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Calm first.
Then Control.

First, we stabilise the thinking.

Then we structure the problem.

Only then do we decide what to do.

When something feels fragile, the instinct is often to act quickly.

That usually increases motion, but not necessarily clarity.

The approach you need is more deliberate.

Slow the spin.

Structure the problem.

Make risk and work visible.

Clarify the decision space.

Then you move.

The 5 Step Process

This is how the method works in practice.

01 Independent Observation

We begin at the only levels that can be directly observed: behaviour and results.

What are people saying, and not saying?
What are they doing, and not doing?
How is the business actually performing, in hard data rather than narrative?

This is not an opinion exercise. It is disciplined observation. The aim is to separate signal from reassurance.

02 Pattern and Structure

Observed behaviour always sits on deeper structure.

Here we look for patterns.
We examine both unwanted and wanted causal chains.
We look for what is present, what is missing, and how the organisation is structurally arranged.

How are responsibilities distributed?
How do departments interact?
What incentives, beliefs, or assumptions are shaping behaviour?
Where are controls real, and where are they ceremonial?

This step uncovers the unobservable factors that drive behaviour and lead to results.

03 Truth and Reflection

Findings are reflected back using structured models, not personal opinion.

This gives the analysis weight. It allows the conversation to move from “I think” to “Here is the mechanism.”

In a before-event scenario, this often reveals fragility in incident prevention.

In an after-event scenario, this reconstructs how events actually occurred.

Either way, the aim is clarity without blame and reality without drama.

04 Option Generation

Once the structure is visible, options surface naturally.

Interventions are grouped within eight structured areas, with the causal chain determining priority and sequence.

The question becomes:

Where would focused intervention most change the trajectory?
What would that intervention realistically deliver?

This is not about producing a long list. It is about identifying the smallest number of meaningful moves.

05 Decision Enabling

By this stage, the accountable person understands:

What is happening.
What is underneath it.
What could be done.
What the trade-offs look like.

You may not have a fully engineered solution.
You will have a defensible direction.

That is the point at which control becomes rational, rather than reactive.

The approach works whether you are sensing drift before an event, or responding to disruption after one. The sequence does not change. The shape of the work does.

This is not a diagnostic product. It is a disciplined way of thinking about fragility and resolving unease.

This way of working tends to make most impact in the following applications

Operational Reality and Drift

An objective view of how work is actually carried out, and how it may have slowly changed over time.

Causal Chain Integrity

Examining whether warning signs exist across the full pathway to failure, especially upstream where incidents are seeded.

Health of Organisational Controls

Assessing whether the controls relied upon are sufficient, resilient, and effective under real operating conditions.

Capability and Culture

Everyday behaviours, competence, and the human performance conditions that shape them, especially when nobody is watching.

Golden Hour Stabilisation

Preserving people, evidence, and context in the immediate aftermath, before truth is lost or distorted.

Independent Incident Investigation

Objective assessment of what happened, scaled to match seriousness and potential consequences.

Reconstructing the Causal Chain

Reconstructing how controls were weakened, bypassed, or absent across the full system.

Sense-Making Under Scrutiny

Supporting clear thinking and interpretation while under regulatory, board, or workforce pressure.

Typical Engagements

ORGANISATIONAL CONTROLS External

Regulator audit of flood risk arrangements

SITUATION

UK Environment Agency scheduled flood risk audit ahead of a planned site visit.

WHY IT MATTERED

Senior management wanted confidence the arrangements would stand up to scrutiny, without relying on luck.

SUPPORT PROVIDED

Independent review of arrangements. Areas of exposure identified. Senior leadership briefed on gaps and closure measures. Processes and procedures rebuilt into a clear, defensible written scheme of control. Presented to regulator.

Regulator awarded highest possible score. Senior manager unease resolved. Site team coached and left with clarity and future-proof ownership.

Flood Risk Bow-Tie Analysis Written Scheme of Control Process Document Operational Procedures Coaching
INCIDENT INVESTIGATION In-House

HV Switching Near Miss Investigation

SITUATION

A routine high-voltage switching exercise resulted in a near miss despite the presence of long-standing Safety Rules intended to prevent it.

WHY IT MATTERED

Scrutiny was immediate. Leadership needed an objective account of what happened, and whether controls were being applied with the rigour depended on.

SUPPORT PROVIDED

Objective review of the near miss and the application of Safety Rules in practice. Delivered a decision-ready briefing and a prioritised set of actions to restore discipline.

Drift from critical verification steps became visible. Written instructions were being relied on where active confirmation was designed to be the safeguard. What needed reinforcing was clear.

Incident Investigation Work Imagined vs Work Done Analysis Evidence Capture Barrier Analysis Human Factors Analysis
Competence and Culture External

Competence framework review for major hazard facility

SITUATION

A key role-holder departure exposed reliance on tacit knowledge. Role coverage and competence were not visible as a single, shared picture, and day-to-day work extended well beyond what job descriptions captured.

WHY IT MATTERED

Leadership needed confidence that critical functions were covered and sustainable through turnover, not dependent on specific individuals remaining in post.

SUPPORT PROVIDED

Role and function mapping across the organisation to reveal true scope, interfaces, and single points of dependency. Role profiles and a competence framework built around critical tasks, with practical assessment criteria and a clear route to strengthen resilience.

Dependency risk became visible. Leadership left with a decision-ready route to improve competence assurance and reduce vulnerability to staff movement.

Role & Function Mapping Critical Task Analysis Competence Framework Design Competence Assessment
ORGANISATIONAL CONTROLS External

Safety Case review of major accident scenarios

SITUATION

It was not clear whether critical hazard scenario controls were adequate and reliable, and that knowledge sat with individuals, not the organisation.

WHY IT MATTERED

Leadership needed defensible evidence that critical controls would hold in the highest consequence scenarios.

SUPPORT PROVIDED

Independent review of controls for the highest consequence scenarios. Assurance activities documented and mapped to make verification, degradation risks and evidence gaps visible. Findings briefed to middle and senior leadership.

Leadership gained a clear, defensible picture of what the plant relied on, where assurance was strong, and where assurance needed strengthening.

Bow Tie Analysis Critical Control Review Assurance Mapping Knowledge Capture Evidence Gap Analysis

If any of these resonate, it is usually the right moment to talk.

Where this approach fits, and where it doesn’t

Built for accountable leaders who want evidence, not reassurance, and who can act on what we find.

Where it fits best

  • When something feels fragile but cannot yet be clearly named.
  • When weak signals or near misses keep appearing.
  • When the simple explanation for an incident feels incomplete.
  • When leaders need clarity before committing to visible action.
  • When reassurance has started to substitute for evidence.

Where it does not fit

  • When reassurance is the primary objective.
  • When a rubber stamp is required.
  • When the solution is already decided and only endorsement is needed.
  • When there is no appetite to surface uncomfortable truths.
  • When authority is absent and structural change is off the table.

This works best when there is both authority and willingness. Without them, clarity has nowhere to land.

How The First Engagement Usually Begins

The first conversation is structured and deliberate.

It is not a sales call.
It is not an audit.
It is not a performative review.

It is a disciplined orientation where we:

  • put form to what you are dealing with
  • clarify what success would look like
  • sketch which intervention areas may matter most

You leave the conversation with clarity about:

What is actually happening.
What is underneath it.
What might change the trajectory.

Sometimes that clarity is enough.
Sometimes it defines a deeper piece of work.

Either way, the objective is the same.

Calm first. Then Control.

01 Shape the situation
We put shape to what you’re dealing with, so you’re not treating different problems as the same one.

Unease before an event has a different structure to disruption after one. Quiet drift is not the same as visible failure. Treating them the same is how organisations waste time, money, and credibility.

Clarity begins by recognising the shape of what you are actually dealing with, not what it superficially resembles.

If this way of thinking resonates, the next step is simple.

End the unease.

Begin the orientation.

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