ICAM Investigations - What happens when you can’t find anything amiss?
So, there you are - you have raked through all the evidence at the incident scene, conducted multiple interviews, gone through your photographs for the umpteenth time and exhaustively worked through every step of the Data Gathering/Data Organisation process where some of the contributing factors would normally lie and guess what – you draw a blank. What happens now?
Every so often, albeit rarely, you end up in the situation described above. You have done some of your best work to get there by looking at, considering and evaluating all of the available evidence. No stone remains unturned, yet there are no clues to assist with your identification of any holes in your Swiss Cheese model.
The reality is that sometimes things do happen that we have not anticipated, have no control over or sit beyond the framework of being ‘reasonable’ from a risk consideration perspective. We can’t control everything (most organisations work to a risk control/reduction/mitigation strategy, not total risk elimination, which is where the ‘risk appetite’ philosophy comes into play) – there will always be factors that sit outside our risk control framework and very occasionally, these do come to the forefront and contribute to some form of event. Examples include where a factor sits outside your evaluation criterion from a likelihood assessment (i.e. beyond ‘Unknow in the industry’ at 10-xxxxx probability) or factors that could be attributed to ‘An Act of God’ philosophy (e.g. meteor strike or something falling from an overflying aircraft and impacting some part of your infrastructure or equipment – see: https://www.abc.net.au/news/2022-05-05/gympie-family-close-call-mysterious-metal-object-through-roof/101039886).
We have seen a few examples of such events during recent investigations. These include an undetected manufacturing defect in a single piece of equipment that passed all quality control inspections and was then used by another company with the defect not becoming evident until the event sequence was triggered, as well as a suicide event and also a bearing failure, that all inspection, servicing, usage and quality control inspections were well managed throughout the life cycle of the equipment.
For such investigations, the important part of the process from the investigator’s perspective is that you have been thorough with your Data Gathering and Data Organisation and that you can ‘put your hand on your heart’ and accept that you have investigated to the best of your ability in accordance with the Terms of Reference.
While the apparent lack of closure of an important investigation may not sit well with the management team who convened the investigation, it is something that is a reality. In such cases, it is best to keep track of what happened from a statistical point of view; just in case the frequency of such events does start to increase. If this is the case, then it will be worth collectively looking at all the events to identify if there is any commonality at all or even revisiting the investigation with revised (normally broader) Terms of Reference. If the event itself remains as an isolated one, then at least you can gain some comfort from the understanding that you have done your job well and that there are no specific learnings for the organisation beyond the ‘record for statistics’ outcome.
As indicated earlier, it is rare to have an investigation that does not identify any contributing factors at all, but sometimes it does happen. If ever you face this situation, it doesn’t mean the process is wrong, it is likely just something beyond the scope of what we have been employed to do.
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- Geoff Roberts
Geoff has been involved with aviation all his working life and has been passionate about flying since he was a child.
He has a background as a rotary-wing and fixed-wing pilot in both military and civilian fields and has an inmpressive track record in management and leadership roles.
Geoff’s passion for the management of aviation risk stems from his inquiring mind and desire to improve safety outcomes.
He has been involved in multiple high-profile aircraft incident and accident investigations and these skills have readily taken root in the broader application of ICAM to any field.
Geoff uses the skills developed as a senior flight instructor to assist organisations with incident investigations and facilitating investigation training.