We identify the root causes of incidents to help prevent them from recurring. In 2008, we began tracking high-potential incidents (HPIs) and in 2012 recognized the need to standardize our process for identifying their root causes and key contributing factors. In 2013, we evaluated three incident investigation methodologies and selected the Incident Cause Analysis Method (ICAM).
ICAM involves the identification of systemic health, safety or environmental deficiencies. It outlines an investigative process and a set of tools that consider, but also look beyond, human error and examine the contributing factors leading to incidents. It also enables the development of recommendations aimed at preventing incidents from reoccurring.
The objectives of ICAM are to:
- Establish the facts
- Identify root causes and key contributing factors
- Review the adequacy of existing controls and procedures
- Recommend corrective actions that can reduce risk and prevent reoccurrence
- Detect organizational factors that can be analyzed to identify specific or recurring problems
- Identify and report on key learnings
We have made a commitment to train over 950 personnel in ICAM investigation methodology. To date, we are 98% complete, with over 900 personnel trained in ICAM.