After the event · Investigations and advisory
Investigate the same way, and you will reach the same conclusions.
Independent learning reviews of significant events, and support for organisations that want their own investigations to produce learning rather than a name. Led by someone who has carried out fatal accident investigations for two national defence forces.
The problem with most investigations
The report found the person. The system was left intact.
After a serious event, there is strong pressure to explain it quickly. The investigation works backwards from the outcome, stops at the last person to act, and recommends retraining or a new rule. The requirement is satisfied, but the conditions that made the event possible are still there.
A learning review asks a different question: not who made the mistake, but what the system made normal, and what it would take to change that. It treats the people involved as the best source of understanding rather than the cause, and it looks at what was different on the day compared with every day it went well.
Human error is where the investigation should start, not where it ends.
The principle behind every review we leadHow we can help
Three kinds of support.
Some organisations need an independent review of a specific event. Others want to know whether their existing process is producing learning, or to build the skills to do this work themselves. Many need a mix of all three.
Independent review
A systemic review after a significant event
An independent learning review that looks at the conditions behind the event, how the actions made sense at the time, and what needs to change. Written to be learned from, not filed.
Suits organisations after a serious incident or near miss who want a systemic review rather than a blame-attribution report.
Process review
Is your investigation process producing learning?
We look at how your organisation investigates and responds to events, using recent reports and conversations with the people involved, and show where the process is generating learning and where it is generating paperwork.
Suits leadership and safety teams who suspect their reviews keep reaching the same conclusions.
Building capability
Support for your own investigators
Advice, review and mentoring for the people who run investigations in your organisation, alongside help to build a Just Culture framework that makes honest accounts possible.
Suits HSE and safety teams building the internal capacity to run learning reviews themselves.
The LFEO Learning Review
Four stages, so nobody rushes to the answer.
Most event discussions start in the middle. Someone tells the story, others say what they would have done, and within minutes there is a cause and a fix, usually landing on the person closest to the outcome. A clear shape slows that rush. Each stage has its own job, and the next one cannot do its job until the last has finished. Unlike improvement cycles that begin with a change to test, the review begins with an outcome you want to understand.
Stage 1
Prepare
Everything that happens before detailed questions are asked.
- Look after the people involved first
- Secure information before it disappears
- Decide the level of review needed
- Agree in writing what the review is for, and keep it separate from discipline
Within 72 hoursfor a serious event
Stage 2
Discover
The first story grows into one with context, and the timeline takes shape.
- Understand events from the view of those who were there
- Stay in learning mode, away from solutions and "why didn't you just..."
- Protect soak time, when details surface overnight
Within 21 daysthe story is shared back with those involved
Stage 3
Synthesise
From what happened to why it made sense at the time.
- Those involved check the timeline first
- Look across PETTEOT, time, and work as imagined versus work as done
- Ask what was working well, and where capacity came from
- Develop proposals with the people who do the work
Within 90 daysa draft report for those involved to comment on
Stage 4
Embed
Proposals become changes, and the story travels.
- A separate group decides which changes to take forward, and owns them
- Actions are tracked to closure
- The story is shared in stages, with identifying detail removed at each step
After 3 to 6 monthsa check on whether the change worked
↻ What the check finds feeds into how the next review is prepared, turning four stages into a cycle rather than a line.
PETTEOT: what to look at
- Person
- Environment
- Tasks
- Tools and technology
- External influences
- Organisation
- Time
Three levels of review
The same four stages, scaled to the event.
The four stages work for a five-minute team debrief and for a review that takes months. What changes is the depth, the time and the skill needed to keep the conversation psychologically safe.
Level 1
Team debrief
Minutes, straight after the task, using four questions: what did we expect, what actually happened, what shaped the difference, and what will we keep or change next time?
Who runs it anyone on the team
Level 2
Small Learning Team
Two short sessions with a night of soak time between them, for an event worth deeper learning where nobody was seriously hurt and the accounts broadly agree.
Who runs it a trained facilitator who was not involved
Level 3
Full LFEO Learning Review
For events involving harm, hierarchy, conflicting accounts, confidentiality concerns, possible consequences for jobs or organisations, or strong emotion.
Who runs it trained and experienced facilitation
A Level 2 review can become a Level 3 when something new surfaces. When that happens, the right move is to pause, protect the people involved and bring in more support. That isn't the review failing. It is the review doing its job.
Where we fit: we lead Level 3 reviews independently, and our Learning from Emergent Outcomes programme prepares your own people to run Level 1 and Level 2 reviews themselves.
Who leads the work
Method, and an understanding of what the findings cost.
Reviews are led by Gareth Lock. He has examined fatal accidents in military settings, and brings both a structured, systemic method and an understanding of what an investigation means to the people and families on the other side of it.
Reviews are priced at a day rate and agreed in writing after the scoping conversation. Everything shared with us is treated in confidence.
Discuss your situation- Fatal accident investigationsFor the UK Ministry of Defence and the New Zealand Defence Force.
- MSc Human Factors and System SafetyLund University, with research on how stories of events shape what organisations learn.
- Learning from Emergent OutcomesThe framework behind our reviews, set out in Gareth's new book.
- Just Culture in PracticeAuthor of the guide used to help organisations respond fairly once the findings are in.
Book a call
Start with a curious conversation.
Tell us what is happening in your organisation, what you have already tried, and what you would like to be different. We will be honest about whether we can help, and point you elsewhere if someone else would serve you better.
Prefer email? Write to [email protected] and we will reply within two working days.