{
  "schemaVersion": 2,
  "title": "Fictional • Northbank dispatch investigation",
  "site": "Northbank Engineering — fictional dispatch bay",
  "hazard": "Moving forklift vehicles and pedestrians in a dispatch bay",
  "topEvent": "Pedestrian and moving vehicle occupy the same space",
  "scope": "Training only. Vehicle/pedestrian segregation during temporary layout changes. No real people, records or outcomes. Fictional connected learning example: Investigate evidence → Pro hypothesis testing → Bowtie safeguards → Assure verification. All outcomes below are invented training records, not operational evidence.",
  "owner": "Training investigation lead",
  "reviewDate": "2026-11-30",
  "threats": [
    {
      "id": "snbThreat",
      "title": "Temporary diversion bypasses pedestrian segregation",
      "description": "Illustrative mapping from supported Pro finding snbF1 and source evidence snbE2. Review before operational adoption."
    }
  ],
  "consequences": [
    {
      "id": "snbConsequence",
      "title": "Pedestrian struck by a moving forklift",
      "description": "Potential consequence; the fictional event was a near miss. Ratings are illustrative judgements.",
      "likelihood": 3,
      "severity": 5,
      "residualLikelihood": 2,
      "residualSeverity": 5
    }
  ],
  "barriers": [
    {
      "id": "snbBarrier",
      "title": "Physical pedestrian segregation",
      "kind": "preventative",
      "pathId": "snbThreat",
      "owner": "Training site manager",
      "type": "Engineered",
      "critical": true,
      "status": "Unknown",
      "standard": "Approved separation remains continuous; no temporary route creates an uncontrolled crossing.",
      "verificationDue": "2026-11-20",
      "pfd": "",
      "independent": false,
      "independenceGroup": "",
      "description": "Fictional teaching control; requires site-specific engineering and approval."
    },
    {
      "id": "snbMitigation",
      "title": "Vehicle speed limiting",
      "kind": "mitigative",
      "pathId": "snbConsequence",
      "owner": "Training site manager",
      "type": "Engineered",
      "critical": true,
      "status": "Unknown",
      "standard": "Competent testing confirms the site-approved speed limit. Not asserted to prevent all injury.",
      "verificationDue": "2026-11-20",
      "pfd": "",
      "independent": false,
      "independenceGroup": "",
      "description": "Fictional teaching control; requires site-specific engineering and approval."
    }
  ],
  "factors": [
    {
      "id": "snbFactor",
      "title": "Temporary layouts bypass change approval",
      "barrierId": "snbBarrier",
      "description": "Mapped from supported Pro finding snbF3 and evidence snbE3."
    }
  ],
  "degradationControls": [
    {
      "id": "snbDegradation",
      "title": "Temporary layout approval and pre-use walkdown",
      "factorId": "snbFactor",
      "owner": "Training operations manager",
      "status": "Unknown",
      "standard": "Every temporary change has an approved route plan and an independent pre-use segregation check.",
      "verificationDue": "2026-11-20",
      "critical": true,
      "description": "Linked to corrective action snbAction3 and Pro assurance plan snbPlan3."
    }
  ],
  "inspections": [
    {
      "id": "snbInspection",
      "title": "Fictional pre-use walkdown: process incomplete",
      "controlId": "snbDegradation",
      "date": "2026-10-01",
      "result": "Partial",
      "inspector": "Training independent reviewer",
      "evidence": "Invented exercise record: two of three temporary changes had documented pre-use checks; one did not. This is not a real inspection.",
      "nextDue": "2026-11-20",
      "recordedAt": "2026-10-01T10:00:00Z"
    }
  ],
  "incidents": [
    {
      "id": "snbIncident",
      "title": "Forklift near miss during a temporary route diversion",
      "date": "2026-09-14",
      "barrierId": "snbBarrier",
      "method": "Root cause analysis",
      "severity": "Near miss",
      "timeline": "See evidence-linked event timeline.",
      "evidence": "Fictional E-01, E-02, E-03 and E-07; no actual documents are attached.",
      "analysis": "Test layout-control and mechanical explanations separately.",
      "causes": "Temporary route bypassed segregation; temporary layouts were outside the approval checklist.",
      "lessons": "Apply the change process to temporary arrangements; confirm physical separation before use.",
      "status": "Learning review",
      "owner": "Training investigation lead"
    }
  ],
  "actions": [
    {
      "id": "snbAction1",
      "title": "Restore and verify the segregated route",
      "linkId": "snbF1",
      "owner": "Training site manager",
      "due": "2026-09-20",
      "priority": "High",
      "status": "Open",
      "evidence": "",
      "description": "Remove obstruction; arrange competent verification before reopening."
    },
    {
      "id": "snbAction3",
      "title": "Include temporary layouts in change approval",
      "linkId": "snbF3",
      "owner": "Training operations manager",
      "due": "2026-09-25",
      "priority": "High",
      "status": "Open",
      "evidence": "",
      "description": "Require a reviewed layout, briefing and pre-use inspection."
    }
  ],
  "lopa": [],
  "workspaceType": "investigate",
  "findings": [
    {
      "id": "snbF1",
      "title": "Temporary walkway crossed the vehicle movement area",
      "status": "Supported",
      "category": "Environment",
      "evidenceIds": [
        "snbE1",
        "snbE2"
      ],
      "rationale": "Consistent accounts and the reconstructed layout support the crossing. Exact separation distance was not recorded.",
      "incidentId": "snbIncident",
      "parentId": ""
    },
    {
      "id": "snbF3",
      "title": "Temporary layouts were excluded from the change-approval checklist",
      "status": "Supported",
      "category": "Organisation",
      "evidenceIds": [
        "snbE3"
      ],
      "rationale": "Document review and supervisor account support this omission. It enabled an unchecked diversion.",
      "incidentId": "snbIncident",
      "parentId": "snbF1"
    },
    {
      "id": "snbF4",
      "title": "Persistent brake malfunction caused the near miss",
      "status": "Refuted",
      "category": "Equipment",
      "evidenceIds": [],
      "rationale": "The post-event test and consistent stopping account contradict persistent malfunction. An intermittent fault is not conclusively excluded.",
      "incidentId": "snbIncident",
      "parentId": ""
    },
    {
      "id": "snbF5",
      "title": "Did delivery pressure influence the decision to divert the route?",
      "status": "Open question",
      "category": "People and conditions",
      "evidenceIds": [],
      "rationale": "No reliable workload record available; do not infer motivation from the outcome.",
      "incidentId": "snbIncident",
      "parentId": ""
    }
  ],
  "evidence": [
    {
      "id": "snbE1",
      "title": "E-01 · Accounts and route observation",
      "incidentId": "snbIncident",
      "kind": "Interview",
      "reference": "Fictional exercise E-01",
      "summary": "Two consistent accounts place the pedestrian in the diverted route; no CCTV or speed measurement.",
      "custodian": "Training facilitator",
      "date": "2026-09-14",
      "reliability": "Corroborated"
    },
    {
      "id": "snbE2",
      "title": "E-02 · Layout walkthrough",
      "incidentId": "snbIncident",
      "kind": "Photo",
      "reference": "Fictional exercise E-02",
      "summary": "Temporary pallets blocked the permanent route and the diversion crossed the vehicle area. Reconstructed after the near miss.",
      "custodian": "Training engineer",
      "date": "2026-09-15",
      "reliability": "Corroborated"
    },
    {
      "id": "snbE3",
      "title": "E-03 · Approval checklist review",
      "incidentId": "snbIncident",
      "kind": "Document",
      "reference": "Fictional exercise E-03",
      "summary": "The checklist covers permanent changes; supervisor account confirms no temporary-layout review was required.",
      "custodian": "Training analyst",
      "date": "2026-09-16",
      "reliability": "Corroborated"
    },
    {
      "id": "snbE4",
      "title": "E-07 · Post-event functional check",
      "incidentId": "snbIncident",
      "kind": "Measurement",
      "reference": "Fictional exercise E-07",
      "summary": "Brake response met the exercise acceptance criteria during a post-event test. This cannot prove every condition at event time.",
      "custodian": "Training engineer",
      "date": "2026-09-16",
      "reliability": "Corroborated"
    }
  ],
  "timelineEvents": [
    {
      "id": "snbTime1",
      "title": "Near miss and stop",
      "date": "2026-09-14",
      "time": "08:42",
      "description": "Pedestrian encountered the reversing forklift; movement stopped without contact.",
      "evidenceIds": [
        "snbE1"
      ],
      "incidentId": "snbIncident"
    },
    {
      "id": "snbTime2",
      "title": "Route reconstruction and evidence collection",
      "date": "2026-09-15",
      "time": "09:00",
      "description": "The team recorded the diverted route and preserved accounts.",
      "evidenceIds": [
        "snbE2"
      ],
      "incidentId": "snbIncident"
    }
  ],
  "assuranceControls": [],
  "effectiveness": [
    {
      "id": "snbEffectiveness",
      "title": "Fictional interim change-process review",
      "actionId": "snbAction3",
      "reviewer": "Training independent reviewer",
      "date": "2026-10-01",
      "result": "Partly effective",
      "criteria": "All sampled temporary layouts require approval, briefing and pre-use inspection.",
      "evidence": "Invented learning outcome: one of three sampled changes lacked its pre-use check. The planned ten-change, eight-week review is not complete.",
      "followUp": "Keep action open, correct the missing check and repeat the full sample before considering closure.",
      "nextReview": "2026-11-20"
    }
  ],
  "proCases": [
    {
      "id": "snbBrief",
      "title": "Northbank investigation terms",
      "incidentId": "snbIncident",
      "objective": "Explain loss of segregation, test competing explanations, identify sustainable improvements.",
      "scope": "Dispatch bay layout, temporary changes and vehicle/pedestrian interface. Excludes company-wide transport design.",
      "lead": "Training investigation lead",
      "team": "Training engineer, operational representative, worker representative; reviewer is separate from author.",
      "terms": "Preserve accounts and document references; test hypotheses; require independent workspace and Bowtie transfer review.",
      "expected": "Physical separation and an approved walking route before dispatch starts.",
      "actual": "A temporary obstruction diverted people across vehicle movement.",
      "limitations": "Fictional data. No CCTV or measured vehicle speed. Delivery-pressure question remains open; lead to seek workload records by 30 November. Post-event testing cannot exclude every intermittent fault."
    }
  ],
  "proTests": [
    {
      "id": "snbTest1",
      "title": "Test route crossing explanation",
      "findingId": "snbF1",
      "testMethod": "Compare independent accounts with reconstructed route.",
      "expectedResult": "Both accounts and the layout identify the same crossing.",
      "observedResult": "Accounts and layout align; exact distances unavailable.",
      "result": "Supports",
      "evidenceIds": [
        "snbE1",
        "snbE2"
      ],
      "contradictingEvidenceIds": [],
      "rationale": "Convergence supports the route explanation, within reconstruction limits.",
      "incidentId": "snbIncident"
    },
    {
      "id": "snbTest3",
      "title": "Test temporary-change process omission",
      "findingId": "snbF3",
      "testMethod": "Inspect checklist scope and compare supervisor account.",
      "expectedResult": "No approval trigger for temporary diversions.",
      "observedResult": "Checklist and account consistently exclude temporary layouts.",
      "result": "Supports",
      "evidenceIds": [
        "snbE3"
      ],
      "contradictingEvidenceIds": [],
      "rationale": "Documented omission explains why the changed route was not reviewed.",
      "incidentId": "snbIncident"
    },
    {
      "id": "snbTest4",
      "title": "Challenge persistent brake malfunction",
      "findingId": "snbF4",
      "testMethod": "Review stopping account and post-event functional test.",
      "expectedResult": "Persistent malfunction would prevent repeatable acceptable braking.",
      "observedResult": "Acceptance criteria met in the fictional test; account describes successful stopping.",
      "result": "Refutes",
      "evidenceIds": [],
      "contradictingEvidenceIds": [
        "snbE1",
        "snbE4"
      ],
      "rationale": "Persistent malfunction is not supported. Intermittent behaviour remains a limitation.",
      "incidentId": "snbIncident"
    }
  ],
  "proLinks": [
    {
      "id": "snbLink1",
      "title": "Unchecked temporary change enabled the crossing",
      "incidentId": "snbIncident",
      "causeId": "snbF3",
      "effectId": "snbF1",
      "relationship": "Contributing",
      "evidenceIds": [
        "snbE2",
        "snbE3"
      ],
      "rationale": "The omitted review allowed a temporary route to bypass the intended segregation; other contributing conditions may exist."
    }
  ],
  "proFactors": [
    {
      "id": "snbFactor1",
      "title": "Temporary layout compared with normal route",
      "findingId": "snbF1",
      "dimension": "Change",
      "expected": "Permanent segregated walking route clear.",
      "actual": "Pallets obstructed the route; the diversion crossed vehicle movement.",
      "analysis": "The temporary arrangement changed exposure without a documented segregation review.",
      "evidenceIds": [
        "snbE2",
        "snbE3"
      ],
      "incidentId": "snbIncident"
    },
    {
      "id": "snbFactor2",
      "title": "Information available to the supervisor",
      "findingId": "snbF3",
      "dimension": "Human factors",
      "expected": "Clear trigger and practical authority to stop unsafe temporary changes.",
      "actual": "The checklist did not tell the supervisor to review temporary diversions.",
      "analysis": "Review information and decision conditions before attributing fault. Workload influence remains unverified.",
      "evidenceIds": [
        "snbE3"
      ],
      "incidentId": "snbIncident"
    }
  ],
  "proActionPlans": [
    {
      "id": "snbPlan1",
      "title": "Verify physical route restoration",
      "actionId": "snbAction1",
      "strength": "Engineered",
      "successCriteria": "Competent inspection confirms the approved physical separation before reopening; repeat weekly for four weeks.",
      "baseline": "E-02 records a crossing created by the temporary diversion.",
      "reviewDate": "2026-10-20",
      "residualRisk": "Keep dispatch restricted until separation is verified; later changes may degrade the route.",
      "rationale": "Restore the physical safeguard; training alone would not remove the crossing.",
      "incidentId": "snbIncident"
    },
    {
      "id": "snbPlan3",
      "title": "Check the change process works in practice",
      "actionId": "snbAction3",
      "strength": "Administrative",
      "successCriteria": "Sample the next ten temporary changes over eight weeks: all require documented approval, briefing and pre-use inspection.",
      "baseline": "E-03 excludes temporary changes from the checklist.",
      "reviewDate": "2026-11-20",
      "residualRisk": "The process depends on recognition and compliance; retain physical separation and independent inspection.",
      "rationale": "Addresses the documented process omission alongside the engineered route correction.",
      "incidentId": "snbIncident"
    }
  ],
  "proLayouts": [],
  "proSolutions": [
    {
      "id": "snbSolution1",
      "title": "Restore and inspect physical separation",
      "incidentId": "snbIncident",
      "findingId": "snbF1",
      "actionId": "snbAction1",
      "estimatedEffectiveness": "High",
      "costBand": "Medium",
      "effort": "Medium",
      "timeframe": "Immediate",
      "decision": "Selected",
      "rationale": "Addresses the physical exposure route; restrict dispatch until competent verification.",
      "assumptions": "Illustrative estimates only; requires site-specific design, resource assessment and verification."
    },
    {
      "id": "snbSolution2",
      "title": "Brief workers without changing the route",
      "incidentId": "snbIncident",
      "findingId": "snbF1",
      "actionId": "",
      "estimatedEffectiveness": "Low",
      "costBand": "Low",
      "effort": "Low",
      "timeframe": "Immediate",
      "decision": "Rejected",
      "rationale": "A briefing alone leaves the crossing in place and depends on consistent behaviour.",
      "assumptions": "Not implemented. No measured effectiveness claimed."
    }
  ]
}