ICAM Incident Investigation Template Checklist

Incident Details

Incident Summary

Collect information and evidence of the incident and report your findings here.

Item detail

Photo evidence

Timeline

List the activities and events leading up to the time of the incident, when the incident happened and what took place afterwards.

Date & Time

Activity

Analysis Overview

The basic cause of an incident is the mechanism of failure.

What happened?

The ICAM model analyses the contributing factors to determine why the incident happened.

Why did the incident happen?

Actual Consequences

Potential Consequences

ICAM Analysis

The contributing factors of this incident were analyzed using the Incident Cause Analysis Method (ICAM) process, an industrial safety initiative used to analyze serious incidents. ICAM is an analysis tool that sorts the findings of an investigation into a structural framework.

An ICAM analysis clarifies why the incident happened and identifies all the factors that contribute to the event. The contributing factors are classified into four categories of the ICAM model which are: Absent or Failed Defences; Individual or Team Actions; Task or Environmental Conditions; Organisational Factors.

Absent or Failed Defences

The situations, systems, conditions, equipment, measures or human factors which normally prevent this type of incident from happening.

Absent or Failed?

Organisational factor type

Hardware
Training
Organisation
Communication
Incompatible goals
Procedures
Maintenance management
Design
Risk management
Management if change
Contractor management
Organisational culture
Vehicle management
Management systems

Details of defence

Individual or Team Actions

The errors or violations made by people directly involved in the event.

Individual or Team?

Organisational factor type

Hardware
Training
Organisation
Communication
Incompatible goals
Procedures
Maintenance management
Design
Risk management
Management if change
Contractor management
Organisational culture
Vehicle management
Management systems

Details of Action

Task or Environment Conditions

The "situational characteristics" which existed immediately prior to the incident, including the work situation, physical or social environment, or a person's mental, physical or emotional state.

Task or Environmental

Organisational factor type

Hardware
Training
Organisation
Communication
Incompatible goals
Procedures
Maintenance management
Design
Risk management
Management if change
Contractor management
Organisational culture
Vehicle management
Management systems

Details of Condition

Organisational Factors

The latent system based factors present before the incident which may have contributed to the presence of specific adverse task or environmental conditions, individual or team actions, or absent or failed defences.

Organisational factor type

Hardware
Training
Organisation
Communication
Incompatible goals
Procedures
Maintenance management
Design
Risk management
Management if change
Contractor management
Organisational culture
Vehicle management
Management systems

Details of Factor

Conclusion

Recommended Corrective Actions

What are we going to do about the incident?
Use the Hierarchy of Control recommendations for corrective actions that will target prevention of recurrence and reduction of risk.
The recommendations will address each identified absent or failed defence (risk controls) and Organisational factor (prevention and risk reduction strategies).

Enter recommended corrective actions here

CAR detail

Key Learnings

Enter Lessons Learned here

Lesson Learned

Sign off

Full name and signature of ICAM report author

ICAM Incident Investigation Template Checklist

Created by: SafetyCulture Staff | Industry: Mining | Downloads: 131

This Incident Cause Analysis Method (ICAM) Investigation Report Checklist is used to assist in the investigation of incidents, accidents and near misses in the field.

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Incident Details

Incident Summary

Collect information and evidence of the incident and report your findings here.

Item detail

Photo evidence

Timeline

List the activities and events leading up to the time of the incident, when the incident happened and what took place afterwards.

Date & Time

Activity

Analysis Overview

The basic cause of an incident is the mechanism of failure.

What happened?

The ICAM model analyses the contributing factors to determine why the incident happened.

Why did the incident happen?

Actual Consequences

Potential Consequences

ICAM Analysis

Absent or Failed Defences

The situations, systems, conditions, equipment, measures or human factors which normally prevent this type of incident from happening.

Absent or Failed?

Organisational factor type

Hardware
Training
Organisation
Communication
Incompatible goals
Procedures
Maintenance management
Design
Risk management
Management if change
Contractor management
Organisational culture
Vehicle management
Management systems

Details of defence

Individual or Team Actions

The errors or violations made by people directly involved in the event.

Individual or Team?

Organisational factor type

Hardware
Training
Organisation
Communication
Incompatible goals
Procedures
Maintenance management
Design
Risk management
Management if change
Contractor management
Organisational culture
Vehicle management
Management systems

Details of Action

Task or Environment Conditions

The "situational characteristics" which existed immediately prior to the incident, including the work situation, physical or social environment, or a person's mental, physical or emotional state.

Task or Environmental

Organisational factor type