When ICAM Findings Trigger Management of Change (MOC)

If you sit on an executive team, here is the uncomfortable truth: most serious incidents are not the result of poor investigations. They are the result of leadership teams approving change without admitting that it is change.

ICAM investigations tell executives things they would rather not hear. They reveal that risk is being traded every day in the normal operation of the business. They show that efficiency, cost, and schedule have quietly been allowed to override control effectiveness. They expose decisions that made sense at the time but now sit uncomfortably in hindsight.

What happens next is the real test of leadership.

Too often, executives accept the findings but sanitise the response. Systemic issues are translated into safe, inexpensive actions. Recommendations that would require genuine organisational change are reframed as procedural updates or training refreshers. The investigation is “supported”, but the change it demands is quietly avoided.

That is not a failure of safety management. It is a failure of governance.

What Management of Change actually exists to do

Management of Change is not paperwork. It is not a safety department hurdle. It is not something you only need when an engineer changes a pipe size.

MOC exists because change is dangerous when it is casual.

Any change that alters how work is done, who does it, what tools are used, what decisions are expected, or how success is measured will change the organisation’s risk profile. Sometimes the risk reduces. Sometimes it simply moves. Sometimes it grows quietly until it is rediscovered through another incident.

MOC is the mechanism that forces an organisation to pause and ask uncomfortable questions before change becomes normalised. What new hazards does this introduce? What controls are we weakening or removing? Who will now be relied upon more heavily? What assumptions are we making about behaviour, competence, and conditions?

If those questions are not being asked, the organisation is not managing change. It is gambling on it.

Why ICAM without MOC is organisational self‑deception

ICAM investigations rarely point to small, isolated fixes. They expose patterns. They reveal systemic drift. They show how multiple reasonable decisions, made over time, combined to produce an outcome nobody wanted.

That kind of insight should be a catalyst for deliberate system redesign.

Instead, many organisations treat ICAM outputs as a list of tasks to be completed as cheaply and quickly as possible. The more uncomfortable the finding, the more likely it is to be diluted into something harmless.

This is where organisations deceive themselves. They convince themselves that because an action has been assigned, risk has been controlled. They mistake activity for effectiveness.

If an ICAM action changes processes, roles, rules, interfaces, technology, or training, then it is not just an action. It is a change to the system. An unmanaged system change is one of the most reliable precursors to serious incidents.

Closing investigations without MOC creates the next incident

When organisations skip MOC after investigations, the consequences are not random. They are highly predictable.

Procedures are updated without checking whether they align with real work. New controls are added without considering how they interact with production pressure. Training expectations are raised without adjusting supervision or resourcing. Accountability is clarified on paper while remaining ambiguous in practice.

People adapt because they must. Work continues through workarounds, informal coordination, and quiet rule-bending. From the executive level, everything appears stable. Until it isn’t.

The next incident is then framed as a failure to follow the new rules, rather than a failure to understand what the system had become.

The excuses organisations use to avoid Management of Change

When MOC is not triggered after an ICAM investigation, it is rarely because leaders do not know better. It is because familiar excuses are allowed to stand in for governance.

The most common is time. The organisation is under pressure, the incident response already took months, and leadership wants to move on. MOC is seen as something that will slow progress. In reality, unmanaged change does not save time; it defers cost. The time is simply paid later, often during another investigation.

Cost is the next excuse. Properly managing change sometimes reveals that fixes are not cheap. Resourcing needs to increase. Systems need redesign. Capability gaps need investment. Avoiding MOC allows organisations to pretend that risk reduction can be achieved at minimal cost. That illusion holds only until the next serious event.

Then there is bureaucracy. MOC is labelled as paperwork, red tape, or safety overreach. What this really signals is discomfort with scrutiny. MOC forces assumptions into the open and makes trade-offs visible. It creates a record of decisions that leaders would rather keep informal. Bureaucracy is not the problem. Accountability is.

Stop calling them actions. Call them what they are: change

One of the most damaging habits in incident management is the word “action”.

Actions sound safe. Actions sound contained. Actions feel like progress.

But many so‑called actions fundamentally alter how work is done. They shift decision‑making, redistribute responsibility, introduce new dependencies, and change the balance between efficiency and thoroughness.

If an ICAM recommendation alters work in any meaningful way, it is a change. Pretending otherwise does not make it less risky; it simply makes the risk invisible.

The rest of this article is blunt by design. These are the types of ICAM findings that should automatically trigger a Management of Change process. Not sometimes. Not if convenient. Automatically.

Procedural changes are never low risk

Rewriting procedures is one of the most common and least examined responses to ICAM investigations. Procedures are updated because they are tangible, auditable, and politically safe.

But procedures are controls. Changing them changes how risk is managed.

A revised procedure might remove a verification step, compress timeframes, or increase reliance on individual judgement. It might conflict with other procedures, training materials, or system constraints. It might look clearer on paper, but harder to use in reality.

Treating procedural change as administrative housekeeping rather than managed change is a mistake organisations repeat endlessly. If ICAM leads to procedural change, MOC should be non‑negotiable.

Role clarity fixes often create new ambiguity

ICAM investigations frequently conclude that roles and responsibilities were unclear. The typical response is to redraw accountability lines, update position descriptions, or add approval layers.

These changes are rarely neutral.

They affect workload, decision speed, escalation pathways, and cognitive demand. They can overload supervisors, slow critical decisions, or dilute ownership. When implemented without MOC, they often replace one form of ambiguity with another.

If an investigation leads you to change who is responsible for what, you are redesigning the organisation. That deserves the same discipline as any other system change.

Adding controls without MOC is how systems become brittle

ICAM findings often highlight missing or weak controls, and the instinctive response is to add more. Checklists, permits, sign‑offs, alarms, and verification steps proliferate.

Each one makes sense in isolation. Collectively, they often make the system harder to operate.

Without MOC, organisations fail to ask whether new controls will actually be used under pressure, how they interact with existing barriers, or what happens when they fail. The result is a system that looks robust on paper and fragile in practice.

MOC forces these questions into the open, where they belong.

Training fixes are often treated far too casually

When ICAM identifies training or competence gaps, organisations rush to update packages or mandate refreshers. This feels proactive, but it is still change.

Training changes alter expectations, authorisation boundaries, and supervision demands. They affect who can do the work and how confidently they can do it. Poorly managed transitions leave people exposed while the organisation assumes capability has been improved.

If training expectations change, MOC should ensure the system is genuinely ready for those expectations to exist.

Technology changes deserve suspicion, not optimism

Equipment and technology are common contributors in ICAM investigations, and the proposed fixes are often technical. Modify the design. Introduce a new tool. Replace the system.

Technology fixes are seductive because they promise reliability and control. They also introduce new failure modes, new dependencies, and new cognitive demands.

Organisations that implement technology changes without MOC usually discover the problems later, in operations, when adaptation becomes the only option. By then, the risk has already shifted.

Structural and resourcing changes are high‑stakes interventions

Some ICAM investigations reveal what everyone already knows but rarely admits: the organisation is stretched too thin. Staffing is inadequate, spans of control are excessive, and workload routinely exceeds capacity.

Changing structure or resourcing is not just a business decision. It changes communication pathways, supervision quality, and risk ownership. Implemented without MOC, these changes can undermine the very resilience they are meant to create.

Contractor interface changes are often where risk hides

ICAM frequently exposes weaknesses at organisational boundaries, particularly with contractors. Actions often involve redefining scopes, tightening oversight, or shifting responsibility.

These changes redistribute risk, sometimes without fully understanding where it lands. MOC is essential to ensure that accountability is clear, obligations are understood, and risk is not simply pushed outside the organisation’s line of sight.

Rules and metrics shape behaviour, whether you like it or not

When ICAM findings point to problematic rules or performance measures, organisations are often reluctant to change them. Metrics feel objective. Rules feel authoritative.

But they drive behaviour, especially under pressure. Changing them reshapes priorities and trade‑offs. Doing so without MOC invites unintended consequences.

Removing controls is not simplification unless risk is understood

Simplification is sometimes necessary. ICAM may show that controls are redundant, ineffective, or actively harmful.

Removing controls without MOC, however, is just as dangerous as adding them blindly. Risk does not disappear because a step is removed. It moves.

Cultural fixes without system change are theatre

Finally, ICAM often surfaces cultural issues: silence, compliance theatre, normalised deviation. The response is frequently leadership training or a new campaign.

Culture does not change in isolation. It changes when systems, incentives, and expectations change. MOC helps ensure cultural interventions are supported by structural reality rather than contradicted by it.

A blunt test for triggering MOC

If an ICAM recommendation would make work feel different tomorrow than it does today, it is a change.

If it would alter decisions, priorities, tools, or responsibilities, it is a change.

If it could create new ways for the system to fail, it is a change.

Stop debating it. Manage it.

What this means for leaders

If you are a leader reading this, the implication is straightforward and confronting.

You cannot endorse ICAM learning while quietly rejecting the change it demands. You cannot ask for systemic investigations and then approve only cosmetic responses. And you cannot delegate Management of Change to technical specialists while retaining decision-making authority at the executive level.

Triggering MOC after ICAM investigations is not a safety decision. It is a governance decision. It is an explicit acknowledgement that leadership choices shape risk, and that those choices deserve the same discipline as any other strategic decision.

Organisations that do this well do not investigate fewer incidents because they are luckier. They investigate fewer incidents because they stop redesigning failure into their systems.

Final word

ICAM is about learning the truth.

Management of Change is about having the courage to act on that truth, even when it is inconvenient, expensive, or uncomfortable.

Executives who separate the two are not leading learning organisations. They are leading organisations that repeat the same lessons with better formatting.

Hope is not a control. Managed change is.