The Diversity of the ICAM Incident Investigation Model
Introduction
The Incident, Cause, Analysis Method (ICAM) Incident Investigation model is the most diverse model any safety specialist will ever use when undertaking an investigation in the workplace. In the past, incident investigators have tended to focus on intentional or unintentional acts of human error – those things that people did or didn’t do – that led to an incident or accident (the “person model”). While this approach provides a superficial explanation of the incident, it does not consider the underlying factors that contributed to the actions, or the context in which they occurred. Considering only the transparent ‘active’ failures and unsafe acts, rather than identifying those potential causes or ‘latent conditions’ lying dormant within the system, limits the potential of an investigation to prevent the same event from recurring.
ICAM is a holistic systemic safety investigation analysis method. It aims to identify both local factors and failures within the broader organisation and productive system that contributed to the incident, such as communication, training, operating procedures, incompatible goals, change management, organisational culture and equipment. Through the analysis of this information, ICAM provides the ability to identify what really 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.
Case Study
The following case study is based on actual events; however names, locations and other identifying details have been changed. Some photos are actual incident photos whereas others are from subsequent re-enactments.
On the 17th March, 2015 contractors were assigned a task to install a new exclusion fence and vehicle gate on a track where it crosses a road.
As part of this task, the existing, deteriorated fence posts (x2) and gate were required to be removed.
On arrival at the site, the crew undertook a pre-start meeting and reviewed the Safe Work Method Statement (SWMS).
During this meeting, a number of options were considered on how best to remove the existing 2 posts. The crew decided the best method would be to use a Snatch Strap being pulled by the company vehicle.
A Spotter was positioned approximately 20 metres up from the vehicle to observe the post removal (see photo below).
The snatch strap was attached to the rear tow bar and the first post was successfully removed using this method, however upon trying to remove the second post, they found it would not budge.
In another attempt to remove the post, the driver applied more power resulting in the post breaking at ground level, catapulting towards the car, first impacting the rear roll bar and then striking the roof, shattering the windscreen, then impacting the bonnet/hood before coming to rest on the ground in front of the car.
It was determined that the Actual Consequence was “Minor” with equipment damage estimated to be about $7000.
The Potential Consequence was determined to be “Significant” with an MTI to the driver of the vehicle.
Analysis Overview
The increased power to extract the post resulted in the post breaking at ground level and the stored energy in the 10 metre snatch strap catapulted the post into the air impacting with the vehicle
Using the ICAM methodology, it was determined that the following contributed to the incident:
Failed Defences-
SWMS was generic and only detailed work method for manual handling or using an excavator
Daily Pre-start did not identify the potential for the post to become airborne and strike the vehicle
Daily Pre-start did not identify and risk assess post extraction methods
Absent Defences-
A damper was not used on the snatch strap
Team/Individual Actions-
Crew believed the post would hit the towbar and did not identify the potential of the post hitting the roof of the vehicle
Crew opted to use a snatch strap method to extract the post rather than use chains
Crew decided to leave the trailer attached to the vehicle during the extraction of the post
Task/Environmental Conditions-
The hard dry ground provided resistance to post extraction
The low coefficient of friction on the gravel road provided reduced traction
The sloping ground influenced the decision to leave the trailer attached
The vehicle had the trailer attached and was towing uphill, this may have masked the force being applied to extract the post
There is a difference in the resistance of pine posts vs redgum posts
The poor condition of the posts influenced the decision to use the snatch strap
The crew were unaware of the depth of the post in the ground
There was a misperception that chains are more hazardous due to recoil if they break
Belief that snatch straps grip the post better than chains influenced the decision
The ease of extraction of the first post re-enforced the decision to use the snatch strap
The length and elasticity of the snatch strap stores considerable potential energy
Snatch straps require momentum to be effective
Organisational Factors-
Risk Management (RM) Extraction methodologies have not been specified or detailed
Training (TR) There is no training on extraction methodologies and equipment selection and usage
Training (TR) Not all staff were trained on using winch ropes when they were introduced
Management Systems (MS) Risks identified during Daily Pre-starts are not always captured and included in SWMS revisions
Risk Management (RM) Insufficient on-site training and mentoring on HIRAC
Recommended Corrective Actions
Revise SWMS 020 & 029 to specify and detail extraction methods, equipment to be used and develop a rollout plan
Risk assess extraction methodologies for anticipated extraction and recovery operations
Develop a training syllabus and identify training providers for extraction and recovery operations
Develop a plan for on-site Daily Pre-start mentoring and set KPI’s to monitor effectiveness
Develop a process to capture risks identified in daily Pre-starts and include in the revision on SWMS
Key Learnings
The experience in the crew identified the potential for serious injury and put effective controls in place to prevent it with the spotter positioned a safe distance away. There is however an over reliance on experience and undocumented risk assessments
A formal management of change process is crucial to ensure that there is a systematic assessment of change to operations, processes, equipment, services and personnel for potential risk and the application of appropriate action to ensure existing performance levels are not compromised. These changes have to be effectively communicated to all stakeholders
Conclusion
As can be seen with this case study, this incident was relatively straight forward to investigate.
Due to its scalability, the ICAM methodology 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
ABOUT THE AUTHOR- Rocco Meraglia (Investigator/Trainer)
Based in Seattle, WA, Rocco Meraglia, has over 27 years' experience in OHS and risk management. He has degrees in Business Administration, an Associated Degree in Occupational Health and Safety and Risk Management, as well as CRSP Canadian Registered Safety Professional.
Rocco has worked on some of the largest projects in the world, including Ground Zero as the Hazardous Waste Removal Coordinator, Katrina Relief efforts, Mega Mining Construction Projects (Ekati Diamond Mine, Diavik Diamond Mine, Snap Lake Diamond Mine, Panama's Mina de Cobre, Ambatovy Nickel-Madagascar, Baro Alto Project, Numerous Oil/Gas & Power projects, Albiansands, Petro-Canada RCP and Suncor as the field and corporate HSSE Director and as Corporate Director for multiple mining and EPCM organizations.
Rocco has presented at international conferences on the topics of Leadership, Team Work, HSE, Wellness Programs, and Hazard Analysis & Emergency Preparedness. IN addition, Rocco is a qualified NFPA (1001, 1003, 1081, E3) Instructor, approved OSHA, MSHA & Mine Rescue Instructor and has vast field safety and project execution experience.
