Thanks to Peter Bateman for the great write up in this week's edition of Safeguard Update Subscriber Newsletter.
Rethinking ICAM
"Think about it in your organisation – where is it that you are relying on a person to do something 100 percent right, 100 percent of the time?"
Australian incident investigation specialist Georgina Poole, speaking at an Auckland NZISM branch meeting, said this is the key message she wanted people to take away.
She outlined her journey from using ICAM as an investigation tool to using a modified form incorporating elements from the HOP approach. ICAM, she said, was developed by BHP in the 1990s – with assistance from James Reason – to provide a consistent investigation framework. Previously, BHP's investigations were inconsistent and tended to focus on who did what and who was to blame. "They were going nowhere." Thirty years on, however, Poole said ICAM's limitations are apparent, including having many categories and boxes into which every situation has to fit. "Find a box and make it fit."
Work, she said, is a messier story than the Swiss cheese model allows for. "All the holes don't need to line up for things to fail. And if you try to apply ICAM to psychosocial risk you'll be there forever."
Another common issue is that people still misunderstand the purpose of an incident investigation, which she emphasised is to learn from an event. "If I ever see an introduction to an investigation report that says the purpose is to prevent something bad from happening, I will vomit into a bucket."
These days Poole is on board with HOP's learning teams, where she brings together the people involved in an event, some of their fellow workers, and an HSR if appropriate. It is, she said, often the only opportunity they have to share "some of the stuff sitting on their shoulders".
"Please be prepared for the amount of information you will be given!"
She asks them what a good day looks like and what is the worst thing that could happen. "If you went home and said you'd had a shitty day, what would you tell them?" The aim is to identify the good, the bad and the ugly, where the ugly is "unmitigated exposure to risk".
Workers will always deviate, she said, so some drift away from procedures is to be expected, provided it is within tighter margins around critical risks. "It is part of human nature to breach a procedure."
Hence her observation about how unrealistic it is to expect someone to do something 100 percent right 100 percent of the time.
"I'm not saying HOP or Safety Differently is better. It's just different."
