Widely used in high-risk industries such as mining, ICAM can help companies understand the contributing factors to safety incidents.
ICAM – incident cause analysis method – is an investigative method offering a structured approach to safety incidents.
By analysing immediate and latent causes, ICAM highlights human and systemic contributing factors and helps organisations reduce the likelihood of similar incidents occurring.
The notion of ‘systems thinking’ focuses on understanding the incident within the context of the organisational system, recognising how various factors interact to create risks. By taking into account human factors, ICAM recognises that human errors are often symptoms of deeper issues in processes, training, equipment or culture.
Ultimately, ICAM aims to generate actionable recommendations that address contributing factors and reduce the likelihood of recurrence.
“The ICAM methodology can be used in multiple ways in the mining industry to assist in risk management,” ICAM senior investigator Pru Giagtzis told Safe to Work.
“One use involves applying ICAM to review legacy mining incidents with the aim of understanding their contributing factors, which is then used to examine what gets measured and monitored and to determine if we are focused on the best predictive indicators.”
Giagtzis recently applied ICAM to the 2006 Sago coal mine incident in the US to gather necessary information that could help prevent such cases in the future.
On January 2, 2006, the Sago underground coal mine in Upshur County, West Virginia, was in the early hours of reopening after the New Year holiday weekend. At 5:50am, a mine fire boss had cleared the mine for use and two carts of workers began making their way underground.
A methane gas explosion occurred deep within the mine at 6:30am, leading to 13 miners becoming trapped. A rescue operation commenced, but only one miner was able to be freed.
The event highlighted the need for a cultural shift towards safety within the US mining industry, which ultimately led to more rigorous training for miners and stricter enforcement of safety standards.
The aftermath revealed a series of failures in safety practices, oversight and communication that contributed to the disaster.
Investigation findings on the possible immediate cause ranged from:
lightning strike and seismic activity
use of foam rather than concrete seals to seal the mine
proximity with active gas and oil wells
sparks from restarting machinery after a holiday weekend.
According to the ICAM methodology, Giagtzis said it can be seen than a number of absent or failed defences, as well as environmental conditions, contributed to the incident:
The build-up of methane gas was a critical factor. The mine had a history of methane issues, but safety measures to monitor and mitigate this risk were not consistently followed.
The ventilation system, which is designed to clear methane from the mine, was not properly maintained or managed. This failure allowed the gas to accumulate to dangerous levels, increasing the risk of an explosion.
Miscommunication between rescue teams and the company included initial reports that suggested all of the miners had survived, but it was later revealed that only one miner was alive. This lack of accurate communication delayed efforts to retrieve the miners and added confusion to an already chaotic situation.
Insufficient corrective actions were taken on safety violations in the months leading up to the explosion. These failures, which included a lack of proper gas monitoring and ventilation maintenance, were critical in setting the stage for the explosion.
A culture of “normalisation of deviations” prevailed in the mine. Workers and management alike had become desensitised to the risks, accepting unsafe conditions as the norm.
Using the ICAM methodology, a series of organisational factors that led to the Sago incident were found.
Organisation
“The mine’s management did not adequately address ongoing safety issues,” Giagtzis said. “Despite warnings from workers and previous inspections pointing to ventilation problems and methane risks, the necessary measures to address these issues were not implemented.
“The failure to prioritise safety and invest in necessary infrastructure led directly to the disaster.”
Incompatible goals
“There was found to be a substandard culture of safety within the mine,” Giagtzis said. “The overarching cultural attitude downplayed safety in favour of productivity and played a significant role in the build-up to the disaster.”
Previous incidents
In 2005, the mine was cited by the US Mine Safety and Health Administration (MSHA) 208 times for violating regulations, up from 68 in 2004.
Of those, 96 were considered significant, serious and substantial. Violations included failure to follow the approved roof control and mine ventilation plans, and problems concerning emergency escapeways and required pre-shift safety examinations.
“Mining operations at the Sago mine more than doubled between 2004 and 2005, and the injury rate was significantly above the national average,” Giagtzis said.
“Sago’s accident rate was 17.04 for 2005, with 16 miners and contractors injured on the job. Sago’s accident rate was 15.9 in 2004, when the national average was 5.66.”
Regulatory issues
Government oversight of coal mining operations at the time was found to be insufficient.
“Although the mine had received multiple citations for safety violations with a dramatic increase by the MSHA on-site inspections, enforcement was weak,” Giagtzis said.
“The MSHA lacked the resources and authority to ensure that mines followed proper safety standards, and inspections were often cursory or inadequate.”
According to Giagtzis, the Sago incident led to significant changes in US mining safety regulations, providing valuable insights for Australian operations.
“Key provisions included more stringent safety protocols, better communication systems, and improved rescue plans,” she said.
“This incident reminds us that weak predictive signals in addition to known predictive indicators to coal mining incidents are equally important in the data equation for pro-active risk managers of mining operations.
“By using the ICAM methodology, we can apply the knowledge gained from legacy incidents to current operations in order to keep miners safer on the job.”
This feature appeared in the May–June edition of Safe to Work.