ICAM Has Come a Long Way
This post outlines a review of various incident investigation techniques and the background behind how and why ICAM was developed and mandated as the investigation process for all incidents involving a fatality and recommended for events with a risk potential of a fatal event by major organisations around the world.
In 1997 a major resource company with global operations was using a myriad of incident investigation tools across the organisation, including MORT, ISRS (with SCAT or RCAT versions), SSAI, TapRoot, Fault Tree, 5 Why's, and TRIPOD. The organisation found that it was difficult to use the learning's from serious incident investigations for trending or collective learning as they were not investigated in a consistent or effective manner (comparing apples with pears).
The organisation decided to commission a project to evaluate the merits of existing investigation methods against defined criteria and then to benchmark the findings against other studies in the public domain.
The following criterion was used:
A method of describing and schematically representing the incident sequence and its contributing conditions.
A method of identifying the critical events and conditions in the incident sequence.
Based on the identification of the critical events or active failures, a method for systematically investigating the management and organisational factors that allowed the active failures to occur, i.e. a method for root causal analysis.
Underpinning these three criteria are the following premises:
The barrier/energy transfer model of incident causation. This postulates that an incident can be likened to the transfer of energy and therefore for an incident to occur, there needs to be a person present, a source of energy and a failed barrier between the two.
Incidents typically have more than one causal factor. Multiple causation models have been utilised throughout the systems reviewed and the methods frequently provide linkages between related factors.
Needs to consider whether the method specifically facilitates the identification of safety management and organisational inadequacies and oversights which relate to their own operations.
The method needs to identify those factors that exert control over the design, development, maintenance and review of their risk control systems and procedures.
Should be current best practice and be able to be amended to meet changing organisational demands and issues
Should be based on current HSE management, risk management, and human factors principles
Should be based on tried and tested methods used in high consequence/low-risk industries (aviation, petroleum, etc.)Should focus on risk reduction and prevention of recurrence
Should integrate with current procedures and processes
Should ensure a uniform and consistent approach to incident investigation with consistent and verifiable results
Should provide a common framework and language across the organisation to allow for shared learning and trending
Should be a complete incident management system integrating analysis with investigation
Should be easy to use for novice and experienced investigators
Should be easy to train - two days or less
Should provide stand-alone support material to allow for investigators to "pick-up and apply" after a period of non-use
Can be deployed across the whole organisation and be effective in the different industrial and cultural domains within the organisation
Can be used for all level of consequence and complexity of event including non- safety occurrences.
A two-day workshop involving 38 HSE professionals from across the organisation was held in Melbourne in 1997 to evaluate current investigation tools with the following outcomes:
There was not an "off the shelf" system that met all the organisation's needs
The majority of root causes analysis methodologies reviewed were essentially checklists of potential root cause factors to stimulate thought. These 'checklists' are presented in a number of forms:
as trees incorporating fault tree logic, e.g. MORT,
as simple trees without fault tree logic, e.g. SRP
as lists with cross-referencing systems e.g. ISRS, SCAT and TOR
as simple lists e.g. SACA
Checklist systems (MORT in particular) were perceived as being potentially onerous and had to be followed through to the conclusion to reach root causes. This could preclude them being used for a low-level consequence or simple events, i.e. they were held in reserve for the big one
Checklist systems could capture and clog up the investigation with quality non- compliance findings that were not contributory factors to the incident
The Reason Model and the Shell Petroleum application TRIPOD were excellent causal analysis tools but did not provide for a complete incident management system
Shell Petroleum had donated the TRIPOD system to industry and had not been developed since 1979
TapRoot was an excellent incident management system but like other proprietary systems such as MORT, ISRS, etc. were subject to copyright and could not be developed and amended to meet the organisation's specific needs.
WORKSHOP ACTION PLAN
Develop an "in-house" incident investigation management system incorporating the best practice elements of all reviewed systems which should:
Be a simple, intuitive process
Be used with or without software
Be used by novices or experts
Integrate analysis with an investigation
Have extensive supporting documentation and tools
Have precise definitions
Have tools that allow trending to identify generic or organisation-wide root causes
Have corrective action guidance
Contact Professor James Reason and work with him in the development of the Reason Model to meet current safety management standards and organisational needs
Develop a suite of resource material and tools to support the new incident investigation management system.
Develop a training package to roll out the system.
With the help of Professor James Reason, the organisation developed ICAM in 1998 and then further developed the process in 2000.
Resource material was developed to support investigations using ICAM
Significant Incident Investigation Procedure (requiring use of ICAM for fatal events)
Incident Investigation Guide
Minicam Investigation Guide
A training package was developed and rolled out across the organisation’s sites (over 1500 staff and contractors trained in 3 years). A network of ICAM practitioners was formed to support novice investigators or to support sites to investigate significant incidents.
In July 2002, the organisation outsourced the provision of ICAM training and consulting services to Safety Wise Solutions.
THE ORGANISATION'S EXPERIENCE
In the nearly 20 years the organisation has been using the process it has found that ICAM:
Provides a consistent approach to incident investigation
Provides repeatable results
Consistently identifies root causes of incidents
Focuses on the human factor, both at the operational end and within the organisation, while it removes focus from human error
Is widely accepted by management, workforce, unions and the regulator
Provides tools for learning the right lessons from an incident and identify "error tolerance" improvement opportunities
Identifies attainable and measurable HSE targets
Is a process that disciplines the investigation team to make recommendations to address all :
Absent or failed defences -. risk controls
Organisational factors – prevention strategies and risk reduction
Filters out non-contributory facts and identifies missing or conflicting information
It provides a useful briefing tool for senior management.
THE CURRENT SITUATION
Safety Wise Solutions Pty. Ltd (Safety Wise) has further developed the incident management system and has produced its own suite of manuals and training packages. Our resource material and training packages have been translated into French, Spanish, Portuguese, Russian, Italian, and Simple Chinese.
Resource material has been developed to support investigations using ICAM:
Pocket Investigation Guide
Editable reporting templates
Additional investigation resource material
Device agnostic applets and apps
Videos, case studies, posters and other free training resources
Safety Wise has now trained over 70,000 people globally, in 7 languages and across 43 countries.
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
Participation in investigations as an external/independent party
ABOUT THE AUTHOR- Luke Dam (Chief Executive 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.