This paper contains several flaws. The first is that investigations are stressful and this leads to short-cuts, errors and assumptions. I disagree. This is the job they signed up to do and although some aspects are unpleasant, it's the job. The second, larger flaw, is that investigators are tainted by initial findings. Again I disagree. You keep interviewing, researching, collecting facts and data until you believe you can justify stopping. The cause may not be evident for some time. This is because only after sufficient facts are unearthed (or kindly presented) can the tough job of "why?" can be answered. The fact-finding has to come first followed by an analysis of the facts as found. The 'blame', if any, can only be attributed during the analysis. This is when the difference between a report written by investigators from a Just Culture varies from a one from a hang'em high mob (rotten apple brigade).