Multi-Jurisdictional ICAM Investigations: Conducting an Investigation Across Regulatory Regimes, States and Countries

A serious incident does not always respect organisational or jurisdictional boundaries.

A vehicle may be registered in one state, operated by an employee based in another and involved in an incident while working at a third-party site elsewhere. A piece of equipment may be designed in Europe, manufactured in Asia, maintained by an Australian contractor and fail during operations in Africa. A logistics incident may involve a transport operator, port authority, principal contractor and equipment supplier, with each organisation subject to different regulatory obligations.

For the investigation team, this creates a difficult question: how do you conduct one coherent ICAM investigation when the incident sits within several regulatory, legal and organisational regimes?

The answer is not to create a different investigation methodology for every jurisdiction. ICAM remains the investigation methodology. What changes is the environment in which the investigation must operate.

That distinction matters.

A multi-jurisdictional investigation still needs to establish what happened, identify the contributing factors, understand the condition of the organisation's controls and develop recommendations that reduce the risk of recurrence. The standard ICAM process remains applicable: Immediate Actions, Investigation Planning, Data Gathering, Data Organisation, Data Analysis, Recommend and Report. Those seven steps sit within the four GOAL phases of Gather, Organise, Analyse and Learn.

The added challenge is governance. Before investigators start gathering evidence, interviewing witnesses and analysing contributing factors, they need to understand who has authority, which requirements apply, what evidence can be accessed, what restrictions exist and how the investigation will interact with regulatory or legal processes already underway.

For a complex investigation, getting this right at the beginning can make the difference between an investigation that produces credible organisational learning and one that becomes fragmented by competing requirements.

One incident can create several obligations

The first mistake is assuming that the location of the incident automatically determines the complete regulatory framework.

Sometimes it does. Often it does not.

Consider a serious incident involving a multinational organisation at a project site. The immediate event may occur in Country A, while the worker is employed by an entity registered in Country B. The equipment may be owned by another company and maintained under a contract governed by the law of Country C. Corporate standards may originate from the organisation's global headquarters in Country D.

Several authorities may also have legitimate interests in the event. Depending on the industry and incident, these might include workplace safety regulators, police, environmental regulators, transport authorities, mining or petroleum regulators, coronial authorities, maritime or aviation bodies and other specialist agencies.

The internal ICAM investigation does not replace those processes.

Its purpose is different. ICAM provides a structured way to understand the incident as a system-level event, examining the Absent / Failed Defences, Individual / Team Actions, Task / Environmental Conditions and Organisational Factors that contributed to the outcome. It looks beyond the immediate actions of the people involved and asks what conditions within the wider system allowed the incident to occur.

That systems focus becomes particularly important in a multi-jurisdictional event because the organisational system itself may cross borders.

A procedure may have been developed globally but implemented locally. A critical control may have been specified by corporate management but verified by a regional operation. Training may have been designed in one country and delivered by a contractor in another. Equipment standards may differ between the manufacturer's jurisdiction and the jurisdiction where the equipment is being operated.

The investigation therefore needs to follow the system, not simply the geography of the incident.

Start with jurisdiction before starting with analysis

ICAM begins with Immediate Actions, and this stage becomes especially important when multiple jurisdictions may be involved.

The investigation team needs to establish the regulatory position early. Safety Wise guidance specifically requires investigators to establish which statutory authorities have jurisdiction over the incident scene and obtain the necessary authorisation before entry. In some jurisdictions, an incident scene cannot be disturbed without approval from authorities such as the inspectorate, police or coroner.

That principle should be expanded for a multi-jurisdictional investigation.

Before evidence is moved, equipment is dismantled, electronic records are collected or witnesses are formally interviewed, the organisation should determine what legal and regulatory requirements apply. This should involve appropriately qualified legal and regulatory advice where necessary, rather than the ICAM team attempting to interpret unfamiliar legislation themselves.

This is particularly important because apparently similar jurisdictions can have materially different requirements.

Australia provides a useful example. Most Australian jurisdictions have implemented laws based on the model WHS laws, but Victoria has not, and jurisdictions that have adopted the model laws can make their own variations. Amendments to the model WHS laws also do not automatically become law in each jurisdiction.

Current Safe Work Australia guidance therefore tells duty holders to check requirements with the relevant state, territory or Commonwealth regulator. Notifications are made to the relevant regulator rather than to Safe Work Australia itself.

The differences become more obvious internationally. In the United States, for example, federal OSHA requires employers under its reporting rule to report a work-related fatality within eight hours and specified inpatient hospitalisations, amputations and losses of an eye within 24 hours.

These examples are not a substitute for jurisdiction-specific advice. They demonstrate why an investigation team should never assume that its normal notification, evidence or investigation practices automatically transfer across a border.

Build a jurisdiction and stakeholder map

For a straightforward incident, the Terms of Reference may identify the scope, purpose, boundaries, authority, confidentiality arrangements, stakeholders and expected reporting timeframe.

For a multi-jurisdictional investigation, those requirements need more work.

Safety Wise describes the Terms of Reference as defining the legitimate extent to which an investigation may reach. It also emphasises that planning should confirm notifications to the appropriate internal parties, regulator, legal team and others as necessary.

A useful addition is a jurisdiction and stakeholder map prepared during Investigation Planning.

This should identify the incident location, organisations involved, employing entities, asset owners, contractors, relevant regulators, applicable corporate standards and any known legal restrictions. It should also identify where important evidence and witnesses are physically located.

The purpose is not to turn investigators into lawyers. It is to identify the interfaces requiring specialist advice.

For example, the team might discover that CCTV is held by the site operator, maintenance data by an overseas equipment manufacturer, training records by a contractor, telematics on a cloud server in another country and employment records by a regional corporate entity.

Without early planning, the investigator may simply issue broad requests for information and assume the material will arrive.

A better approach asks: who controls this evidence, where is it held, who can authorise access, are there restrictions on copying or transferring it, and what needs to happen to preserve it now?

Those questions belong in the Investigation Action Plan.

Create one investigation governance structure

Multiple jurisdictions should not automatically produce multiple competing ICAM teams.

Where practical, establish one lead investigation structure with clearly defined local support.

The Team Leader needs enough authority to coordinate the investigation across the relevant business units and organisations. Local representatives can provide regulatory, operational, language and cultural knowledge. Subject matter experts can be brought in where technical questions require them.

The investigation team also needs sufficient independence.

If one regional business unit is investigating another, or if several contractors are involved, perceived ownership of the investigation can quickly become an issue. Parties may become protective of documents, witnesses or findings. A suitably independent Team Leader or facilitator can help maintain a consistent methodology and keep the investigation focused on evidence.

The Safety Wise investigation process expects the organisation to select a team appropriate to the risk and complexity of the event. For significant events, the team may include a Lead ICAM Investigator, HSE personnel and relevant subject matter expertise.

For a multi-country investigation, competence should therefore extend beyond technical knowledge. The team may need people who understand local operations, languages, cultural expectations, employment arrangements and regulatory requirements.

The solution is not to make the team enormous. Too many investigators can make coordination harder.

Build a core ICAM team, then draw on jurisdiction-specific expertise as required.

Keep the Terms of Reference clear

Scope creep is a significant risk in a multi-jurisdictional investigation.

Imagine an equipment failure involving a global fleet. The incident occurred on one site, but investigators quickly discover similar equipment in six countries. Does the ICAM now investigate every asset globally?

Not necessarily.

The Terms of Reference should establish the legitimate boundaries of the investigation while allowing the team to follow relevant evidence. 

Safety Wise guidance makes this distinction because poorly defined investigations can drift into broad system audits rather than remaining focused on understanding the incident and preventing recurrence.

A multi-jurisdictional Terms of Reference should therefore make clear which event is being investigated, which entities and operations fall within scope, the authority of the investigation team, the regulatory interfaces that need to be managed, how confidentiality and information handling will work, who receives the final report and how a material expansion of scope will be approved.

This becomes particularly important when the evidence points beyond the original site.

Suppose a failed maintenance control was created by a global asset management process. The fact that the process owner sits in another country does not make that Organisational Factor irrelevant. The investigation needs authority to examine the organisational system sufficiently to understand whether it contributed to the incident.

Geographic boundaries should not become artificial barriers to systems thinking.

Manage evidence as one controlled body of information

Evidence becomes harder to manage as the number of organisations and jurisdictions increases.

ICAM data gathering should remain structured around PEEPO: People, Environment, Equipment, Procedures and Organisation. The purpose of PEEPO Mark 1 is to plan what information needs to be gathered. PEEPO Mark 2 then helps investigators work methodically through the evidence, separating information that contributed to the event from information that did not.

For a multi-jurisdictional investigation, PEEPO Mark 1 should also identify the source and custodian of important evidence.

Under People, for example, witnesses may include employees, contractors, supervisors, designers and remote technical specialists located in several countries. Equipment data might include maintenance records, telemetry,

engineering specifications and manufacturer information controlled by different entities. Procedures may include corporate standards, local procedures, contractor instructions and jurisdiction-specific requirements. Organisation data may extend from local supervision through regional management to corporate decisions made elsewhere.

This is where a single document-control system becomes essential.

Evidence should have a clear source, date of receipt, custodian and version. Where translations are required, retain the original alongside the translated version. Where electronic data is extracted, record how it was obtained. If an item cannot legally or practically be transferred, record where it is held and how the investigation team accessed it.

The objective is traceability.

Months later, another investigator should be able to determine where a finding came from and what evidence supports it.

That is also consistent with Safety Wise report-writing requirements. Investigation findings should be factual, accurate and supported by evidence, rather than opinion or emotive interpretation.

Evidence preservation comes before convenience

A multi-jurisdictional investigation can create tension between operational recovery and evidence preservation.

A damaged asset may need to be moved. A production site may need to restart. Perishable electronic information may be overwritten. A contractor may be scheduled to leave the country.

Do not treat all of these as administrative issues.

Evidence gathering should begin as soon as practicable to minimise deterioration, contamination or loss.

Regulatory requirements can add another layer. Under Australia's model WHS framework, for example, a notifiable incident may trigger requirements relating to preservation of the incident site, subject to exceptions such as assisting an injured person or making the site safe. The applicable local law must still be checked because adoption and requirements vary between jurisdictions.

The practical lesson is simple: never move or alter evidence merely because the internal investigation is ready to proceed.

Confirm authority first.

Interview across cultures without changing the investigation standard

Witness interviews can be one of the most valuable parts of an ICAM investigation, but multi-country investigations introduce additional considerations.

Language is the obvious one. Culture is often less obvious.

Communication behaviours such as eye contact can have different meanings between cultures and recommends the use of a culturally acceptable interpreter where necessary. The interpreter should not take over the role of the investigator.

The same principle applies more broadly.

Investigators should not mistake communication style for reliability. A witness who is highly deferential to management may provide information differently from someone accustomed to challenging authority openly. Employees may also have different expectations about confidentiality, representation or participation in a workplace investigation.

The methodology should remain consistent: begin with free recall, use open questions, listen actively, clarify with more specific questions where necessary and avoid prematurely leading the witness.

The standard of evidence does not change because the interview occurs through an interpreter.

Record which language was used, who interpreted, whether translated statements were reviewed by the witness and how any material ambiguity was resolved.

Build one timeline

Different locations often create different versions of time.

That sounds trivial until investigators are comparing CCTV timestamps, control-system logs, phone records, telematics, emails and witness recollections across several time zones.

The ICAM timeline must remain one coherent sequence of established events. Ourt quality guidance requires the timeline to be logical, contain established facts and cover the relevant pre-incident, incident and post-incident events.

For an international event, choose a reference time standard and use it consistently. Local time can still be shown where useful, but the team should be able to align every material event against a common chronology.

Do not silently correct conflicting timestamps. Investigate the discrepancy.

A system clock that was seven minutes out may itself be irrelevant to causation, but the discrepancy needs to be resolved before investigators start drawing conclusions about event sequence.

Analyse the system across organisational boundaries

This is where ICAM earns its value in a multi-jurisdictional investigation.

Once the evidence has been gathered and organised, the analysis should not become a comparison of which country, contractor or business unit failed.

The question remains: what contributed to the incident?

The four ICAM categories provide the structure. Examine the Absent / Failed Defences that did not prevent or mitigate the event. Identify relevant Individual / Team Actions, then establish the Task / Environmental Conditions that influenced those actions. Follow the evidence into the Organisational Factors that created or allowed those conditions to exist.

The central principle is that incidents should be considered in the context of the system rather than simply as failures of individuals, even where human errors or violations are present.

In a multi-jurisdictional investigation, an Organisational Factor may sit thousands of kilometres from the incident.

A global procurement decision may have influenced equipment selection. A regional resourcing decision may have affected maintenance capability. A corporate training standard may not have accounted for local operational conditions. A contractor management process may have allowed different competency requirements between locations.

The investigation should follow the evidence to the contributing factor.

It should not stop at a national border on the organisation chart.

Recommendations must work where they are implemented

A common failure after a multi-jurisdictional investigation is to develop one global recommendation and assume it can simply be copied everywhere.

A recommendation needs to address the identified contributing factor, but its implementation may need to vary.

For example, the investigation might identify a weakness in the verification of a critical control across several operations. The required outcome may be consistent globally, while the mechanism used to achieve it differs because of local legislation, equipment, workforce arrangements or regulatory requirements.

That is acceptable.

Consistency of control intent does not require identical paperwork.

Our governance guidance requires recommendations to be supported by the analysis and findings, relevant to the incident, practical, achievable, risk assessed, assigned to a responsible manager and assessed as contributing positively to risk reduction or prevention of recurrence.

For multi-jurisdictional actions, ownership is particularly important. A global recommendation without an accountable owner can disappear between corporate, regional and local management.

Specify who owns the change, where it applies, what successful implementation looks like and how effectiveness will be verified.

Legal privilege, confidentiality and privacy require deliberate control

Complex investigations can generate sensitive material very quickly.

We recognise that some investigations may be conducted under Legal Professional Privilege and that confidentiality is central to maintaining that arrangement. It also cautions against uncontrolled distribution of investigation materials. Investigation records must likewise respect applicable privilege, privacy and non-disclosure arrangements.

When several countries are involved, these questions should be dealt with at the beginning, not when the report is ready for distribution.

Who commissioned the investigation? Who is the client for any legal advice? Which materials can be shared? Where can personal information be stored? Can interview recordings or personnel records be transferred across borders? Who may receive draft findings?

Those are questions for appropriately qualified legal and privacy advisers in the relevant jurisdictions. The ICAM investigator's role is to recognise that the issue exists and make sure the investigation process complies with the advice received.

Privilege should also never be treated as a substitute for investigation quality. Evidence still needs to support findings. Findings still need to explain what contributed to the event.

One investigation, one evidence base, one coherent explanation

Multi-jurisdictional ICAM investigations are more demanding because there are more interfaces to manage. More regulators may be involved. Evidence may sit with different entities. Witnesses can be spread across countries. Legal requirements may conflict or change the way information can be gathered and shared.

But the fundamental investigation task remains remarkably stable.

Establish the facts. Organise the evidence. Understand what happened. Identify the contributing factors. Examine the controls and wider organisational conditions. Develop recommendations that address what the investigation actually found.

The regulatory framework determines some of the boundaries within which the investigation operates. It should not be allowed to fragment the analysis into disconnected local stories.

A strong multi-jurisdictional ICAM investigation maintains one disciplined investigation methodology while deliberately managing the differences between jurisdictions. It establishes regulatory authority early, defines a clear Terms of Reference, builds a competent investigation team, protects evidence, maintains document control and uses PEEPO to gather information across the full system. It then constructs a common timeline and applies the ICAM analysis to the evidence, wherever that evidence leads.

That final point matters most.

When an incident crosses a border, the investigation should be capable of crossing the organisational system with it. The purpose is not to determine which jurisdiction has the better procedure or which business unit made the mistake. The purpose is to understand how the system operated, where controls were absent or failed, what conditions influenced the people involved and which organisational factors need attention.

Jurisdictions may change.

The discipline of the investigation should not.