Decision 01
Reconstruct before you explain
Incident reconstruction, evidence clustered into a six-category taxonomy, a recurrence map and a failure-chain map.
Designed
Research · Forensic systems investigation
ZEWM_EXCMON
A forensic systems investigation into how a cold-chain temperature exception lost its owner across fragmented institutional layers — told in six evidence frames and a reconstructed evidence chamber.
Reconstruction01 — The investigation in 10 secondsZEWM_EXCMON
The failure was not a missed alert.
- What it is
- An investigation package: six evidence frames, a failure-chain map, a recurrence wall and a rendered evidence chamber, REC-041.
- Who it is for
- Quality, operations and governance teams responsible for recurring exceptions.
- The problem
- In the record, a temperature exception recurs seven times in 48 hours and nobody owns it.
- What is different
- It reads the failure as an inherited governance condition, not a missed alert — and gives every colour exactly one meaning.
- Incidents in 48 h on the recurrence wallDesigned · reconstruction
- 7
- Risk priority number (RPN), rising from 312 to 334Designed · reconstruction
- 312 → 334
- Nodes in the failure chainDesigned
- 8
- Evidence framesDesigned
- 6
Source of these figuresThese figures come from the investigation’s own evidence frames. The record is a reconstruction: it is not presented as a real, verified incident, and no figure is measured operational data.
02 — The design challenge
Seven exceptions. Nobody owned them.
In the reconstructed record, corrective action stayed open for 11 days, the owner field was unassigned, a monitoring dependency was dead and a shift ran an undocumented workaround. The investigation argues the cause was not a missed alert or a software bug.
03 — My contributionIndependent investigation
What I did.
- Investigation framing
- Forensic information architecture
- Evidence taxonomy
- Governance-chain mapping
- Spatial reconstruction direction
- Art direction
04 — Design response3 decisions · reason · evidence
The decisions that shaped it.
Decision 02
One colour, one meaning
Violet for governance, red for failure, amber for warning: colour encodes system meaning, never decoration.
Designed
Decision 03
Make the failure spatial
A static evidence chamber, built from a script in Blender, gives the record a room you can stand in.
Designed · reconstruction05 — Investigation notes
Research / investigationEngineering notes the longer story
The failure was an inherited governance condition: ownership, documentation and responsibility drifted apart until a repeated signal belonged to no one.
Colour encodes meaning, never decoration: violet for governance, red for failure, amber for warning. The chamber is a static spatial reconstruction, built from a script and rendered in Blender.
06 — The evidence
ZEWM_EXCMON
07 — Project status
Research / investigation- Stage
- Research / investigationA research output — an investigation, a method or a set of principles — rather than a product.
- What exists
- A six-frame investigation package (PDF) and the REC-041 chamber render.
- Physical evidence
- None — a digital investigation package.
- Not claimed
- That REC-041 is a real, verified incident
- Measured operational data
- An FMEA worksheet behind RPN 312 → 334
- Source of the figures
- These figures come from the investigation’s own evidence frames. The record is a reconstruction: it is not presented as a real, verified incident, and no figure is measured operational data.
- Images
- Static reconstruction rendered in Blender Cycles; evidence frames as published.
ArchiveDevelopment dossier — the archived 2026 technical sheet, for more depth →
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