Safe workplace, safe systems, safe people
Maintain a safe and healthy workplace
Safe auditing, safe training, safety consulting
 
INCIDENT INVESTIGATIONS

ICAM stands for Incident Causation Analysis Methodology.

The process is for companies that are serious about the safety of its employees, finding root cause of incidents and having a process to put preventive measures into place to prevent their reoccurrence. It allows us to identify factors and failures within any organisation that contributed to the incident, such as communication, training, operating procedures, unseen pressures, organisational culture and equipment design. Through the analysis of this information, it enables the ability to identify what really went wrong. Our facilitators using this methodology can make recommendations to reduce risk, it also identifies where we need to build in a tolerance for errors. ICAM has been recognised world wide including Australia, Canada, Chile, Indonesia, Pakistan, Papua New Guinea, Peru, and South Africa.It has been used in the investigation of incidents and accidents in the aviation, rail, road, mining, and petroleum industries.

ICAM draws on the work of the eminent organisational psychologist and human error expert Professor James Reason (University of Manchester, UK) and incorporates best practice Human Factors and Risk Management principles.

 
Case Histories
ICAMs that our consultants have facilitated and carried out.

Case #1
Large Steel making Operation.

Equipment failure 8 hours downtime - lost Production

Potential for:-
- Significant Plant damage
- Many days lost production.
- Additional hazards creating potential for injury.

The investigation team using the ICAM process identified the root cause of the incident and why the equipment failed.

Recommendations were made to prevent reoccurrence, with responsible persons identified to carry out the fix, by agreed deadlines.

Recommendations

  • Develop Standard Operating Procedure for managing and repair of critical equipment:
    - Removal and replace
    - Rotation strategy for spares
    - Equipment planned maintenance
    - Equipment repair standard
  • Tracking maintenance critical equipment.
  • Develop emergency procedure
  • Train Operators in use of alarm systems
  • Stores department to review the standard for storage of critical equipment.
  • Purchase critical spares.
  • Investigate the use of remote equipment to detect deterioration thinning of the pipe work walls. (x-ray, ultra sonic etc.)
  • Source local manufactures for bowl replacement

As well as recommendations the ICAM also identified vulnerabilities in the overall system. Further recommendations were developed to build in a tolerance for error.

Case #2
Serious Harm Injury
Heavy Machine Driver Head Injury.

High potential for more severe injury.

Carrying out unusual operation with heavy machinery.

Operator Error or Organisational Factor?

Due to injuries received the investigation team where unable to determine the exact cause of the incident. However using the ICAM process operating and safety procedures where interrogated, gaps in the system were found. Recommendations were made to prevent the reoccurrence of the incident.

  • Update SOP to reflect the actual operation.
  • Reposition location and placement of radios and other equipment in cab.
  • Check seatbelt design what is new on the market.
  • Communicate on injury management procedure to all employees.
  • Company review management and care of injured parties.
  • Design of operating area to be reviewed WRT size and lighting. Review pecking of bowls possibilities after hours Who: PS
  • Investigate elimination of hazardous part of the task.
  • Communicate to company workforce the incident, and the importance of reporting Near Miss Incidents

Case #3
Plant Damage and High Potential Near Miss
20 Tonne Lifter dropped from Overhead Crane.

Extensive Plant damage when lifter dropped from Crane
Potential for Fatality.

The investigation team consisted of various levels in the organisation and skills ranging from operators, crane drivers to specialised engineers, with a common goal to find the root cause and the prevent reoccurrence of the incident.
The ICAM process using the array of skills of the team was able to design out the weakness in the attachment connection. Also recommend other operating and procedural changes to increase the safety within the operating area.

  • Redesign lifter attachment remove ability for lifter to self detach.
  • Audit all other attachments, redesign as necessary.
  • Update training records and SOP's after modifications have been made.
  • Audit training is per the new standard.
  • Review current training methods including assessment methods.
  • Conduct interview with crane trainer.
  • Repair clamp closed indicator light.
  • Institute integrity of operation of indicator light into operator's checks.

Key Learnings to be shared with other plants, company sites, and industry crane association.

Case #4
Plant Damage, Lost Production and High Potential Near Miss Incident 3.3KV Switchgear Explosion

Increase recommend other evaluate other were able to identify allowed the
High potential for more severe injury
Company assisted or totally independent we will investigate and make recommendations to assist improve your business performance.