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Change Analysis

What was different this time? That is where the cause hides.

Most incidents happen on a day that was different. A new supplier, a borrowed machine, a double shift, a changed setting. We line up the normal day against the incident day, list every difference, and prove which ones mattered.

NORMAL DAYINCIDENT DAYShiftDay shift≠Third night in a rowMaterialUsual supplier≠New supplierFloorDry=Dry

≠ a difference to test  ·  = the same, ruled out

Normal operation compared with the incident day during an investigation

Since the 1990s

30

years investigating

250+

investigations closed, incl. HiPOs

15

countries served

20+

countries of lead seminars

100+

nationalities trained

Spot what changed

A forklift tipped over in a Karachi warehouse. Compare it with a normal night.

Switch on the differences, then tap any row to see whether it mattered. Illustrative example.

8 factors compared

FACTORNORMAL NIGHTINCIDENT NIGHTVERDICT

SHIFT · CHANGED · CAUSAL

Fatigue after three nights reduced his hazard awareness on the turn.

Normal day and incident day compared side by side on a whiteboard
Two columns, one question: what was different?

Why it works

People remember the incident. They forget what was normal.

1

It turns "we have done this a hundred times" into a list of what was different this time.

2

It is fast: a first comparison can be built on the first day of fieldwork.

3

It shows leadership exactly which change needed a review and did not get one.

Use it for

Something that usually works suddenly failed

New suppliers, staff, equipment or settings

Events after a reorganisation or shift change

On its own it cannot

Explain a problem that has always existed

Show why the change was not reviewed

So we pair it with

Events & Causal Factors →The P3i Causation Model →Bow-Tie & Barrier Analysis →

Method names are given for reference. Several are proprietary or trademarked; P3i selects the approach that suits each case and does not claim licensed certification in proprietary methods.

Shift rosters compared for the normal and incident days
Rosters show the third night in a row.
Supplier delivery notes checked during a change analysis
The new supplier’s taller stacks.
Forklift service record reviewed
The borrowed truck’s overdue service.

Something failed that has never failed before? A first call costs nothing, and we will tell you what to compare.

Talk to an investigator WhatsApp

The P3i approach

How we investigate by finding what changed. Fact-finding, not fault-finding.

Every P3i investigation is led by a senior investigator and supported by internationally qualified process specialists. You will not receive a list of people to blame, or a long list of generic actions. You will receive the facts, the proven causes, and a short plan that closes the gaps, in this case and across your system.

Independent

No products, repairs or contracts to sell you afterwards.

Senior-led

Thirty years of investigation, from the first call to the final briefing.

Beyond the event

Process specialists find the other cracks before they fail.

Ready to present

Written for boards, buyers, insurers and regulators.

How P3i does it for you

  1. 01

    Define the normal day

    What usually happens when things go right.

  2. 02

    Line up the incident day

    Side by side, line by line.

  3. 03

    List every difference

    People, materials, settings, schedules, suppliers.

  4. 04

    Test each change

    Which ones actually mattered — with evidence.

  5. 05

    Put change control in place

    So the next change is reviewed before it bites.

What you receive

Normal vs incident comparisonList of changesChanges that matteredChange-control gapsAction planBriefing

Call us when

"We have done this a hundred times"A new supplier, shift or setting came inOutput or quality dropped suddenlyNobody reviewed the change

Free 30-minute case assessment.

Tell us what happened. In confidence, we will tell you what the investigation should cover, how long it will take and what to preserve today.

Questions

What managers ask about change analysis.

What counts as a change?

Anything that differed from a normal, successful day: people, shifts, materials, suppliers, equipment, settings, procedures, weather and workload.

How do you define the normal day?

From records and interviews about recent days when the same work went right, not from the written procedure alone.

Is every change a cause?

No. Each difference is tested against the evidence. Many are ruled out; the ones that remain are the causal changes.

Does it help us prevent the next one?

Yes. It usually shows where change control was missing, so future changes are reviewed before work starts.

Find what changed. Then control the next change.

Discuss a caseTrain your team in RCA
Investigator measuring a pallet stack height
Measuring what changed, not guessing.
Management of change form reviewed
The change nobody reviewed.