Organisational investigations // For boards and chief executives

Find the Cause. Fix the System.

When a problem survives 2 restructures, the cause is usually in the system, not the people. We investigate it the way air accident investigators examine a crash. Your board receives a written finding: what is causing the problem, what it costs and what to change.

Board pack // Item 6 // Quarter 3 Page 14 of 62 Operations report Overall status Quarterly targets Regional restructure Escalations Risk register Green Met, with minor variances Complete None raised this quarter No new risks FOUND Green for 14 months. Nobody has tested it.
Above the glass is what the board was told. Under it is what an investigation found.Specimen. A composite of disguised cases. It describes no client.

Exhibit 01 // The story

The Green Dashboard

Our founder’s own story, and the reason this approach exists.

  1. For 2 years

    The board reviewed a green dashboard.

  2. Meanwhile

    A systems change had stalled. The people doing the work knew why. Nobody could say so.

  3. The turn

    The chair asked our founder to find out. He listened to the people doing the work.

  4. Then

    The chair heard the truth. The board changed the targets.

  5. 3 months later

    The system launched.

Ask it of every green report: who told us, and how do they know?

Nobody lied. Each layer softened the bad news a little, and the softening added up. We find out what the people doing the work already know, and put it in writing for the board.

Exhibit 02 // The problem

3 Signs the Problem Is in the System

If one of these describes your organisation, the cause is unlikely to be the people you have been changing.

It Keeps Coming Back

You have restructured the same area more than twice, and the problem returned each time. If the structure were the cause, the first change would have fixed it.

Agreed in the Room, Not Funded Outside It

The minutes say the decision was unanimous. What gets funded afterwards says something else.

The Reports Changed Nothing

You already hold good analysis. The recommendations were written before the diagnosis was finished, so the problem is still there.

Where a Small Failure Costs Millions

At a mobile operator, an outage of a few minutes can stop calls and payments for millions of people. At a mine, one power failure can stop production for a whole shift. These are the organisations we work for. These are the people who call us.

  • Board chairs and directorsReports say the plan is on track. Results say it is not.
  • Audit and risk committee chairsClean audits and a quiet risk register that feel too clean.
  • Chief executives and chief operating officersThe same problem back after the second restructure.
  • Chief risk officers and heads of internal auditFindings raised, closed and raised again.

Exhibit 03 // Why the cause hides

Fix the System. Not the Pilot.

Our method is adapted from air accident investigation. Investigators there may not ask whose fault it was, because blame does not prevent the next accident. They ask what made the mistake likely.

Every organisation leans on 5 defences. Each one has gaps. A failure gets through only when the gaps line up.

Select a defence to weaken it, or select it again to make it sound.

One weak defence is survivable.

After the Swiss cheese model, James Reason, 1990.

Exhibit 04 // The plan

3 Steps, in This Order

A fixed scope and a fixed fee, agreed before we start.

  1. Week 0 // No fee

    Talk

    90 minutes with the executive who would sponsor the work. You leave with a clear answer on whether an investigation is worth doing.

  2. Weeks 1–14

    Find the Cause

    Confidential interviews, from the leadership team to the front line. Your board receives a written finding: what is causing the problem, what it costs and what to change.

  3. Weeks 12–28

    Fix It and Keep It Fixed

    Using the FRANK Method™, every change gets one owner and a test anyone can check. We support your team for 12 weeks, then step back.

Exhibit 05 // What is at stake

If Nothing Changes, the Problem Stays

If nothing changes

  • The problem comes back after the next restructure.
  • Good people keep leaving, with nothing specific in the exit interview.
  • The board keeps approving plans it cannot see becoming action.

After the investigation

  • You know why it keeps happening, in writing.
  • The fix targets the cause, so it holds.
  • Your board can act, because the cost has a number on it.