An event report becomes an investigation. Evidence is planned and collected against the PEEPO categories: people, environment, equipment, procedures and organisation. Findings feed a factual timeline.
Contributing factors are identified against the ICAM families and linked to the evidence that supports them. Bow-tie barriers are assessed as failed, missing, degraded, bypassed or effective.
Recommendations are written against the factors they address, and corrective actions are tracked to verified closure rather than to a closed ticket.
SafetyPulse by ICAM Australia Pty Ltd. ICAM training and methodology.