Structured incident cause analysis to get to the real root cause, capture the lessons and put controls in place that stop it happening again.
When something has gone wrong on your site - a serious injury, a major near-miss, a piece of plant damaged - the temptation is to label it human error and move on. ICAM (Incident Cause Analysis Method) says: stop. Look beneath the action. Find the conditions and the system failures that allowed it to happen. Fix those. That is how you stop the same incident showing up again on a different day with a different worker.
Any incident with serious injury or significant property damage warrants a formal investigation. So does any high-potential near-miss - the event where nobody got hurt this time but easily could have. Calling early matters: evidence degrades, memories fade, and the people who were there get reassigned to other jobs. The first 24 to 48 hours after the event is when the highest-quality information is available.
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