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00 Introduction

icam pocket guide

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48 views8 pages

00 Introduction

icam pocket guide

Uploaded by

govindaraj nr
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 8

SAFETY WISE

Pocket
Investigation
Guide
Issue 3, December 2007
INTRODUCTION 2

USING THIS GUIDELINE 3

OBJECTIVES 4

THE INVESTIGATION PROCESS 5

01 – IMMEDIATE • Mobilising to Site


ACTIONS • Emergency Response
page 7 • Risk Assessment
• Appointing the Team

02 – INVESTIGATION • Planning Meeting


PLANNING
page 13

03 – DATA COLLECTION • People


page 15 • Environment
• Equipment
• Procedures

04 – DATA • Event and Condition Charts


ORGANISATION • Incident Trees
page 31

05 – DATA ANALYSIS • Analysing the Findings


page 35 • Identify the Absent / Failed
Defences
• Identify the Individual / Team Actions

06 – RECOMMEND • Recommendations for Corrective Actions


AND REPORT • Hierarchy of Controls
page 73 • Impact and Potential Benefit
Assessment

POCKET INVESTIGATION GUIDE


Contents

• Securing the Site • What to Look For 01


• Team Safety • Investigator’s Toolkit
• Site Inspection
• Authorisation to Enter the Site

02

• Organisation • Witness Interviewing 03


• Additional Data Sources Techniques
• Data Preservation

04

• Identify the Task / • Validate the Organisational 05


Environmental Conditions Factor Types
• Identify the Organisational • Coding of ICAM Elements
Factors • Sample ICAM Chart

• Sample Impact and Potential • Concluding the Investigation 06


Benefit Assessment • Report the Findings
• Payoff Matrix • Lessons Learnt: Significant
• Sample Payoff Matrix Incident Flash Report

POCKET INVESTIGATION GUIDE


1
Introduction

This booklet has been prepared to provide guidance for personnel


empowered to complete incident or near miss investigations. It
outlines an investigation process (and tools) that looks beyond the
errors and violations of individuals and examines the contributing
factors leading to these occurrences.
The Incident Cause Analysis Method (ICAM) enables identification
of systemic health, safety or environmental deficiencies, assists
investigation teams to identify what really went wrong and ensures
recommendations are focused on what needs to be done to
prevent recurrence. It is directed towards building ‘error-tolerant’
defences against future incidents.

2 POCKET INVESTIGATION GUIDE


Using this Guideline

Overview
This guideline defines the ICAM methodology for the investigation
of accidents and incidents.
The information in this document is arranged in 6 steps that guide
the user sequentially through an investigation.
Similarly, the document is used in conjunction with the Incident
Investigation Reference Guide and ICAM Support CD, which
contain further information on the 6 investigation steps. The Incident
Investigation Reference Guide and CD have been prepared to
provide resource material and specific guidance for personnel
required to conduct formal investigations. Many of the tools in the
Guide include checklists and templates and are intended to be
used as worksheets during the investigation. References to the
tools can be found throughout this guideline.

Supporting Documents
• Incident Investigation Reference Guide
• ICAM Support CD

POCKET INVESTIGATION GUIDE


3
Objectives
The objectives of an incident investigation using this process are to:
• Establish the facts.
• Identify contributing factors and latent hazards.
• Review the adequacy of existing controls and procedures.
• Report the findings.
• Recommend corrective actions which can reduce risk and
prevent recurrence.
• Detect organisational factors that can be analysed to identify
specific or recurring problems.
• Identify key learnings for distribution.

Note: It is not the purpose of an ICAM investigation to


apportion blame or liability

4 POCKET INVESTIGATION GUIDE


The Investigation Process
What is an investigation, what do we want from it?

Step Determination Process Tools


1 “What happened” Data collection PEEPO

2 “Why it happened” Collected data ICAM


analysis

3 “What are we going Develop Hierarchy of control


to do about it?” recommendations Benefit assessment
4 “What did we learn Key learnings Incident Report
that we can share?” Toolbox briefings

The investigation of an incident or near miss should begin as soon


as practicable after the event. In this way, the investigator is most
likely to be able to observe the conditions as they were at the time,
prevent disturbance of evidence, identify witnesses and secure
the scene.

POCKET INVESTIGATION GUIDE


5
6
S2 Investigation Planning S1 Immediate Actions

Establish Implement
Obtain Initial Set Terms of Develop
Investigation Document
Briefing Reference Action Plan
Centre Control

S3 Data Collection

Conduct Site
Inspection Gather Data
• People
• Environment Preserve Data
• Equipment
• Procedures
Conduct
• Organisation
Interviews
All data
No recovered from
incident scene
Obtain Gather
Documents & Photographic Release site to
Statements Evidence responsible Yes
manager

POCKET INVESTIGATION GUIDE

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