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

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

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

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

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.

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

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

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.

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.

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

Enter Lessons Learned here