Incident Cause Analysis Method

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					Incident Cause Analysis Method

        Why did it happen!
      Not Why did it happen?
        Think what did happen
Significant factors leading to the incident, and
the subsequent actions necessary to prevent
recurrence, do not always emerge from the
physical evidence of the case alone. Many
incidents occur, not because they could not be
prevented, but because the organization did not
appreciate the gaps in their safety systems, nor
learn from, or retain the lessons from past
incidents within or outside their organization.
            All base upon Logic
The principle objective of incident investigation is
to prevent recurrence, reduce risk and advance
health and safety performance. It is not the
purpose of this activity to apportion blame or
liability. The use of established investigation
methodologies guide the investigation team in
following a structured, logical path during the
course of an investigation.
Investigation methodologies provide guidance in
gathering investigative data and a framework for
organizing and analyzing the data.
Flow the steps
• (ICAM) The principles of the Incident Cause
  Analysis Method (ICAM), stem from the work
  of organizational psychologist and human
  error expert, thus developing a conceptual
  and theoretical approach to the safety of large,
  complex, socio-technical systems.
             latent conditions
Reason defines organizational accidents as
those in which latent conditions (arising
mainlyfrom management decisions, practices or
cultural influences), combine adversely with
triggering conditions (weather, location etc.)
and with active failures (errors and/or
violations) committed by individuals or teams at
the front line or "sharp end" of an organization,
to produce an accident
 objectives of (ICAM)investigations
• To establish all the relevant and material facts surrounding
  the event.
• To ensure the investigation is not restricted to the errors
  and violations of operational personnel. To identify
  underlying or latent causes of the event.
• To review the adequacy of existing controls and procedures.
To recommend corrective actions which when applied can:
• - reduce risk,
• - prevent recurrence;
• - and by default, improve operational efficiency.
• Detect developing trends that can be analyzed
  to identify specific or recurring problems.
• To ensure that it is not the purpose of the
  investigation to apportion blame or liability.
• Where a criminal act or an act of willful
  negligence is discovered, the information will
  be passed to the appropriate authority.
• To meet relevant statutory requirements for
  incident investigation and reporting.
Yes the Chart of Answers
The Risk Assessments are intended to
objectively identify hazards and to effectively
manage health, safety and environment related
risk, using a risk analysis technique to quantify
the degree of risk and to apply the appropriate
level of control to bring high levels of risk within
a level that is As Low as Reasonably Practical
ICAM vs. Risk Model
3W2H Example
Now look the ICAM
            ICAM drilled down

An incident is an unplanned event or chain of events that results in
losses such as fatalities or injuries, damage to assets, equipment,
the environment, business performance or company reputation. A
near miss is an event that could have potentially resulted in the
abovementioned losses, but the chain of events stopped in time to
prevent this. These incidents can be classified in all kinds of
severities and types, and thus into categories. Investigation and
cause analysis should take these different categories into
   Provides the ability to identify what
              went wrong
• communication
• training
• operating procedures
• incompatible goals
• change management
• organizational culture
• equipment
Through the analysis of this information, ICAM provides the ability to
identify what went wrong and to make recommendations on
necessary remedial actions to reduce risk and build error-tolerant
defences against future incidents. The ICAM process incorporates best
practice Human Factors and Risk Management principles.
       Your success depends on
Relevance and accuracy
»Speculation as to causes and contributing factors
»Including perceived deficiencies not strictly
related to the incident
»Apportioning blame
Qualify any conclusions and ensure they are placed
in context . Allows mitigation if it becomes
apparent at a later date that they were not correct
Find the Cause not the Incident

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Description: fall arrest fall arrest inspection body harness inspection field level risk assessment FLHA incidnet causation pipeline hm