Seeing the Blind Spots: What Investigators Often Miss

The ICAM (Incident Cause Analysis Method) model is widely respected for a reason. When applied well, it moves investigations beyond simplistic “human error” explanations and toward a systemic understanding of how incidents actually occur. It creates space for learning, accountability without blame, and meaningful organisational change.

And yet, despite its strengths, many ICAM investigations still produce shallow findings, recycled recommendations, and limited organisational learning.

The issue is rarely the model itself.

The issue is what investigators miss while using it.

This article explores the most common blind spots in ICAM investigations- not as a critique of the methodology, but as a practical reflection on how it is often applied in the real world. These gaps show up across industries, incident types, and investigator experience levels. Left unaddressed, they quietly weaken investigations, frustrate leaders, and allow similar incidents to recur under new labels.

If you are an investigator, safety professional, HR practitioner, or leader who relies on ICAM for learning and assurance, this article is for you.

1. Treating ICAM as a Categorisation Exercise Instead of an Inquiry

One of the most common mistakes investigators make is approaching ICAM as a filing system rather than an investigative framework.

Evidence is gathered. Findings are slotted into boxes. The charts are completed. The report is written.

On paper, the investigation looks thorough.

In reality, the thinking stopped too early.

ICAM is not designed to simply classify causes into:

• Individual / Team Actions

• Task / Environmental Conditions

• Organisational Factors

It is designed to force deeper questioning about why those conditions existed and why those actions made sense at the time.

When investigators focus on “what category does this fit into?” instead of “what does this reveal about how the system actually operates?”, the model becomes performative rather than insightful.

What gets missed:

• The dynamic interaction between categories

• The decision-making logic of the people involved

• The organisational signals that shaped behaviour

What it leads to:

• Overly neat charts

• Underwhelming recommendations

• A false sense of completeness

A completed ICAM chart does not equal a completed investigation.

2. Confusing Human Error with Human Explanation

ICAM was created to move investigations away from blame, yet human error remains one of the most misused concepts within the model.

Many investigations still stop at statements like:

• “The worker failed to follow the procedure”

• “The supervisor did not identify the hazard”

• “The operator made an incorrect decision”

These statements describe outcomes, not explanations.

ICAM requires investigators to ask:

Why did this action make sense to the person at the time?

When investigators fail to explore this question, they unintentionally repackage blame in neutral language.

What gets missed:

• Competing priorities (time, production, workload)

• Normalisation of deviance

• Ambiguous procedures

• Informal workarounds that had previously been rewarded

• Cognitive overload, fatigue, or stress

What it leads to:

• Training recommendations that don’t address context

• Disciplinary actions disguised as “controls”

• A culture where people learn to say less in interviews

Understanding human behaviour is not about excusing actions. It is about explaining them accurately enough to prevent recurrence.

3. Ignoring “Success Bias” in Organisational Learning

Most ICAM investigations are conducted after something has gone wrong. This creates a powerful cognitive bias: the belief that the system is generally safe, and this incident was an exception.

In reality, the same conditions that allow work to succeed most days are often the conditions that allow incidents to occur.

Investigators often miss:

• How frequently similar shortcuts are used

• How often hazards are “managed” informally

• How often success depends on individual adaptation rather than system design

ICAM investigations that focus only on failure miss an enormous learning opportunity.

What gets missed:

• The gap between work as imagined and work as done

• How frontline staff routinely compensate for system weaknesses

• Why previous near misses didn’t trigger action

What it leads to:

• Overconfidence in existing controls

• Surprise when “unexpected” incidents recur

• Missed opportunities for proactive improvement

A strong ICAM investigation doesn’t just ask, “Why did this fail?” It asks, “How does this normally succeed, and at what cost?”

4. Superficial Treatment of Organisational Factors

The “Organisational Factors” section of ICAM is often the least developed, and yet, the most important.

Many investigations include generic entries such as:

• “Inadequate training”

• “Insufficient supervision”

• “Poor communication”

• “Lack of resources”

While these may be true, they are often descriptive rather than diagnostic.

ICAM is not asking investigators to identify vague organisational weaknesses. It is asking them to examine how organisational decisions, structures, and priorities shaped the conditions for the incident.

What often gets missed:

• How KPIs and incentives influence behaviour

• How resourcing decisions create trade-offs

• How leadership messaging is interpreted at the frontline

• How change management failures introduce risk

• How governance processes dilute accountability

What it leads to:

• Recommendations that sound reasonable but change nothing

• Leaders agreeing with findings but not feeling implicated

• Repetition of the same “root causes” across multiple incidents

True organisational learning requires discomfort. If organisational factors feel safe and generic, they are probably incomplete.

5. Failing to Trace Decisions Back to Their Origin

ICAM encourages investigators to look beyond immediate actions- but many stop too soon.

For example:

• A worker bypasses a guard

• A supervisor approves a deviation

• A planner schedules conflicting tasks

Investigations often record these as local decisions, without tracing where those decisions originated.

What gets missed:

• Earlier design decisions that constrained options

• Legacy systems that normalised risk

• Policy decisions that prioritised speed or cost

• Unresolved issues that were deferred repeatedly

Every operational decision sits within a decision-making lineage.

ICAM investigations that fail to follow that lineage tend to overemphasise frontline behaviour and underemphasise upstream influence.

What it leads to:

• Repeated focus on “last line” controls

• Minimal scrutiny of strategic or managerial decisions

• A perception that incidents are caused “down there”

Good ICAM investigations ask:

Who created the conditions where this was the most reasonable option available?

6. Treating Procedures as Static Truths

Procedures play a central role in many ICAM investigations, but they are often treated as immutable standards rather than living artefacts.

Investigators frequently ask:

• “Was there a procedure?”

• “Was it followed?”

Less frequently do they ask:

• “Was the procedure usable?”

• “Was it realistic in the context?”

• “How often is it actually followed?”

• “Who last reviewed it, and why?”

What gets missed:

• Procedures that conflict with real-world constraints

• Documents written for compliance rather than use

• Gaps between formal rules and informal practices

• Silent adaptations that have become normal

When procedures are treated as unquestionable, non-compliance becomes the explanation by default.

ICAM is strongest when procedures are examined as:

• Design tools

• Communication mechanisms

• Indicators of organisational priorities

Not simply as rules that were or weren’t followed.

7. Overlooking the Role of Weak Signals and Drift

Many serious incidents are preceded by small, ambiguous signals:

• Minor deviations

• Informal workarounds

• Near misses

• Complaints that went unresolved

ICAM investigations often mention these signals, but rarely explore why they failed to trigger action.

What gets missed:

• How risk gradually increases through normalisation

• How competing priorities suppress escalation

• How reporting systems discourage “low-level” issues

• How leadership attention is allocated

This phenomenon, often referred to as drift into failure, is central to understanding complex incidents.

What it leads to:

• Surprise at escalation

• Overconfidence in lagging indicators

• Reactive rather than adaptive safety management

A mature ICAM investigation doesn’t just document weak signals. It examines the system’s sensitivity to them.

8. Inadequate Exploration of Interfaces and Handoffs

Incidents rarely occur in isolation. They occur at boundaries:

• Between teams

• Between contractors and clients

• Between shifts

• Between planning and execution

ICAM investigations often identify “communication failures” at these interfaces, but stop there.

What gets missed:

• Ambiguous ownership

• Assumptions about shared understanding

• Conflicting goals between groups

• Structural barriers to coordination

Interfaces are where responsibility is often diffused, and where risk accumulates quietly.

What it leads to:

• Recommendations to “improve communication”

• No change in how work is actually coordinated

• Continued vulnerability at the same boundaries

Effective ICAM investigations examine how work is handed over, negotiated, and translated across organisational lines.

9. Recommendations That Mirror the Causes

One of the clearest indicators of a shallow ICAM investigation is when recommendations simply restate the causes.

Examples include:

• Cause: “Inadequate training” Recommendation: “Provide additional training”

• Cause: “Procedure not followed” Recommendation: “Reinforce procedure compliance”

These recommendations are easy to write and easy to accept, but rarely effective.

What gets missed:

• System redesign opportunities

• Control effectiveness

• Behavioural and organisational leverage points

• Sustainability of controls

ICAM is not about identifying what went wrong. It is about changing the system so the same combination of factors cannot reoccur.

Strong recommendations:

• Address multiple contributing factors

• Reduce reliance on human perfection

• Reflect how work actually happens

• Are owned, resourced, and measurable

10. Underestimating the Investigator’s Influence

Finally, one of the most overlooked elements in ICAM investigations is the investigator themselves.

Investigators influence:

• What questions are asked

• What evidence is pursued

• How interviews are framed

• Which explanations feel “reasonable”

• How findings are written and presented

ICAM does not remove subjectivity- it requires investigators to manage it consciously.

What often gets missed:

• Confirmation bias

• Organisational pressure (explicit or implicit)

• Fear of challenging senior decisions

• Overreliance on precedent investigations

Reflective investigators ask:

What assumptions am I bringing into this investigation? What explanations feel uncomfortable, and why?

The quality of an ICAM investigation is inseparable from the mindset of the person conducting it.

Closing Reflection: ICAM as a Learning Discipline

ICAM is not a checklist. It is not a chart or diagram on its own. It is not a compliance exercise.

It is a discipline of inquiry- one that demands curiosity, humility, and courage.

The most powerful ICAM investigations:

• Make the system visible

• Explain behaviour rather than judge it

• Surface uncomfortable truths

• Create learning that extends beyond the incident

What investigators miss is rarely due to lack of knowledge. It is usually due to time pressure, organisational expectations, or unexamined assumptions.

If ICAM investigations feel repetitive, shallow, or disconnected from real change, the solution is not a new model.

The solution is deeper thinking within the one we already have.