Icam incident investigation template checklist

Template Questions

• Collect information and evidence of the incident and report your findings here.
• Item detail
• Photo evidence
• List the activities and events leading up to the time of the incident, when the incident happened and
• Date & Time Date
• Activity
• The basic cause of an incident is the mechanism of failure.
• What happened?
• The ICAM model analyses the contributing factors to determine why the incident happened.
• Why did the incident happen?
• Actual Consequences
• Potential Consequences
• The contributing factors of this incident were analyzed using the Incident Cause Analysis Method (ICA
• The situations, systems, conditions, equipment, measures or human factors which normally prevent this
• Absent or Failed Defences
• Organisational factor type
• Details of defence
• The errors or violations made by people directly involved in the event.
• Individual or Team Actions
• Details of Action
• The "situational characteristics" which existed immediately prior to the incident, including the work
• Task or Environment Conditions
• Details of Condition
• The latent system based factors present before the incident which may have contributed to the presenc
• Details of Factor
• What are we going to do about the incident? Use the Hierarchy of Control recommendations for correcti
• Enter recommended corrective actions here
• CAR detail
• Enter Lessons Learned here
• Lesson Learned
• Full name and signature of ICAM report author