His name was Michael. Thirty-two years old. Two kids under 5 years old.

I stood in the plant manager's office reviewing the preliminary incident report. "Fall from height," it read. "Inadequate fall protection. Worker failed to clip on."

Three sentences. One life reduced to a procedural violation.

But I'd learned to read between the lines. So I went to the site. Talked to Michael's work mates. Not in the meeting room—at the job site, during their breaks, where people actually talk.

"We told them the anchor points were too far apart," one said.

"You can't reach the next clip point without unclipping from the last one," said another.

"Michael knew. We all knew. But the job had to get done."

I looked up at the work area. The anchor points were twelve feet apart. The safety harness lanyard was six feet long. The math didn't work. It had never worked.

Michael didn't fail to clip on. The system failed Michael.

I pulled the maintenance records. The anchor configuration had been identified as inadequate eighteen months earlier. The modification was "pending budget approval." Cost: £1,200.

We spent £80,000 investigating Michael's death. We'll spend more on the legal settlement. But we couldn't find £1,200 to fix what we knew was broken.

When I present my findings, I don't start with "root causes" or "contributing factors." I start with Michael. I show his picture. I say his name. Because that's who we failed.

Then I show them the eighteen-month-old maintenance request. The budget meeting minutes. The production schedule that didn't account for working safely. The gap between what the risk assessment said and what was actually possible.

Investigation isn't about documents and diagrams. It's about the person who isn't coming home.

Every time I map out an accident sequence, draw a fault tree, or trace back organisational decisions, I'm asking: where did we—not Michael, but we—go wrong?

Next time, in the final post of this series: The framework I use to ensure we're asking the right questions about the right failures. Because Michael deserves better than "failed to clip on."

So do the people working in your organisation right now.