ICAM Investigation Guideline

Issue 3 September 2005 Guideline Number G44

Incident

Method ICAM Cause

Analysis

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 ICAM INVESTIGATION GUIDELINE

Copyright BHP Billiton Limited 2005

This publication is copyright. Apart from fair dealing as permitted under the
Copyright Act, no reproduction may occur without the prior written consent of
the copyright owner.

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CONTENTS
PURPOSE ............................................................................................................4
SCOPE ................................................................................................................4
USING THE GUIDELINE ........................................................................................5
OBJECTIVES ........................................................................................................6
THE 7-STEP INVESTIGATION PROCESS ..................................................................7
STEP 1: IMMEDIATE ACTIONS ...................................................................9
Emergency response and securing the site
Appointing the team
Mobilising to site
STEP 2: INVESTIGATION PLANNING ......................................................... 10
Overview by management
Authorisation to enter the site
Site visit
Planning meeting
STEP 3: DATA COLLECTION ...................................................................... 13
Data categories
STEP 4: DATA ORGANISATION ................................................................. 21
Requirements for data organising
Timeline Chart and the 5 Whys Process
STEP 5: ICAM ANALYSIS ..........................................................................26
Constructing an ICAM Chart
Step 5.1 Classify the contributing factors
and underlying causes
Step 5.2 Transferring contributing factors
and underlying causes to the ICAM Chart
Step 5.3 Validate the organisational factors
against the incident
STEP 6: PREVENTIVE AND CORRECTIVE ACTIONS ....................................55
Developing recommendations
Hierarchy of controls
Payoff Matrix
CONCLUDING THE INVESTIGATION - Steps 1 - 6........................................59
STEP 7: REPORT THE FINDINGS ...............................................................60
Minimum report requirements
Bow Tie analysis
Lessons learnt
DEFINITIONS .....................................................................................................63

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 ICAM INVESTIGATION GUIDELINE

PURPOSE
This guideline has been prepared to provide advice in
completing incident investigations for Health, Safety,
Environment and Community (HSEC) incidents. It
outlines the BHP Billiton investigation process that
examines the causes and contributing factors leading to
these events.

The Incident Cause Analysis Method (ICAM) enables

identification of any HSEC deficiencies. It provides
a process to identify what led to the event so that
effective corrective and preventive actions can be
implemented to prevent reoccurrence.

SCOPE
It is a requirement that an ICAM investigation and
report be completed following all actual and potential
significant HSEC incidents for all BHP Billiton controlled
sites and activities. However with potential incidents
the responsible line manager can determine the
formality of the investigation ensuring it is consistent
with the HSEC Reporting Manual requirements. In all
cases the findings of the ICAM shall be included in the
report.

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USING THIS GUIDELINE
The information in this guideline is arranged in seven
steps that guide the user through an investigation.

This guideline is used in conjunction with a series of

toolkits to support the investigation process. These
toolkits provide further information on the seven steps
as well as check sheets and forms to be used by the
investigation team. The toolkits are referenced within
the relevant sections of this guideline.
The guideline and toolkits are available electronically on
the BHP Billiton intranet site:
http://hsec.bhpbilliton.net/Bb/safety/icam.asp

Documents referred to in this guideline are:

• BHP Billiton HSEC Management Standards

• BHP Billiton HSEC Reporting Manual
• Fatal Risk Control Protocols
• HSEC Toolkits 28 - 34
• Significant Incident Report

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 ICAM INVESTIGATION GUIDELINE

OBJECTIVES
The objectives of incident investigations using this
guideline are to:

• Establish the facts surrounding the event

• Identify contributing factors and underlying
causes
• Review the adequacy of existing controls and
procedures
• Recommend preventive and corrective actions
• Report the findings in order to share key
learnings
• Not apportion blame or liability

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THE 7-STEP INVESTIGATION PROCESS

1. 2.
Immediate Investigation Supporting
Actions Planning
Documentation

4. 3. Toolkits
Data Data 28 - 34
Organisation Collection

5. 6. 7.
ICAM Preventive Report the
Analysis and Corrective Findings
Actions
Figure 1

The investigation of an incident shall begin as soon as

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

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 MINICAM
INCIDENT
ICAM INVESTIGATION
INVESTIGATION
GUIDELINE
GUIDELINE
GUIDE

Investigation flowchart

The diagram illustrates how the steps contribute towards achieving the desired
outcome to prevent a repeat or similar incident in the future.

1. Immediate Actions
ELAPSED TIME OF INCIDENT INVESTIGATION

2. Investigation Planning

Data Collection

3. Data Collection

4. Data Organisation Timeline Chart

and 5 Whys Process

5. ICAM Analysis ICAM

Chart

Contributing
Factors
6. Preventive and
and
Corrective Actions Underlying
Causes PAYOFF
MATRIX
7. Report the Findings

PRIORITISED PREVENTIVE
AND CORRECTIVE ACTIONS

Figure 2
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pg8
STEP 1: IMMEDIATE ACTIONS
Emergency response and securing the site

Following an incident it is the responsibility of the

supervisor, senior person present, or emergency
response group coordinator to ensure appropriate first
aid and/or emergency response is provided and the
site is secured. Before proceeding ensure the hazards
have been dealt with in accordance with the hierarchy
of controls (shown on page 56). HSEC Toolkit 28
– Immediate Actions provides a summary of post-
incident immediate actions.

Appointing the team

The responsible line manager shall coordinate the

investigation team (leader and members) activities
in accordance with the requirements of the HSEC
Reporting Manual. The line manager shall ensure that
he or she obtain advice on matters of legal privilege.

The investigation team is responsible for following site

practices and procedures and ensuring their individual
and team safety, whilst overall responsibility for safety
remains with line management. Team members must
exercise care when conducting the investigation and
follow all established procedures and warning signs
designed to protect the health and safety of site
personnel and the environment. Enthusiasm for the task
of investigating should not override HSEC practices.
Specifics on team make-up, qualities, roles and
responsibilities are shown in the HSEC Toolkit 28.

Mobilising to site

Investigators shall arrive at the incident site well

prepared and as soon as practicable after the incident.
HSEC Toolkit 28 provides a checklist of the equipment
requirements for investigation.
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 ICAM INVESTIGATION GUIDELINE

STEP 2: INVESTIGATION PLANNING

Overview by management
When the investigation team is assembled at the
site the team leader shall schedule a meeting of the
investigation team and arrange for a presentation
from the site management. The presentation by site
management is not to be used to draw preliminary
conclusions. The meeting facilitator (normally the
team leader) must ensure that the presentation is used
to brief the investigation team on:

• An overview of operations
• The known sequence of events
• The site management should hand over to the
investigation team any photographs, data
collected or pertinent facts

Authorisation to enter the site

Prior to the site inspection approval must be received

from line management to enter the incident site.

An incident site must not be disturbed without prior

approval from appropriate authorities such as the
coroner, inspectorate or police as per local legislation.

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Site visits

The initial site visit is to familiarise the investigation

team with the incident site. A familiarisation with the
incident site can be beneficial in fully understanding
the overview by management and in the planning
meeting stage.

Planning meeting – refer to HSEC Toolkit 29 –

Investigation Planning

Depending on the scope of the investigation, there

may be a need to establish Terms of Reference for the
investigation team to ensure:

• The purpose of the investigation is clear

• The requirements of all stakeholders
(inspectorate, worker, legal representation,
business or corporate) are considered
• The requirements for legal privilege and
confidentiality are considered
• The investigation boundaries are determined
• Expected date for completion of interim and final
reports are agreed
• Establishment of investigation centre and
resources:
o secure meeting and interview rooms
o access to computers, phones, facsimile
o administrative support
o identify and mobilise specialist support

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 ICAM INVESTIGATION GUIDELINE

Issues to be considered/decided at the initial planning

meeting shall include as a minimum:

• Identification of personnel to be interviewed

• Adequate document control and management
procedures are in place to document the
investigation
• Development of an Investigation Action Plan.
Once the Terms of Reference have been
established an appropriate action plan for the
investigation should be developed

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STEP 3: DATA COLLECTION
Data categories – refer to HSEC Toolkit 30 – Data
Collection

During the data collection phase of the investigation

the team shall gather relevant facts to understand the
incident and the events which led to the incident. The
collection of the data is divided into five areas:

• People
• Environment
• Equipment
• Procedures and Documents
• Organisation

For each of these five data categories the team should

identify all conditions, actions or deficiencies, which
may have been contributing factors to the incident.
Figure 3 shows examples of collection methods for the
data categories.

To ensure that all the facts are uncovered, ask the

following questions for each category:
Who? What? When? Where? Why? and How?
For most of these questions, an important follow-up
question is: If not, why not?
Ensure care is taken to preserve data as it is collected.
All gathered evidence should be logged and securely
preserved to allow for retrieval at a later date. This
could be a matter of years if the incident is the subject
of coronial inquiry.

Sample questions and further guidance on data

collection are available in HSEC Toolkit 30.

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 ICAM INVESTIGATION GUIDELINE

A summary of Data Categories and Collection Method

Data Category Collection Method

People Interview
Witnesses
P Relevant people
Written Witness Form
Observation
involved

Environment Observation/Review
Weather Inspection/
E Workplace Photography
Incident Scene Re-enactment*

Equipment Inspection
E Vehicles, plant, tools, Testing
infrastructure etc. Operation

Procedures and
Documents
Existing maps, charts,
P documents, reports,
Review/Comparison
procedures, JSA/JHA,
photographs etc.
Organisation
Anything that pertains
O to the BHP Billiton Review/Comparison
HSEC Management
Standards

Figure 3
*Caution: If it is necessary to re-enact the incident,
be sure that the team does not generate another incident.

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DATA CATEGORY: PEOPLE

The purpose of an incident investigation interview is to

obtain a picture of what happened.
Where legal action may result from the incident, the
relevant BHP Billiton lawyer should be consulted prior to
commencing interviews.

• Identify all people who might have information

and obtain statements as soon as possible
• Conduct interviews individually and revisit the
scene as required
• Ask the witness to explain:
o the sequence of events, their observations and
actions
o existing or desirable risk controls for the task
o any similar previous incidents or near misses
o experience of those involved
o what training those involved received
o any physical limitations or health issues
o any stress or time pressures

Reassure the interviewee that the investigation is

being conducted to prevent recurrence and not to
apportion blame.
Continue to ask questions and investigate the site until
all the facts and information have been identified.
Statements by witnesses can usually be better
understood and verified on site. Witnesses should be
available to the investigation team for clarification.

Further guidance on interview techniques are provided

in the HSEC Toolkit 30 – Data Collection.

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 ICAM INVESTIGATION GUIDELINE

DATA CATEGORY: ENVIRONMENT

Examine the scene of the incident and consider any

impact the local environmental conditions may have had
on the task being conducted.

The physical environment, especially sudden changes to

that environment, is a factor that needs to be identified.
The situation at the time of the incident is important,
not what the “usual” conditions were. For example,
incident investigators may want to know:

• What were the weather conditions?

• What time of day was the incident/
investigation?
• Were any housekeeping issues involved?
• What were the workplace conditions?
• What surrounding noises were present?
• What were the light conditions?
• Were toxic or hazardous gases, dusts, or fumes
present?
• Are samples of air, surface water, ground water,
flora, fauna, soil or sediment required? (this
may be important to determine the level of
potential environmental impact)

Photography is one of the most useful tools to the

investigation team. It can document the situation
as it exists now, or the situation as it changes due to
movement or disassembly. Before anything is moved,
ensure that plenty of photographs are taken, both of
the general area and specific items. Ensure photos
include a scale ie. a pen, ruler etc. Refer to HSEC
Toolkit 30 – Data Collection.

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DATA CATEGORY: EQUIPMENT

Examine the equipment or plant involved in the

incident. Pay particular attention to the condition of
equipment, anything that may have changed or be out
of the ordinary e.g. abnormal stress, modifications,
substitutions, distortions, fractures etc. Identify
any design flaws, construction flaws, mismatched
components or confusing labelling or marking. Ensure
the equipment was appropriate for the task being
conducted.

To seek out possible causes resulting from the

equipment and materials used, investigators might ask:

• How did the equipment function?

• If hazardous substances were involved, what
characteristics did they have? Were any
alternative substances available?
• What was the state of the raw material?
• What personal protective equipment (PPE) was
being used? Was it appropriate? Was it worn
correctly?
• How did the safety devices work?

In addition, the following should be considered:

• Operating manuals/procedures
• Maintenance programs/records
• Condition monitoring
• Operating history
• Modifications/changes to equipment design,
settings and functionality

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 ICAM INVESTIGATION GUIDELINE

DATA CATEGORY: PROCEDURES AND

DOCUMENTS

Review the task that was being conducted. Examine

the work procedures and the scheduling of the work
to ascertain whether they contributed to the incident.
Examine the availability, suitability, use and supervisory
requirements of standard operating procedures or work
instructions. The actual work procedure being used at
the time of the incident must be explored. Members of
the incident investigation team will look for answers to
questions such as:

• Was the correct procedure available/known?

Was the procedure used? Was the correct revision
used?
• Was a Job Safety Analysis conducted as part of
the planning prior to the task?
• How were hazards and risks assessed?
• Had conditions changed that would have affected
the way the normal procedure worked?
• Were the appropriate tools and materials
available? If so, were they used?
• How did the safety devices work?
• What lockout or isolation procedures were used?
• Were the applicable Fatal Risk Control Protocols
complied with?

Pre-Incident photographs - If available, these

photographs may be compared with post-incident
photographs to help explain the incident. Staged
photographs of the incident may be taken at a later
time if they will help clarify the final report.

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Drawings and Sketches - These may be used in addition
to photographs and can be especially useful when it
is necessary to illustrate movements e.g. personnel
location or vehicle movements before and during an
incident. Record distances, directions, dimensions and
other relevant factors.

Maps - These show the relative locations of buildings

and events. Maps should be used for plotting the
location of personnel who are injured or have become
ill as a result of a hazardous material release. This
empirical “time and place” information is also useful
for planning adequate evacuation distances in future
emergencies.

Other Documents - A review of documents may also

uncover contributing factors and should include:

• Applicable regulations and other legal

requirements
• Training, medical and work history records
• Applicable procedures, work instructions,
equipment manuals and maintenance records
• Incident reports, audit reports and inspection
reports
• Material safety data sheets (MSDS)
• Organisational policies and procedures
• Diagrams and process flow charts
• Permit to work
• Work order
• Original equipment manufacturer (OEM) manuals
and procedures

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 ICAM INVESTIGATION GUIDELINE

DATA CATEGORY: ORGANISATION

Management holds the legal responsibility for the

safety of the workplace and the workforce. The role
of supervisors and management must always be
considered in an incident investigation. Answers to any
of the preceding types of questions logically lead to
further questions such as:

• What applicable safety rules were communicated

to employees? When?
• Were written procedures available? If so, how
were they enforced?
• What supervision was in place?
• What training was given in "how to do the
work"? When was it given? Is it still current?
• How were hazards identified and what
procedures had been developed to overcome
them?
• How were unsafe conditions corrected?
• Was regular maintenance of equipment carried
out?
• Were regular safety inspections carried out?
• Were there any changes to equipment,
environment, people or procedures?
• Is any data from behavioral observations
involving the activity available?
• Have there been similar incidents on site or in the
organisation?

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STEP 4: DATA ORGANISATION

Requirements for data organising

Once the data has been collected it is important that it

be correlated in preparation for ICAM analysis.

Several data organising techniques can be used to

assist with the correlation. The method/s used should
meet the following requirements:
• Provide a framework to organise the data
collected
• Assist in ensuring the investigation follows a
logical path
• Aid in the resolution of conflicting information
and the identification of missing data
• Provide a diagrammatical display of the
investigative process for management briefing

The methods recommended in this guideline are the

Timeline Chart and the 5 Whys process.

Timeline Chart and the 5 Whys process – refer to HSEC

Toolkit 31 – Data Organisation

Timeline Charts are simple to construct and are an

excellent means of depicting complex events in a
logical manner. Timeline Charts are ideally suited to
incidents that have a number of events occurring over
an extended period. Information obtained during the
data collection process is used to construct the chart
using a large sheet of paper, a whiteboard, or Post-it®
notes on the wall of a room.

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 ICAM INVESTIGATION GUIDELINE

Events affecting them are arranged on a timeline

progressing from left to right, as shown in figure 4 on
page 24. The resulting sequence of events organises the
data for further analysis.

When separate sequences of events converge to create

an incident, separate timelines are drawn on the
Timeline Chart, showing the interrelationship between
those events.

The sample Timeline Chart, figure 4 on page 24 shows

two sequences of events coming together to cause an
incident. Do not speculate on possible causes in case
it leads to inappropriate conclusions. Refer to HSEC
Toolkit 31.

The 5 Whys methodology uses a structured discussion

to identify contributing factors and underlying causes.
These are usually identified when 'Why?' can no longer
be answered. Preventive and corrective actions can
then be developed to eliminate or reduce the source of
the hazard.

Key events from the Timeline Chart are examined and

the 5 Whys methodology applied. The process is based
on factual information and the question of what caused
this to contribute to the incident is asked. Asking
'why?' must be applied at least twice to each event and
should be asked until the question cannot be answered.

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Develop the 5 Whys process chart and label the final
answer of each branch as ‘Y’ or ‘N’ where ‘Y’ indicates
that the item is a contributing factor and ‘N’ indicates
a non-contributing factor. Contributing factors are then
linked to the relevant ICAM Categories as discussed in
Step 5, page 26. Refer to HSEC Toolkit 31.

Underlying causes are contained within contributing

factors. Figure 4 shows examples of contributing factors
and underlying causes. In the example on page 24 and 25,
each box in the 5 Whys process is a potential contributing
factor and underlying cause.

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 ICAM INVESTIGATION GUIDELINE

Timeline Chart and the 5 Whys Process

Man leaves Exceeding Runs red light
restaurant late speed limit
Timeline

Child enters car Boy releases Car rolls into

parking brake intersection on
green light

Man ran red

light

Man unable to Defective

stop in time brakes

Man was speeding Poor Y

maintenance
10
Familiar with Man was Man was
roads and distracted running late
conditions
5 Whys

Used the route Talking on Extended

daily his mobile meal
phone

Normal route Routinely Drinks with

between home N friends during
did so
and work business hours

Company had Y Non-compliance with

Unaware of the
no rules about code of business
associated risk
mobile phone use conduct
10
Code not
No awareness Y communicated
Y
training
to employees
Figure 4 5 8
Application of the 5 Whys process: These charts are illustrative
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the theoretical incident.
 Cars collide Boy injured Police arrive

Uncontrolled
vehicle ran into Vehicle parked
intersection on hill

Child released
Outside of N
owners home
hand brake

Unintentional Child is in the vehicle

action unattended

Did not
understand the Vehicle left
consequence unlocked

Not trained or
experienced in
Routinely Y
left unlocked
operating vehicles

Too young N
to drive

Contributing Factors
Y = Within organisations control
N = Beyond organisations control

8 = Organisational Factors(page 34)

(BHP Billiton HSEC Management Standards)

only of the 5 Whys process and are not an exhaustive analysis of

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 ICAM INVESTIGATION GUIDELINE

STEP 5: ICAM ANALYSIS

At this point of the investigation the team will have
gathered and organised the initial findings. The next
stage is to transfer those findings to an ICAM Chart
(refer example page 52).

Construct an ICAM Chart – refer to HSEC Toolkit 32

– ICAM Analysis

Step 5.1 Classify the contributing factors and underlying

causes as identified by the Timeline Chart and 5 Whys
Process into the ICAM categories

Step 5.2 Transfer the contributing factors and

underlying causes into ICAM categories on the ICAM
Chart, as identified in Step 5.1 and show relationships
(page 52)

Step 5.3 Validate the organisational factors against the

incident (page 54)

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Step 5.1 Classify the contributing factors and underlying
causes

Extract each piece of factual information from the

investigation findings and classify it into one of the
following ICAM categories. Refer HSEC Toolkit 32
– ICAM Analysis.

• Absent/Failed Defences (page 30)

• Individual/Team Actions (page 32)
• Task/Environmental Conditions (page 33)
• Organisational Factors (aligned with the BHP Billiton HSEC
Management Standards) (page 34)
• Non-contributing Factors

Figure 5, on page 28 provides the list of contributing

factors and underlying causes that make up each of the
ICAM categories. When an incident occurs deficiencies
will exist in one or more of the factors.

The factors ensure consistent use of terminology to

allow broader analysis of incident findings. These
factors are used in First Priority enterprise (FPe) and
can be used in alternative similar systems. The chart in
figure 5 provides coding for each factor as listed in the
FPe system.

The following pages define each ICAM category and

provide a check question to be asked to ensure that the
information has been correctly classified.

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 ICAM INVESTIGATION GUIDELINE
ICAM Categories and Factors Chart
Organisational
Factors*
OS01: Leadership and
Accountability
OS02: Legal Requirements,
Commitments and
Document Control
OS03: Risk and Change
Management (including
FRCP failures)
OS04: Planning, Goals and
Targets
OS05: Awareness,
Competence and Behaviour
OS06: Health and Hygiene
OS07: Communication,
Consultation and
Participation
OS08: Business Conduct,
Human Rights and
Factors
Community Development
OS09: Design, Construction
and Commissioning
OS10: Operations and
Maintenance
OS11: Suppliers, Contractors
and Partners
OS12: Stewardship
OS13: Incident Reporting
and Investigation
OS14: Crisis and Emergency
Management
OS15: Monitoring, Audit and
Review
Figure 5
28
Task/WorkTask/Environmental
Environment
Factors Conditions
Workplace Factors
TW01: Task Planning/ Preparation/ Manning
TW02: Hazard Analysis/ Job Safety Analysis/ Take 5
TW03: Work Procedures - availability and
suitability
TW04: Permit to work - availability and suitability
TW05: Abnormal operational situation or condition
TW06: Tools/ equipment/ materials (condition/
availability/ suitability)
TW07: Equipment integrity
TW08: Housekeeping
TW09: Weather Conditions
TW10: Congestion/ restriction/ access
TW11: Routine/ non routine task
TW12: Fire and/or explosion hazard
TW13: Lighting
TW14: Temperature
TW15: Noise
TW16: Ventilation
TW17: Pressure
TW18: Gas dust or fumes
TW19: Radiation
TW20: Chemical
TW21: Training
TW22: Wildlife
TW23: Surface Gradient/ Conditions
Human Factors
HF01: Complacency/ motivation/ attitude
HF02: Drugs / Alcohol influence
HF03: Fatigue
HF04: Time/productivity pressures
HF05: Peer pressure/supervisory example
HF06: Physical/ mental capabilities
HF07: Physical/ mental stress
HF08: Personal issues
HF09: Distraction/pre-occupation
HF10: Competency/ Experience/ Skill for task
HF11: Poor/ inadequate communications
HF12: Tolerance of Violations
HF13: Change of routine
*Organisational Factors are aligned to the
 Individual/Team Absent/Failed
Outcomes
Actions Defences

IT01: Supervision DF01: Detection

IT02: Operating Systems
authority DF02: Protection
IT03: Operating speed Systems
IT04: Equipment use DF03: Warning
IT05: Personal Systems
Protective Equipment DF04: Guards or
use Barriers
IT06: Procedural DF05: Recovery
compliance
IT07: Change
management INCIDENT
IT08: Equipment/
materials handling DF06: Escape
IT09: Misconduct DF07: Rescue
IT10: Work method DF08: Safety Device
IT11: Occupational Operation
hygiene practices DF09: Personal
IT12: Hazard Protective Equipment
recognition/ DF10: Hazard
perception Identification
IT13: Risk DF11: Control Systems
management

The codes in front of

the factors are FPe
system codes.

BHP Billiton HSEC Management Standards

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 ICAM INVESTIGATION GUIDELINE

Identify the Absent/Failed Defences

These incidents result from inadequate or absent

defences that failed to detect and protect the system
against technical and human failures. These are
the last minute measures which did not prevent
the outcome of the incident or mitigate/reduce its
consequences.

Figure 6 – Hierarchy of Absent/Failed Defences, on the

following page shows successive layers of defence
where each defensive layer comes into operation on the
failure of its predecessor. As an example, where there
is a poor level of hazard awareness then there is more
reliance on detection as a defence and so on. Refer to
HSEC Toolkit 32.

Absent/Failed Defences can be manifested if there is

non-compliance with the requirements of the Fatal Risk
Control Protocols (FRCP) under the focus areas of plant
and equipment, procedural and people requirements.
These focus areas are covered in the Absent/Failed
Defence categories as listed on page 31.

Check question: Does the Absent or Failed Defence describe

the equipment, work process, control measure, detection
system, procedure or attribute which normally prevents this
incident or limits the consequences?

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Hierarchy of Absent/Failed Defences
Defence Defence
Definition
Category Example

Awareness To understand the nature and severity Induction Training,

of the hazardous conditions present Ongoing Training,
at the worksite. Awareness problems Communication,
can apply to those involved or those Risk Assessment,
supervising or managing processes. Competency,
Reporting

Detection To provide clear warning of both Signage,

the presence and the nature of a Warning Lights,
potentially hazardous condition. Traffic Warning
Sirens,
Gas Detectors,
Speed Sensors

Control and To restore the process to a safe state Procedures,

Interim with minimal injury or damage. Protocols,
Recovery Safety Switch,
By-pass Valves,
Emergency Shut
Down Systems,
Guards

Protection and To limit the adverse consequences of PPE,

Containment any unplanned release of mass, energy Fire Extinguishers,
or hazardous material. Spill Response Kits,
Bunded Areas

Escape and To evacuate all potential victims from Safe Access/Exit,

Rescue the location as quickly and as safely Emergency Escape,
as possible. Emergency Planning,
Emergency
Communication

Figure 6

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 ICAM INVESTIGATION GUIDELINE

Identify the Individual/Team Actions

These are the errors or violations that led directly to the

incident. They are typically associated with personnel
such as operators or maintainers having direct contact
with equipment or material. They are always committed
‘actively’ (someone did or didn’t do something) and
have a direct relation with the incident. The theory of
human error and violation is described in HSEC
Toolkit 32.

For most of the time however, the defences built into

our operations prevent these ‘human errors’ from
causing harm.

Once again, keep asking “Why?” someone acted (or

was allowed to act) or didn’t act in the way they did
leading up to the incident.

Examples of Individual/Team Actions may include

issues such as supervision, authority, speed, procedural
compliance, position, horseplay and PPE use.

Check question: Does the Individual/Team Action indicate

an error or violation of a standard or procedure which led
to the incident?

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Identify the Task/Environmental Conditions

These are the conditions in existence immediately prior

to or at the time of the incident that directly influence
human and equipment performance in the workplace.
These are the circumstances under which errors and
violations took place and relate to task demands, the
work environment, individual capabilities and human
factors.

The Task/Environmental Conditions can be categorised

in two groups:

• Workplace Factors
• Human Factors

Workplace Factors and Human factors are described in

HSEC Toolkit 32.

Examples of Task and Environmental Conditions may

include issues such as noise, dust, heat, cold, light,
abnormal conditions, risk assessment, work permits,
planning, fatigue, complacency, drug/alcohol, time
pressure and peer pressure.

Check question: Does this Task/Environmental Condition

describe something about the task demands, work
environment, individual capabilities or human factors
that promoted errors and/or violations or undermined
the effectiveness of system defences?

33
 ICAM INVESTIGATION GUIDELINE

Identify the Organisational Factors

The next step of the analysis is to identify the

organisational factors (aligned with the BHP Billiton
HSEC Management Standards), which are implicated in
producing the identified Task/Environmental Conditions
or Individual/Team Actions or Absent/Failed Defences.
These organisational factors are listed in figure 7 on
page 35.

They are the underlying organisational factors that

produce the conditions affecting performance in the
workplace. They may lie dormant or undetected for
a long time within an organisation. Their effect only
becomes apparent when they combine with the local
conditions and errors or violations to breach the
system's defences.

Check question: Does this organisational factor identify

a non-conformance with a HSEC Management Standard
which resulted in Task/Environmental Conditions or
Individual/Team Actions or Absent/Failed Defences to go
unaddressed?

34
 Organisational Factors
BHP Billiton HSEC Management Standards
Standard 1 Leadership and Accountability
Legal Requirements, Commitments and
Standard 2
Document Control
Standard 3 Risk and Change Management
Standard 4 Planning, Goals and Targets
Standard 5 Awareness, Competence and Behaviour
Standard 6 Health and Hygiene
Communication, Consultation and
Standard 7
Participation
Business Conduct, Human Rights and
Standard 8
Community Development
Standard 9 Design, Construction and Commissioning
Standard 10 Operations and Maintenance
Standard 11 Suppliers, Contractors and Partners
Standard 12 Stewardship
Standard 13 Incident Reporting and Investigation
Standard 14 Crisis and Emergency Management
Standard 15 Monitoring, Audit and Review

Figure 7

35
 ICAM INVESTIGATION GUIDELINE

The BHP Billiton HSEC Management Standards cover all

operational aspects and activities that have the potential
to affect, positively or negatively, the health and safety of
people, the environment or the community.

HSEC Toolkit 32 – ICAM Analysis, lists and defines the BHP

Billiton HSEC Management Standards as well as describing
the causes and results of non-conformance with the BHP
Billiton HSEC Management Standards.

Examples from the toolkit of non-conformance are shown

on the following pages.

36
Standard 1: Leadership and Accountability

Intent: Directors, managers, employees and contractors

understand their accountabilities and demonstrate
leadership and commitment to sustainable development
and Zero Harm through effective HSEC management.

Inadequate Leadership and Accountability may be caused

by:

• Lack of management accountability for business unit

HSEC performance and resources
• Lack of visible leadership

Inadequate Leadership and Accountability may result in:

• Confusion and lack of direction

• Unsafe work conditions not addressed

37
 ICAM INVESTIGATION GUIDELINE

Standard 2: Legal Requirements, Commitments and

Document Control

Intent: Relevant legal, regulatory and other HSEC

requirements are identified, accessible, understood and
complied with and an effective HSEC document control
system is in place.

Inadequate Compliance and Document Control can be

caused by:

• Absence of systems to identify, assess and document

compliance obligations
• Inappropriate or absent Document Management System

Inadequate Compliance and Document Control may result

in:

• Inability to demonstrate compliance and satisfy legal

and other requirements
• Use of incorrect or outdated documents

38
Standard 3: Risk and Change Management

Intent: HSEC hazards are identified and associated risks

assessed and managed. Planned and unplanned changes
are identified and managed.

Inadequate Risk and Change Management can be caused

by:

• Risk assessments not done or not conducted by persons

with the appropriate competencies or experience
• Failure to communicate proposed changes to those
affected

Inadequate Risk and Change Management may result in:

• Uncontrolled/unknown hazards and consequences

• Failure to adequately consider HSEC issues associated
with changes

39
 ICAM INVESTIGATION GUIDELINE

Standard 4: Planning, Goals and Targets

Intent: Sustainable development is an integral part of

business planning with HSEC goals and targets established
to drive continual improvement in performance.

Inadequate Planning and Goal Setting can be caused by:

• Failure to integrate HSEC planning into broader business

planning activities
• Failure to use HSEC performance data to refine plans,
goals and targets

Inadequate Planning and Goal Setting may result in:

• Conflicts between HSEC and production priorities

• Poor understanding of company’s HSEC expectations,
goals and targets

40
Standard 5: Awareness, Competence and Behaviour

Intent: Employees, contractors and visitors are aware of

relevant HSEC requirements, hazards, risks and controls,
are competent to conduct their activities and behave in a
responsible manner.

Inadequate Awareness, Competence and Behaviour can be

caused by:

• Absence of systems that ensure training requirements

are managed so that employees and contractors are
competent to meet their HSEC responsibilities
• Failure to have effective behavioural observation
processes in place

Inadequate Awareness, Competence and Behaviour may

result in:

• Lack of understanding of HSEC hazards and

performance expectations
• Inappropriate behaviour resulting in adverse HSEC
outcomes

41
 ICAM INVESTIGATION GUIDELINE

Standard 6: Health and Hygiene

Intent: Employees and contractors are assessed for their

fitness for work and, along with visitors, are protected
from health hazards associated with Company operations.
Community health issues relevant to Company operations
are identified and effectively managed.

Inadequate Management of Health and Hygiene can be

caused by:

• Absence of health and hygiene assessment programs

and medical surveillance programs
• Absence of fatigue management and drug and alcohol
programs

Inadequate Management of Health and Hygiene may result

in:

• Possible prevalence of acute and or chronic

occupational disease
• Adverse HSEC impacts as a result of employees/
contractors being unfit for work (including fatigue
through drug and alcohol related issues)

42
Standard 7: Communication, Consultation and
Participation

Intent: Effective, transparent and open communication and

consultation is maintained with stakeholders associated
with Company activities. Stakeholders are encouraged to
participate in and contribute to sustainable development
through HSEC performance improvement initiatives.

Inadequate Communication, Consultation and Participation

can be caused by:

• Poor communication of HSEC expectations, plans and

performance
• Lack of opportunities for stakeholders to participate in
the development, implementation and management of
HSEC initiatives

Inadequate Communication, Consultation and Participation

may result in:

• Misunderstanding or incorrect interpretations

• Employees/contractors doing the wrong thing, at the
wrong time or place

43
 ICAM INVESTIGATION GUIDELINE

Standard 8: Business Conduct, Human Rights and

Community Development

Intent: Activities and operations are conducted in an ethical

manner that supports fundamental human rights and
respects traditional rights, values and cultural heritage.
Opportunities are sought for contributing to sustainable
community development.

Inadequate Business Conduct and management of Human

Rights and Community Development can be caused by:

• Lack of awareness and training on company values and

expectations
• Failure to properly assess impacts of operations on local
and indigenous communities

Inadequate Business Conduct and management of Human

Rights and Community Development may result in:

• Lack of trust between management and employees,

customers, suppliers, communities and shareholders
• Project/Business becoming unsustainable

44
Standard 9: Design, Construction and Commissioning

Intent: Management of HSEC risks and opportunities is

an integral part of all projects through design, approval,
procurement, construction and commissioning.

Inadequate Design, Construction and Commissioning can be

caused by:

• Substandard design, construction and commissioning

techniques
• Failure to identify and provide project specific
operations training

Inadequate Design, Construction and Commissioning may

result in:

• Unexpected/incorrect operation of plant and equipment

• Inability to construct, operate and maintain equipment
safely

45
 ICAM INVESTIGATION GUIDELINE

Standard 10: Operations and Maintenance

Intent: All plant and equipment is operated, maintained,

inspected and tested using systems and procedures that
manage HSEC risks.

Inadequate Operations and Maintenance can be caused by:

• Lack of systems, manuals and procedures that ensure

operations and maintenance activities are managed to
minimise HSEC risk and impacts
• Lack of appropriate maintenance, inspection, testing
and calibration schedules

Inadequate Operations and Maintenance may result in:

• Defective or malfunctioning equipment

• Improvisation or use of tools unsuitable for the job or
equipment not operated in the way intended

46
Standard 11: Suppliers, Contractors and Partners

Intent: The contracting of services, the purchase, hire

or lease of equipment and materials, and activities with
partners, are carried out so as to minimise any adverse
HSEC consequences and, where possible, to enhance
community development opportunities.

Inadequate management of Suppliers, Contractors and

Partners can be caused by:

• Contracts not stipulating HSEC performance

requirements and consequence of non-compliance
• Lack of consideration of risk associated with supplier
and contractor equipment, products and services

Inadequate management of Suppliers, Contractors and

Partners may result in:

• Substandard contractor competency

• Lack of compliance with HSEC obligations

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 ICAM INVESTIGATION GUIDELINE

Standard 12: Stewardship

Intent: The lifecycle HSEC impacts associated with

resources, materials, processes and products are minimised
and managed.

Inadequate Stewardship can be caused by:

• Absent or ineffective programs aimed at ensuring

wastes are eliminated, reduced, recovered and re-used
• Lack of communication to employees, contractors,
distributors, customers and communities regarding
possible HSEC impacts of company products

Inadequate Stewardship may result in:

• Lack of participation in conservation and waste

management programs
• Incidents as a result of not understanding the impact of
exposures to products and by-products

48
Standard 13: Incident Reporting and Investigation

Intent: HSEC incidents, including near misses, are reported,

investigated and analysed. Corrective and preventive
actions are taken and learnings shared.

Inadequate Incident Reporting and Investigation can be

caused by:

• Lack of systematic reporting and investigation

methodologies
• Failure to track and confirm effectiveness of corrective
actions

Inadequate Incident Reporting and Investigation may result

in:

• Inability to identify gaps, predict/ prevent future

incidents
• Inability to confirm the effectiveness of corrective
actions

49
 ICAM INVESTIGATION GUIDELINE

Standard 14: Crisis and Emergency Management

Intent: Procedures and resources are in place to effectively

respond to crisis and emergency situations.

Inadequate Crisis and Emergency Management can be

caused by:

• Failure to develop and implement appropriate

emergency and crisis management plans
• Poorly defined crisis and emergency response team
structures

Inadequate Crisis and Emergency Management may result

in:

• Delayed or inadequate crisis and/or emergency

responses
• Inability to prevent escalation and minimise
consequences

50
Standard 15: Monitoring, Audit and Review

Intent: HSEC performance and systems are monitored,

audited and reviewed to identify trends, measure progress,
assess conformance and drive continual improvement.

Inadequate Monitoring, Audit and Review can be caused by:

• Lack of systematic audit/review methodologies and

protocols
• Lack of follow-up on agreed audit recommendations

Inadequate Monitoring, Audit and Review may result in:

• Inability to measure performance and progress

• Inability to share lessons learnt or best practices
identified

51
 Once the facts have been classified into one of the following ICAM categories, the investigation team can transfer

52
all but the non-contributing facts to an ICAM chart.

• Absent/Failed Defences
• Individual/Team Actions
• Task/Environmental Conditions
• Organisational Factors (aligned with the BHP Billiton HSEC Management Standards)
• Non-contributing Factors

The workflow diagram, figure 8 below, shows how the ICAM Chart is constructed. Once the facts have been
transferred to the ICAM Chart the team should arrange them so that the relationships between the categories can
be shown, however this is not always necessary. The following illustration is a real example of an incident within
the company.

Review and Categorise Each Finding

underlying causes to the ICAM Chart

Identify Non- Identify Task/ Identify Individual Identify Absent/

conformance with Environmental or Team Actions Failed Defences
HSEC Standards Conditions
Step 5.2 Transferring contributing factors and

Is this a "No"
Contributing Issue remains as part
Factor or underlying of initial findings and
cause
is documented
"Yes" Add item to ICAM Chart under correct heading

Organisational Task/
Individual/team Absent/
Factors Environmental Incident
Actions Failed Defences
Conditions
ICAM
 11 Strong customer Customer requests
truck location No formalised
focus motivation safe working
practice/procedure
Operator customer for operating near
Chart
focused powerlines
3 Site access
assessment Unique site access
procedures less than problems
adequate Truck-crane placed No JSA or take-two
in location where as a common work
crane working practice
3 Management of position could result
risk associated with in contact with
working around powerlines
Common to work
powerlines near powerlines
Truck-crane
5 Lack of training Desensitisation to No physical or driver
in JSA or Take-2 hazard "exclusion" barriers operates
hazard assessment to prevent vehicle/ the crane
techniques crane proximity to in vertical

Figure 8
the powerlines position near
overhead
5 Lack of Confined area of powerlines
knowledge, access operation for crane and is
to training in load + electrocuted
unload guidelines Operator not aware
Confined and uneven of electricity ability
work area and Crane operated to to jump air gap
10 Work procedures position for operator vertical position in
and practices not close proximity to
subject to review powerlines
and audit
Driver distraction No observer to
watch proximity to
10 Truck-crane safe powerlines
working procedures Crane arm working
not in place zone encroaches
hazard zone

53
 ICAM INVESTIGATION GUIDELINE

Step 5.3 Validate the organisational factors against the

Incident

The ICAM chart is constructed by working backwards

from the incident to the organisational factors. The
method is validated by working from each HSEC
Management Standard towards the incident. For
example, ask the question, “Is the Operation and
Maintenance HSEC Standard implicated anywhere in
this incident?” and then ask the same question for each
of the other HSEC Standards. This approach helps to
find organisational factors which might not have been
considered. These may be failures that came close to
escalating the incident but were blocked by a defence.

Conclusion

Incident investigations are part of the continual

improvement process. The focus of investigations
must be on identifying any organisational weaknesses,
errors and absent or failed defences. Once identified,
appropriate control measures must be implemented to
prevent recurrence of the incident.

54
STEP 6: PREVENTIVE AND CORRECTIVE
ACTIONS

Developing recommendations
The investigation shall identify recommendations for
preventive and corrective actions. This is achieved
by addressing all absent or failed defences and
organisational factors identified by the ICAM analysis.
Not all contributing factors and underlying causes can
be completely eliminated, and some may be eliminated
only at a prohibitive cost.

The investigation team should work with line

management in the development of preventive
and corrective actions. Each recommendation is a
written statement of the action management should
take to correct a contributing factor. The resulting
recommendations will be those identified using the
Payoff Matrix, figure 10, page 58.

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 ICAM INVESTIGATION GUIDELINE

The team reviews each contributing factor and

underlying cause and:

• Formulates recommendations which, if implemented,

will eliminate or reduce the risk of recurrence of that
contributing factor
• Recommends improvement of the defences to limit
the consequences of the hazards so that the risk is
accepted by management as a tolerable risk
• Makes interim recommendations for preventive and
corrective action that may be made immediately after
an incident or near miss as a short-term measure to
mitigate current risks prior to the establishment of
long-term corrective actions
• Ensures any corrective action is fully evaluated to
ensure change/s do not weaken other defences or
introduce other hazards

Hierarchy of controls

Recommendations should be based upon the Hierarchy

of Controls shown in figure 9.
Hierarchy of Controls
Eliminate The complete elimination of the hazard.
Replacing the material, equipment or process with a less
Substitute
hazardous one.
Redesign Redesigning the equipment or work processes.

Separate Isolating the hazard by guarding or enclosure.

Administrative Providing controls such as training, procedures etc.

Personal Protective Using properly fitted PPE and/or appropriate pollution

Equipment/Pollution control equipment where other controls are not
Control Device practicable.

Figure 9
56
 Eliminate, substitute and redesign are preferred control
options as they remove the hazard so that other
controls are redundant. Administrative and Personal
Protective Equipment (PPE) provide interim controls in a
planned programme to eliminate or reduce a particular
risk or may be used to supplement other control
methods. However, they are not the preferred control
measures. Refer to HSEC Toolkit 33 – Preventive and
Corrective Actions.

Payoff Matrix

The identified Absent/Failed Defences or organisational

factors can be evaluated with respect to the ease of
implementation (using the Payoff Matrix). This will
prioritise the recommendations.

A Payoff Matrix is a tool than can be used by the

investigation team and can be applied in a multitude of
ways. Being able to look at an option or issue from two
different angles at once is often a useful way to gain
perspective.

In the example, a 2 X 2 matrix has been constructed

with the two dimensions represented as Ease of
Implementation and Payoff/Impact/Risk Reduction.
When ranking the recommendations on the Payoff
Matrix consider the effort required versus the potential
benefits, bearing in mind the hierarchy of controls.

57
 The Matrix is divided into four quadrants and labelled:

• Q1 Must do - highlights an opportunity to focus on

those issues that can potentially provide the greatest
impact.
• Q2 Easy to do -relatively easy to implement with
up to a moderate impact with the added bonus of
showing managements commitment to making
changes quickly in response to an incident.
• Q3 Difficult change - issues that fall in this quadrant
can take a little more time to implement and typically
address the elimination or substantial reduction of an
identified risk.
• Q4 Difficult to justify - demonstrates to the team that
energies may be better focused elsewhere.

PAYOFF MATRIX

HARD Task/Work
Q4 Q3 Factors
Environment
Difficult to justify Difficult change
Ease of
Implementation
Q2 Q1
Easy to do Must do
EASY
LOW HIGH
Payoff/Impact
/Risk Reduction

58
Concluding the Investigation – Steps 1 – 6

The investigation will be concluded when the following

points have been addressed:

• Interview summaries have been reviewed to ensure

any outstanding Health, Safety, Environment and/or
Community issues have been addressed.
• The requirement for additional information or
documentation has been determined.
• The findings, conclusions and recommended actions
from other investigators (external, regulatory etc.)
have been reviewed, considered and incorporated as
appropriate.
• All documentation has been reviewed to ensure it
supports the recommendations for preventive and
corrective actions.
• A draft report has been developed on the investigation
findings and disseminated for comment to relevant
parties to the investigation, and to a legal advisor
where appropriate. Legal review of the draft ICAM
report is mandatory in relation to all fatalities and
environmental and community significant incidents.
• Key learnings have been identified for the
organisation.
• Presentation of findings has been prepared for line
management.
• Report sign off as per the HSEC Reporting Manual.

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 ICAM INVESTIGATION GUIDELINE

STEP 7: REPORT THE FINDINGS

Minimum report requirements

The investigation report is the presentation of

the investigation findings and recommendations.
Inclusion of the ICAM chart will assist management in
understanding the factors contributing to the incident.
Refer to HSEC Toolkit 34 – Report the Findings.
As a minimum the report should include:

• Executive Summary
• Incident Description
• Contributing Factors and Underlying Causes
• Key Findings
• Conclusions and Observations
• Recommendations
• Corrective Action Plan
• Report Sign-off
• Timeline Chart
• ICAM Chart
• Key Learnings
• Appendices

The investigation outcomes listed above should also be

entered into FPe or alternative similar systems.

60
Bow Tie analysis
The Bow Tie methodology can be used for
communicating the findings of incidents in a simple
model. Figure 11 on page 62 shows an example of
a Bow Tie analysis from an incident at a mining
operation.

As determined by the ICAM investigation findings:

• The centre of the bow represents the incident

• The left side of the bow represents the
contributing factors and underlying causes that
failed to prevent the incident
• The right side of the bow represents the
contributing factors and underlying causes that
failed to mitigate the outcomes

The outcomes, outside the Bow Tie, represent the

actual consequences of the incident.
Lessons learnt

The fundamental aim of any ICAM investigation is to

learn from the incident and prevent future occurrences
by identifying and correcting system deficiencies.

In BHP Billiton lessons learnt are communicated

through a Significant Incident Report (with summary
details, key learnings, recommendations and actions)
which shall be circulated as per the BHP Billiton HSEC
Reporting Manual. Part 1 of the HSEC Significant
Incident Report form shall be completed within 24
hours of the incident.

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 ICAM INVESTIGATION GUIDELINE

Community Outrage

Equipment Damage
Lost Production
Single Fatality
Outcomes

Emergency Response
Underlying Causes that would
have mitigated the outcomes
Contributing Factors and

PPE

Hazard Awareness Training

Bow Tie Analysis

Overhead Height Barriers

Trip Mechanism
Electrocuted
Incident

Driver

Job Hazard Analysis (JHA/JSA)

Underlying Causes that should
have prevented the incident
Contributing Factors and

Procedure for Operating Near Powerlines

Isolation Procedure

Observer in Place (Rigger)

Knowledge of Operator to Perform Task

Figure 11
62
DEFINITIONS
Absent/Failed Defences: The last minute measures which did not prevent
the outcome of the incident or mitigate/reduce its consequences.

Contributing Factors and Underlying Cause: Contributing Factors are

those factors which were involved in the outcome of the incident and
supported the sequence of events leading up to it. An Underlying Cause
is Organisational Factors (as determined by the ICAM Analysis) that
contributed to the event.

First Priority enterprise (FPe): FPe is BHP Billiton’s HSEC information

system. It includes events (incidents), risk/hazard, audits/inspections and
corrective action data. The full ICAM analysis can be entered into the
FPe system for storage, additionally reporting can be investigated across
multiple events.

ICAM: An acronym for “Incident Cause Analysis Method”. This is a

systemic HSEC investigation analysis method.

Individual/Team Actions: The errors or violations that led directly to

the incident. They are typically associated with personnel having direct
contact with the equipment. They are always committed “actively”
(someone did or didn’t do something) and have a direct relation with the
incident.

Incident: Any occurrence that has resulted in, or has the potential
to result in (i.e. a near miss), adverse consequences to people, the
environment, property, reputation or a combination of these. Significant
deviations from standard operating procedures are also classed as an
‘incident’. Ongoing conditions that have the potential to result in
adverse consequences are considered to be incidents.

Near Miss: A near miss is any occurrence or a situation which potentially

could have caused adverse consequences to people, the environment,
property, or reputation, or a combination of these but which did not.

Organisational Factors: The underlying factors in the organisation

that influence and produce the conditions affecting performance in the
workplace. The effect of these factors only becomes apparent when they
combine with the local conditions and errors or violations to breach the
system defences. These are the factors the BHP Billiton HSEC Management
Standards align with.

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 ICAM INVESTIGATION GUIDELINE

Payoff Matrix: A tool which helps prioritise those corrective actions to

yield the desired results in order to address the causes of the incident
considering impact and ease of implementation.

Significant incident: A significant (HSEC) incident is any occurrence that

has resulted in or had the potential to result in the descriptions outlined
in the shaded areas of the Consequence Severity Table contained in the
BHP Billiton HSEC Reporting Manual.

Task/Environmental Conditions: The conditions, circumstances or objects

in existence and by which one is surrounded, immediately prior to or at
the time of the incident, that directly influence human and equipment
performance in the workplace.

Terms of Reference: The agreed scope and boundary within which the
investigation should take place.

Timeline Chart: A graphic representation on a timeline of how

the incident resulted by describing the events and conditions in a
chronological manner.

5 Whys: The process of probing into the reasons for an event having taken
place by interrogating responses to their logical conclusion. Asking “why”
five times assists in identifying underlying causes.

64
NOTES

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 ICAM INVESTIGATION GUIDELINE

NOTES

66
NOTES

67
68 bhpbilliton.com
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