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The Diversity of the ICAM Incident Investigation Model


Introduction

The Incident, Cause, Analysis Method (ICAM) Incident Investigation model is the most diverse model any safety specialist will ever use when undertaking an investigation in the workplace. In the past, incident investigators have tended to focus on intentional or unintentional acts of human error – those things that people did or didn’t do – that led to an incident or accident (the “person model”). While this approach provides a superficial explanation of the incident, it does not consider the underlying factors that contributed to the actions, or the context in which they occurred. Considering only the transparent ‘active’ failures and unsafe acts, rather than identifying those potential causes or ‘latent conditions’ lying dormant within the system, limits the potential of an investigation to prevent the same event from recurring.

ICAM is a holistic systemic safety investigation analysis method. It aims to identify both local factors and failures within the broader organisation and productive system that contributed to the incident, such as communication, training, operating procedures, incompatible goals, change management, organisational culture and equipment. Through the analysis of this information, ICAM provides the ability to identify what really went wrong and to make recommendations on necessary remedial actions to reduce risk and build error-tolerant defences against future incidents. The ICAM process incorporates best practice Human Factors and Risk Management principles.

Case Study

The following case study is based on actual events; however names, locations and other identifying details have been changed. Some photos are actual incident photos whereas others are from subsequent re-enactments.

On the 17th March, 2015 contractors were assigned a task to install a new exclusion fence and vehicle gate on a track where it crosses a road.

As part of this task, the existing, deteriorated fence posts (x2) and gate were required to be removed.

On arrival at the site, the crew undertook a pre-start meeting and reviewed the Safe Work Method Statement (SWMS).

During this meeting, a number of options were considered on how best to remove the existing 2 posts. The crew decided the best method would be to use a Snatch Strap being pulled by the company vehicle.

A Spotter was positioned approximately 20 metres up from the vehicle to observe the post removal (see photo below).

The snatch strap was attached to the rear tow bar and the first post was successfully removed using this method, however upon trying to remove the second post, they found it would not budge.

In another attempt to remove the post, the driver applied more power resulting in the post breaking at ground level, catapulting towards the car, first impacting the rear roll bar and then striking the roof, shattering the windscreen, then impacting the bonnet/hood before coming to rest on the ground in front of the car.