Focus on human behaviour and intent. Interview with person and other persons involved.
You will need to collect information about the intent of the human behaviour of the action in question. Most effectively this is done through direct interview with the most directly concerned people. Keep asking why the actions were performed. Be aware for factors that invariably play a role here such as the drive to ‘produce’ rather than ‘protect’. The information retrieved is this phase is critical and essential for later assessment of human behaviour.