Looking beyond compliance with ICAM
The Incident Cause Analysis Method bridges operational reality and strategic risk governance, placing safety at the centre of mine sites.
The effective management of safety in complex, high-risk systems, such as those in mining, depends on an organisation’s ability to reconcile the difference between how work is imagined and how it is actually performed.
In high-risk or complex workplaces, there is a critical need to understand and document the reasoning behind actions and decisions taken prior to an incident so valuable lessons can be captured and systemic improvements made. Contemporary safety thinking recognises that investigations must move beyond surface-level fault-finding to explore the systemic pressures that shape human performance and normalise deviation from ideal conditions.
This requires a deep understanding of the interplay between ‘work as imagined, work as normal, and work as done’ – together forming the operational reality triad.
The operational reality triad provides a conceptual foundation for understanding how failures emerge in organisational systems.
Work as imagined (WAI) refers to the formalised, idealised procedures, standards and protocols established for performing a task. These are designed with the intent of maximising safety, consistency and efficiency, often reflecting regulatory and best-practice influences. However, WAI is commonly authored by people removed from the realities of frontline work, meaning it may overlook the contextual variability workers face daily.
Work as done (WAD) represents the real, moment-to-moment performance of work; the decisions, adaptations and trade-offs people make to achieve the task under actual conditions.
A key tenet of contemporary safety theory is that WAD will routinely differ from WAI. Understanding these differences lies at the heart of systemic investigation models such as the Incident Cause Analysis Method (ICAM).
Work as normal (WAN) describes the evolution of daily practice; the habitual, accepted deviations from the formal standard. WAN captures the local adjustments, shortcuts and normalised compromises workers use to balance productivity, time pressure and limited resources. It sits between WAI (the prescribed ideal) and WAD (the real-time action).
The divergence between WAI and WAD challenges long-held managerial assumptions about control and compliance. Recognising this gap requires organisations to value frontline insight as the most accurate window into operational reality. The difference between WAI and WAD indicates procedural drift or that controls are not usable in real conditions. This identifies the gaps between risk controls and the safety system process.
Bridging this divide is essential for improving safety and productivity. ICAM investigations depend on understanding the work as disclosed (WAD-D), what workers say happened, which is collected through interviews and documentation.
The accuracy of WAD-D hinges on psychological safety. In an open, trust-based culture, workers freely disclose deviations and contextual pressures, allowing investigators to accurately reconstruct WAD. In cultures where blame is a concern, disclosures can sometimes be incomplete, which may affect the accuracy of findings and limit systemic learning. The methodology may reveal challenging issues, such as conflicting goals or oversight gaps, which can prompt reflection on existing structures.
Equally, the success of an investigation depends on how effectively it identifies WAN, the background of routine deviations and organisational drift that made the failure possible. When WAN is overlooked, the analysis risks stopping at the immediate act rather than exposing the latent organisational and systemic contributors.
An organisation’s cultural maturity ultimately dictates how deeply it can learn from its ICAM process. An open disclosure environment tends to enhance the value of training and investigative capability.
A systemic framework
ICAM is a globally recognised model for structured investigation, particularly in complex, high-risk sectors. ICAM is designed to move beyond individual blame and deliver systemic learning by linking frontline performance to organisational governance.
It is grounded in the research of organisational psychologist Professor James Reason, whose work on human error and organisational accidents revolutionised safety science.
Reason’s Swiss Cheese Model (SCM) visualises safety defences as layers of Swiss cheese, each with inherent weaknesses, or “holes”. When these holes align, latent conditions and active failures combine to cause an incident.
ICAM translates this model into a structured investigative process. It distinguishes between active failures (immediate errors or violations by individuals) and latent conditions (underlying system weaknesses such as insufficient resourcing, poor supervision, flawed design or inadequate training).
This marked a decisive shift away from the outdated “person model” of investigation, which focused solely on individual error.
Instead, ICAM embraces a systems model, recognising that most failures arise from complex organisational interactions, not isolated human mistakes.
ICAM provides a logical pathway to identify not only what happened, but why. ICAM Australia’s method has evolved to include seven investigation stages, designed to ensure consistency, rigour and alignment with organisational governance structures:
Emergency response
The priority is to secure the site, preserve evidence and stabilise the situation. This phase begins uncovering early insights into WAD, capturing how individuals responded in real time under stress or uncertainty.
Investigation planning
The investigation planning phase is confirming the scope, gathering the team, and admin around the conduct of the investigation.
PEEPO planning
The PEEPO (people, environment, equipment, procedures, organisation) framework guides data collection. This planning step identifies which domains may reveal deviations between WAI, WAN and WAD. PEEPO planning is what the investigator wants to know and verify, and who will gather it.
PEEPO collection
Investigators collect evidence through interviews, documentation, digital means and observations, focusing on obtaining accurate WAD-D narratives. The success of this phase relies on establishing psychological safety and trust to ensure unfiltered insight.
ICAM analysis
Data is categorised into ICAM’s four key contributing factor groups:
Absent or failed defences – barriers that failed to prevent or mitigate the event
Individual or team actions – observable actions or errors by people directly involved
Task or environmental conditions – local circumstances influencing performance
Organisational factors – deeper, systemic contributors such as management systems, planning, culture or leadership
The analysis connects these layers, tracing WAD back through WAN to WAI to expose the latent system conditions that created vulnerability.
Recommendations
Recommendations target systemic improvement, not individual blame. Actions are designed to strengthen defences, improve task conditions and address organisational weaknesses identified in the analysis.
Reporting
The reporting stage consolidates findings into a coherent narrative that communicates not only what happened, but why it made sense to those involved. Reports promote learning and cultural growth rather than punishment, reinforcing safety as a strategic function of governance.
ICAM’s investigative power lies in its ability to bridge the gap between WAI and WAD, transforming the investigation into a diagnostic tool for system resilience.
Each ICAM category helps operationalise latent conditions and identify where procedural and cultural barriers broke down. For example, during the analysis of absent or failed controls, if a critical risk control such as a required equipment safeguard or procedural check was missing or did not function as intended, this exposes a disconnect between what was expected in the system design and what actually occurred in practice.
At the organisational factors level, ICAM exposes dormant weaknesses such as leadership decisions, goal conflicts, inadequate resourcing or poor change management. Research consistently shows that organisational factors and absent or failed defences each account for approximately 22 per cent of identified causes and, within those, management system deficiencies make up more than 60 per cent.
ICAM’s objective is to reduce recurrence and enhance safety performance through systemic learning, not blame. It provides a framework to diagnose procedural failure along the WAI–WAD continuum:
Flawed WAI – the procedure was poorly designed or unrealistic
Flawed WAN – systemic pressures caused deviation to become normalised
Flawed defence – supervisory systems failed to detect or address the drift
By tracing the event across this continuum, ICAM helps to ensure corrective actions address root organisational causes, not apparent behaviours.
Successful ICAM programs require leadership endorsement and cultural maturity. The methodology may reveal challenging issues, such as conflicting goals or oversight gaps, which can prompt reflection on existing structures. Without executive support to act on findings, even the best investigation becomes a static report rather than a catalyst for improvement.
