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Selected investigation case experience

Real incidents. Evidence-led findings.

Over more than three decades, our investigators have examined fatalities, serious injuries, road crashes, fires, equipment losses, information incidents, security failures and operational disruptions. Sixteen of those cases are summarised here.

ANONYMISED

Client names, people, exact locations, dates and asset identities have been removed or generalised. Nothing here identifies an organisation or an individual.

Beyond safety

We investigate loss, not only injury.

Fatalities Serious injuries Vehicle crashes Industrial incidents Fires Equipment failures Property damage Information loss Security incidents Operational disruption Financial loss Reputational exposure

What happened?

How did it happen?

Why did the controls fail?

What made it possible?

Where else could it happen?

What must change?

Evidence before opinion

Four sources. Every case.

People

Witnesses, operators, supervisors, specialists and managers.

Position

The scene, measurements, conditions and reconstruction.

Parts

Vehicles, machinery, components, tools and materials.

Paper & digital

Procedures, permits, records, video, data and history.

Evidence & scene management →

The method follows the evidence

We do not force every case into one method.

Events & Causal Factors · Timeline→ Bow-Tie & Barrier Analysis→ Human Factors→ Change Analysis→ 5 Whys / Why Tree→ Fault / Analytical Tree→ Investigative Interviewing→ The P3i Causation Model→

From incident to organisational learning

Closing an investigation is not the same as learning from it.

Could this happen somewhere else?

Are the same weaknesses in another site, department or operation?

Do the corrective actions address the real causes?

How will we know the risk has actually fallen?

Your case will be confidential too. Talk to us.

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