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The ICAM Investigation Tool

Herramienta investigación ICAM

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juan flores
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169 views7 pages

The ICAM Investigation Tool

Herramienta investigación ICAM

Uploaded by

juan flores
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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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-?
Tell the catering worker to take more care?
Conduct a “quick and dirty” ICAM investigation?
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.
Contributory Categories:
Non-contributory Facts
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
Conclusion
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

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