Better leadership insight: Senior leaders gain visibility into the strength of their systems.

  
  

Perhaps most importantly, ICAM fosters organizational maturity. It encourages leaders to look beyond compliance checklists and ask: What are our systems really enabling or constraining?

Conclusion: A Smarter Way to Respond to Incidents

The true value of ICAM lies not in assigning blame but in uncovering the conditions that made the incident possible. By focusing on the interplay between people and systems, ICAM transforms the investigation process into one of learning rather than blaming.

So, was it human error or system error? ICAM reminds us it’s often both—and it provides the insight needed to prevent recurrence.

If your investigations still hinge on identifying “who messed up,” it's time to elevate your approach. ICAM training equips your teams with skills to uncover systemic weaknesses, promote learning, and drive tangible change. Don’t just react—investigate to improve.

Learn more at www.safetywise.com or reach out to book an ICAM course tailored for your team.