2023–2026 · Power transmission
ISA Energia Brasil
Support for the investigation of a fatal accident, including analysis of behavioral triggers and risk amplifiers.
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Accident Investigation
An investigation needs to establish what happened and respect the people involved. We lead, review, or deepen investigations of serious accidents, including fatalities, alongside the organization’s teams.
Discuss the investigationReconstructing the sequence of events helps examine the barriers, system factors, and conditions surrounding 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 begins with respect for people
A fatality calls for rigor, care, and the ability to handle sensitive information. The investigation seeks to understand the event in depth. It considers immediate causes, contributing factors, and system conditions.
Support for people and the preservation of evidence begin in a coordinated way. Listening carefully to those involved is part of the work. It can reveal pressures, changes, and conditions that do not appear in procedures or records.
Events that require a structured investigation
- After a fatality or a serious accident.
- When a high-potential incident requires analysis proportionate to its severity.
- When an internal investigation has identified only immediate causes or produced conflicting interpretations.
- When the organization needs technical guidance to bring together different areas and perspectives.
- When an investigation already underway needs to be reviewed or examined in greater depth.
The service focuses on fatalities and serious accidents. Other events may be assessed according to their criticality and the organization’s needs.
How the investigation is conducted
The approach depends on the event, the information available, and the responsibilities involved. The work may include:
- Defining the scope and organizing a multidisciplinary team;
- Listening to the people involved and analyzing available records;
- Understanding the sequence of events and the conditions surrounding each decision;
- Identifying immediate causes, contributing factors, and issues related to the management system;
- Analyzing the barriers that existed, failed, or were absent;
- Reviewing proposed actions and their relationship with the hierarchy of controls;
- Consolidating lessons learned and criteria for monitoring actions;
- Reviewing or expanding on a previous investigation.
Tools are chosen according to what the investigation needs to clarify. The work does not start with a ready-made answer or seek a single cause to explain a complex event.
Responsibilities and limits of the work
Participation within the scope is defined and coordinated with the organization’s departments and the professionals legally responsible for legal, regulatory, labor, or forensic obligations.
The work is organizational and preventive in nature. It does not replace technical or court-appointed expert examination, legal advice, or duties formally reserved for another professional.
Investigation and Culture Assessment
An investigation starts with a specific event. The Safety Culture Assessment examines broader organizational patterns, such as leadership, trust, responses to risk, and differences between what people say and what they do.
A fatality may reveal issues that need a broader cultural assessment. The assessment, in turn, may show weaknesses in how the organization recognizes risks and learns from events.
Published experience
The Projects page documents support for incident investigation in the work carried out with Bayer.
Investigation support for organizations
All projects2019 · Pharmaceuticals
Bayer
Support for incident investigation, among the areas of work described in the project.
Explore the projectFurther reading
In this article, I discuss preparedness and the decisions that come before an accident.
Other services
All services
Safety Culture Assessment
Gaps between words and practice, cultural maturity, and priorities for leadership.
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Maturity assessment for serious and fatal incident prevention (SIF)
Assessment of the prevention program using an exclusive methodology, focused on critical exposures and controls.
Explore the serviceSupport to understand the event.
Tell us the type of event, the current stage of the investigation, and what support is needed.