Organisational investigations for boards and chief executives
Find the cause.
Fix the system.
When a problem keeps coming back, 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: the cause, the cost and what to change.
- 12–16 weeksto a written finding and agreed changes
- Fixed scope, fixed feeagreed before the first interview
- Independentoutside your reporting line, and we leave
3 signs the cause 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.
We work for the boards and chief executives of organisations where a small failure costs millions: a mobile operator, a mine, a bank, a utility.
The sample report
Judge the work, not the brochure.
Most firms describe what they would produce. This is the thing itself: a real preliminary report, disguised, written after one 90-minute meeting.
Preliminary report · Section 01 · The position
The Group is running 2 different definitions of plant availability. Operations plans maintenance against one, and Commercial contracts against the other. Neither function is in error, no document reconciles the 2, and the maintenance programme has been relaunched 3 times against a number it could not meet.
Where the gaps line up
No owner, no document, no deadlinefor reconciling the 2 numbers.
What it is costing
US$4.2m a monthThe low case, built from the Group’s own figures.
What to do now
One page, both numbersSide by side, every month. It costs nothing.
Fix the system.
Not the pilot.
Flying became one of the safest ways to travel by learning from every accident. Our method is adapted from how those accidents are investigated.
No blame
The international standard for air accident investigation exists to prevent the next accident, not to apportion blame. Investigators ask what made the mistake likely. So do we.
Confirmed twice
A claim becomes a finding only when a second source agrees: another person, a document or a number.
Facts, then the board
A finding says what arrived, when and what followed, never motive or character. We establish the facts. The board makes the call.
3 steps, in this order
Investigate first. Fix second. The scope and the fee are fixed before we start.
Week 0 · No fee
Talk
90 minutes with the executive who would sponsor the work, and a clear answer on whether an investigation is worth doing.
Weeks 1–14
Find the cause
Confidential interviews, from the leadership team to the front line, set against the record. Then the written finding.
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 stay for 12 weeks, then step back.
What we found, and what it cost
From 6 investigations, disguised. The mechanism and the order of magnitude are unchanged.
If nothing changes, the problem stays.
It returns after the next restructure, and the board keeps approving plans it cannot see becoming action. The first meeting is 90 minutes, with no fee, and ends with a clear answer.
Not a problem that keeps coming back? If it is a decision in front of you, Frank Tsuro advises leaders one to one.