The ICAM Investigation Tool is a very diverse model for investigating incidents and near misses, however when we talk about ICAM to safety professionals, many feel that it is too cumbersome or requires too much input and detail to be effective.
In this case study, will introduce you to the "Quick and Dirty" ICAM which can be completed in around 45 minutes.
Background to the ICAM Process
There are 4 keys steps in completing an ICAM investigation, as outlined below:
Case Study- Background
A catering worker was working on a mine site and was cleaning the floor following a spill in the cafeteria.
The worker slipped on the floor and as a result, sustained a bruised left elbow.
We’ve been advised that we have no more than 1 hour to investigate as the worker’s shift will end and he flies off site and will commence annual leave upon his return home.
We now have to decide, do we-?
Despite the connotations that may come to mind with the reference to a quick and dirty investigation, this is still a thorough process which will establish robust recommendations and learning's for the organisation. The point is the ICAM is diverse enough that it can be scaled up and down according to the nature of the incident.
Case Study- PEEPO
During this phase, the investigation team must gather as many relevant facts as possible so as to understand the incident and the events leading up to it.
For each of the 5 data categories shown below, the team should identify all conditions, actions or deficiencies, which may have been contributing factors to the incident.
To ensure that all the facts are uncovered, ask the following questions for each category: Who? What? When? Where? Why? And How?
For this investigation, our PEEPO looks like:
Case Study- Data Organisation
Once the data has been collected, it is important that it be organised logically and sequentially in preparation for ICAM analysis.
Several data organising techniques can be used to assist with the correlation.
There are many data organisation tools available. Data organisation tools can either be timeline or flowchart based. Examples of data organisation tools are shown below:
Time lines Flow charts
– Simple Timeline – 5 Whys
– Parallel Timeline – Incident Trees
– Event and Condition Charts – Fault Tree Analysis
– Time Ordered Event Charts – Root Cause Analysis
Case Study- Data Analysis
To analyse, extract each piece of factual information from the investigation findings or the draft incident report and classify it into one of the 5 ‘contributory’ categories shown below.
Absent / Failed Defences
Individual / Team Actions
Task / Environmental Conditions
Organisational Factor Types
Note – Some of the findings will just be facts and will not be contributory factors to the incident or outcome, e.g. the time of the incident is a fact but is non-contributory to the event.
Absent/Failed Defences- These contributing factors result from inadequate or absent defences that failed to detect and protect the system against technical and human failures. These are the control measures which did not prevent the incident or limit its consequences.
Individual/Team Actions- These are the errors or violations that led directly to the incident. They are typically associated with personnel having direct contact with the equipment, such as operators or maintenance personnel. They are always committed ‘actively’ (someone did or didn’t do something) and have a direct relation with the incident.
Task/Environmental Conditions- These are the conditions in existence immediately prior or at the time of the incident that directly influence human and equipment performance in the workplace. These are the circumstances under which the errors and violations took place and can be embedded in task demands, the work environment, individual capabilities and human factors.
Organisational Factors- These are the underlying organisational factors that produce the conditions that affect performance in the workplace. They may lie dormant or undetected for a long time within an organisation and only become apparent when they combine with other contributing factors that led to the incident. These may include management decisions, processes and practices.
In this instance, the data analysis identified the following:
Case Study- Recommendations
The following recommendations were made as a result of this ICAM Investigation:
Issue non-slip shoes to catering staff
Reinforce the spill policy and audit for compliance
Revise standard services contract to include minimum PPE requirements
Conduct post contract award review to ensure level of service and risk has not been compromised
Introduce procedure to strip wax, once-a-month and reapply
Case Study- Learnings
The following key learning's were identified as a result of this ICAM Investigation:
Procedures are useless if they are not enforced
When a contract changes hands based on costs, we must ensure that performance levels are, including HSE related, are not compromised
As can be seen with this case study, this incident was relatively straight forward to investigate. Due to the ability to scale the ICAM process up or down to suit the incident. it highlights that it is suitable to use in any industry, for any type of investigation.
Interested in Knowing More?
Further information on Safety Wise’s Incident Cause Analysis (ICAM) Training is available from our website: http://www.safetywise.com/
Additional ICAM Related Services
Safety Wise also offers the following additional services for sites that adopt the ICAM investigation analysis method:
Quality review of incident investigations using ICAM
Trend analysis of organisational factors contributing to serious incidents
Participation in investigations as an external / independent party
ABOUT THE AUTHOR- Luke Dam (Chief Operations Officer)
Luke has worked in various industries over the years including pharmaceutical, retail, manufacturing, and transport including iconic brands like WesFarmers, Goodyear, CSL Limited, and Incitec Pivot Limited.
His work in OHS and learning and development has seen him deliver services to clients, both internal and external as well as managing service delivery teams around the world.
Luke holds a Graduate Certificate of Management (Learning) as well as a Diploma of Occupational Health and Safety, a Diploma of Training and Assessment Systems, a Certificate IV Workplace Training and Assessment, a Certificate III in Mine Emergency Response & Rescue and a Certificate II in Public Safety (SES Rescue).
Luke is extensively involved in a project to establish an association dedicated to confined space safety and to drive change in legislation to promote best-practice in this high-risk area. Luke is passionate about online OHS and incident investigation communities, moderating a number of large LinkedIn groups boasting over 11,000 members globally.