ABSTRACT
In late 2004 RailCorp adopted a new safety occurrence investigation method – ICAM (Incident Cause Analysis Method). ICAM breaks new ground in the area of incident investigation which, in the past, has tended to focus on intentional or unintentional acts of human error – those things that people did or did not do – that lead to an incident or accident. ICAM is a holistic method, which aims to identify both local and wider systemic factors within the entire organizational system that contributed to the incident. Through the analysis of this information, ICAM provides the ability to identify what really went wrong and to make recommendations on what needs to be done to prevent recurrence. It is directed towards building error-tolerant defences against future incidents.
