Organisational investigations
Find the cause. Fix the system.
When a problem keeps coming back, we go inside your organisation, talk to your leadership team and the people below them, and give you a written finding: what is causing it, what it is costing you, and what to change.
01 / When to call us
Three signs the problem is structural.
If one of these describes your business, 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 changing the structure were the fix, it would have worked on the first attempt.
Agreed in the room, not funded outside it
The minutes say the decision was unanimous. What actually gets funded afterwards says something else.
The reports did not change anything
You already hold good analysis. The recommendations were written before the diagnosis was finished, so the underlying problem is still there.
Recognise one of those? The first meeting costs nothing.
Book the first meeting 90 minutes · Written outcomeAn accident does not begin when something goes wrong. It begins when the system stops being able to see itself.
Applied from ICAO Annex 13, the international standard for air accident investigation.
02 / How we investigate
Four phases. The same four, every time.
The four phases are the same in every engagement. That is what lets us tell you how your business compares with the others we have examined, rather than just describing it.
Preserve the scene
We collect the evidence already sitting in your business before anything moves: board packs, minutes, exit interviews, the org chart and the one people actually use.
Listen properly
One-to-one sessions across the leadership team and the layer below. Nothing is attributed to anyone. We record what people actually say, word for word.
Trace the cause
A dated timeline of decisions, followed back four levels past the symptom. A failure like this usually rests on 7 to 12 small factors rather than one big one.
Score the defences
Strategy, communication, trust, accountability and escalation, each scored from the evidence. The finding is the place where all five have a gap at once.
03 / How we fix it
The FRANK Method™
Find out what is really happening. Then fix what is causing it. An investigation with no intervention is an expensive document. An intervention with no investigation is a guess.
Frame the reality
We put the facts and the evidence in front of the team as one shared picture, so the conversation afterwards has somewhere solid to stand.
Reflect on alignment
We check whether what the team actually did matches what it agreed to do. The question is what the system was missing, not who is at fault.
Articulate the impact
We put a number on it: delay, rework, replacement costs, slow decisions, penalty exposure. A board can act on a finding it can price.
Name the adjustments
We agree exactly what changes, who owns each change, and how anyone outside the room could tell it was done.
Kickstart realignment
Twelve weeks of putting the changes into practice, tracked against the register, with our support withdrawn on a schedule you can see in advance.
04 / Where the method comes from
Fix the system. Not the pilot.
Our method is adapted from air accident investigation. When a plane crashes, investigators do not ask who to blame. They ask what the system was missing. We ask the same question inside a business.
05 / What you get
Four documents, and one you keep using.
Preliminary report
A written position on three things: whether this looks like an alignment problem, what an investigation would examine, and what it would cost. Where we conclude that an investigation is not warranted, the report says so in the first paragraph and there is nothing further to pay or decide.
Findings report
Numbered findings, one to a page, each carrying the pattern, the evidence and the consequence together. How many people we heard it from is in the sentence.
Alignment register
Every change scored, owned by one named person and given a completion test somebody outside could verify. This is the one your board keeps.
Embedding protocol
A published schedule for withdrawing our support, with the register re-scored at each step so you can see whether the fixes are holding.
Specimen · alignment register
| Ref | Change | Owner | Sev. | Det. | Status |
|---|---|---|---|---|---|
| A-01 | Decision rights restated for capital spend above threshold | Chief Financial Officer | 8 | 7 | OpenMonitoring |
| A-02 | Escalation route published, with a stated time to respond | Chief Operating Officer | 7 | 9 | Open |
| A-03 | Minutes record dissent by function rather than by name | Company Secretary | 5 | 4 | Monitoring |
| A-04 | Incident reviews separated from performance reviews | Chief People Officer | 6 | 8 | Closed |
| A-05 | Escalation on capital variance routed through the Chief Financial Officer's own office | Chief Financial Officer | 9 | 2 | Open |
Specimen only. The figures are made up and describe no client.
Severity and detectability are each scored 1 to 10. Severity is how bad the impact would be if the gap stays open. Detectability is how easily anyone outside would notice that it exists.
06 / What it costs
A fixed scope and a fixed fee.
We do not quote a day rate. You are buying a finding, not a number of days.
The first meeting
90 minutes with the executive who would sponsor the work. It ends with a written position: the preliminary report.
The investigation
The full investigation and the intervention that closes it. Priced by how many defences are in scope, not by hours.
Realignment
The fix on its own, where a sound investigation already exists and the business has not been able to act on it.
Register oversight
Quarterly re-scoring reported straight to the board, independently of the executives it measures.
07 / The decision
Two things can happen. One of them is happening already.
The problem continues
- You restructure the same area a third time
- Decisions keep getting made on a version of the business that was tidied on the way up
- People leave, are replaced, and the replacements meet the same conditions
- You automate on top of the record exactly as it stands
You can see it
- A dated chain of cause your executive team can look at together
- Five defences scored, and the exact place where the gaps line up
- Changes with named owners and tests anyone could verify
- A register your board can re-score without us in the room
08 / Start here
90 minutes, and a written answer.
Questions rather than a presentation. It ends with a written position on whether an investigation is warranted. If it is not, that is what the report says.
Four-minute check
Ten questions, on your own, on screen. Ends with a drawing of where your gaps line up.
Take the check Step 02 · 90 minutesThe first meeting
About your business, with whoever would sponsor the work. Ends with a written position: the preliminary report.
Book the first meeting Step 03 · 12–16 weeksThe investigation
The full inquiry and the intervention that closes it. From US$35,000.
How it runsNot a problem that keeps coming back? If it is a decision in front of you, Frank Tsuro advises leaders one to one. Frank Tsuro’s advisory
We need a sponsor with the authority to act on whatever the investigation finds.