Safety Seminar about Incident Investigation

The Incident Cause Assessment Methodology (ICAM) is now globally recognised as a peak incident investigation methodology and is widely used in industry for safety related incidents. Many concepts such as the Swiss Cheese Model, Active and Latent Failures etc. have now become part of the safety vocabulary of incident investigation. Numerous industries and many major construction and resources clients require their supervisors, managers and safety officers to be competent in using this methodology for incident investigations.

CTC’s latest Seminar in the Safety Series focused on Incident Investigation using ICAM methodology. Guest speaker Simon Phillips, Managing Director of CTC tenant OHSA is an ICAM expert having conducted many investigations using the methodology across a range of industries both in Australia and overseas.

Simon started his presentation by describing James Reason’s Swiss Cheese model of accident causation. In the Swiss Cheese model, an organisation’s defences against failure are modelled as a series of barriers, represented as slices of the cheese. The holes in the cheese slices represent individual weaknesses in individual parts of the system, and are continually varying in size and position in all slices. The system as a whole produces failures when holes in all of the slices momentarily align, permitting “a trajectory of accident opportunity”, so that a hazard passes through holes in all of the defences, leading to an accident.

Reason hypothesized that most accidents can be traced to one or more of four levels of failure:

• Organisational influences,
• Unsafe supervision,
• Preconditions for unsafe acts, and
• The unsafe acts themselves.

In his presentation, Simon summarised the ICAM process as follows:

• Establish the facts.
• Identify contributing factors and latent hazards.
• Review the adequacy of existing controls and procedures.
• Report the findings.
• Recommend corrective actions which can reduce risk and prevent recurrence.
• Detect organisational factors than can be analysed to identify specific or recurring problems.
• Identify key learnings for distribution.

The ICAM investigation process focuses on:

• Data collection using the PEEPO tool.
• Data analysis.
• Development recommendations using the Hierarchy of control.
• Key learnings presented in an ICAM Investigation Report.

ICAM seeks to look further and focuses on:

• Immediate causes
• Contributing factors
• Underlying causes

The following six steps are recommended when facilitating incident analysis:

The ICAM report should include the following:

• Incident Description
• Key Findings
• Conclusion and Observations
• Recommendations
• Significant Learnings
• Appendices
• ICAM Analysis
• Corrective Action
• Report Sign Off

The Seminar offered only a very brief overview of the ICAM methodology. However, OHSA conducts a 2-day ICAM Training Course here at CTC.  To find out more about this course, visit their website.