Accident Investigation

Reconstructing the sequence of events makes it possible to examine the barriers, the system factors and the conditions present at each decision. Reducing a complex event to one person's error leaves part of what happened unexplained and limits what the organization can learn.

Technical work that starts with respect for people

A fatality demands rigor, care and the ability to handle sensitive information. The investigation seeks an in-depth understanding of the event, looking at immediate causes, contributing factors and system conditions.

Supporting the people affected and preserving evidence begin together, in a coordinated way. Listening carefully to those involved is part of the work. It can reveal pressures, changes and conditions that do not show up in procedures or records.

Events that call for a structured investigation

• After a fatality or a serious accident.
• When a high-potential event needs an analysis proportional to its severity.
• When the internal investigation only reached the immediate causes or produced conflicting interpretations.
• When the organization needs technical leadership to bring together different departments and perspectives.
• When an investigation already under way needs to be reviewed or taken further.

The service focuses on fatalities and serious accidents. Other events can be considered based on their criticality and the organization's needs.

How the investigation is conducted

The design depends on the event, the information available and the responsibilities involved. The work may include:

• Defining the scope and organizing the multidisciplinary team;
• Listening to the people involved and analyzing the available records;
• Understanding the sequence of events and the conditions present at each decision;
• Identifying immediate causes, contributing factors and issues related to the management system;
• Analyzing the barriers that were in place, failed or were missing;
• Reviewing the proposed actions and how they relate to the hierarchy of controls;
• Consolidating the lessons learned and the criteria for tracking actions;
• Reviewing or deepening an investigation conducted previously.

Tools are chosen according to what the investigation needs to clarify. The work does not start from a ready-made answer, nor does it look for a single cause to explain a complex event.

Responsibilities and limits of the work

Our role in the scope is defined and coordinated with the organization's departments and with the professionals legally responsible for legal, regulatory, labor or forensic obligations.

The work is organizational and preventive in nature. It does not replace a technical or court-appointed forensic examination, legal counsel, or any formal duty reserved for another professional.

Investigation and Culture Assessment

An investigation starts from a specific event. The Safety Culture Assessment looks at broader patterns in the organization, such as leadership, trust, response to risk and the gaps between what is said and what is done.

A fatality can reveal issues that call for a broader cultural reading. The assessment, in turn, can expose weaknesses in how the organization recognizes risks and learns from events.

Published experience

The Projects page records support for incident investigation in the work carried out with Bayer.