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This paper uses a systemic approach to accident investigation, based upon AcciMaps, to model the events leading up to the shooting of Jean Charles de Menezes at Stockwell Underground station in July 2005. The model captures many of the findings of the Independent Police Complaints Commission's report in a single representation, modelling their interdependencies and the causal flow. Furthermore, by taking a systemic approach, the analysis identifies further considerations related to the suitability of the Metropolitan Police Service's organisational structure to support rapid-paced operations, where reliable identification of a suspect is not possible. Based upon the analysis, the paper questions the division of functions between teams and the suitability of an organisational structure that relies upon the complex flow of information between separate teams for surveillance and for controlling the suspect. A dynamic organisational structure is proposed that changes in response to operation type and unfolding events. STATEMENT OF RELEVANCE: This paper provides much needed and called for validation for a systemic approach to accident analysis. A widely reported case study is used to illustrate the process. The paper shows how such an approach can consolidate the key findings of much larger reports as well as draw out additional recommendations.