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Incidents & operations

Incident investigation

After a serious incident or a near miss, the useful question is why the system allowed it, not who to blame. We investigate independently, reconstruct the sequence from evidence and interviews, and trace the causes back to the controls that failed or were never there. Recommendations are specific enough to implement and to verify.

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What you receive

Concrete outputs you can use the day they arrive. Scope and format are agreed in the proposal.

  1. 01 Evidence log, timeline and sequence-of-events reconstruction
  2. 02 Root-cause analysis to system and control level
  3. 03 Investigation report written for both the board and the plant
  4. 04 Corrective and preventive action plan with owners and dates
  5. 05 Lessons-learned briefing for other sites in the group

How we work on this

  1. 01

    Secure the facts

    Preserve evidence, collect documents and take statements early, before memory fades.

  2. 02

    Reconstruct

    Build the timeline and test each step against what the evidence supports.

  3. 03

    Find the causes

    Trace immediate and underlying causes to the controls, decisions and conditions behind them.

  4. 04

    Recommend and verify

    Actions with owners and dates, then a follow-up to check they closed and worked.

An example

Illustrative example

Independent investigation of a high-potential near miss

Sequence reconstruction, root causes traced to two missing controls, and actions verified three months later. To be replaced with a real anonymised case.

Illustrative: shown to explain the format. It is not a client result.

Often combined with

Tell us the site, the sector and the problem.

You get a reply from the consultant who would do the work, with a scope, a fee basis and an honest view on whether it is worth doing.

Request a proposal

arildo@settigroup.com