ICAM Incident Investigation Template Checklist

• Audit Title

• Project No. & Name

• Date & Time of incident

  Date

• Conducted on

  Date

• Prepared by

• Location
  Address

Incident Summary

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

Items

• Item detail

• Photo evidence

  Media

Timeline

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

Activity

• Date & Time

  Date

• Activity

• 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

• 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.

Defence

• Absent or Failed?

  Task

  Environmental

• Organisational factor type

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

  • 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.

Actions

• Individual or Team?

  Team

  Individual

• Organisational factor type

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

  • 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.

Conditions

• Task or Environmental

  Task

  Environmental

• Organisational factor type

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

  • 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.

Factor

• Organisational factor type

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

  • 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

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

• CAR detail

Key Learnings

• Enter Lessons Learned here

Lesson

• Lesson Learned

Sign off

• Full name and signature of ICAM report author

  Sign