List of Slides

• Slide 1 Presentation purposes
• Slide 2 Presentation promises
• Slide 3 List of investigation problem areas
• Slide 4 (A local accident Slide can be used here.)
• Slide 5 Objectives for investigations?
• Slide 6 (A local accident Slide can be used here.)
• Slide 7 Beginning and end
• Slide 8 (A local accident Slide can be used here.)
• Slide 9 Selection criteria for best method
• Slide 10 (A Slide showing a local accident report can be used here)
• Slide 10A Work product specifications
• Slide 11 Work product usage
• Slide 11A Lots of questions: Answers?
• Slide 12 Personalized investigations
• Slide 13 Adverse effects for investigators
• Slide 14 Adverse effects on others
• Slide 15 Safety's hidden defect iceberg
• Slide 16 Investigation methods research
• Slide 17 List of findings
• Slide 18 Perceptions of accident phenomenon
• Slide 19 Findings led to synthesis, etc.
• Slide 20 Conceptual glue
• Slide 21 Tape transcript I
• Slide 21A Tape transcript II
• Slide 22: 4 Key principles
• Slide 23 Synthesized investigative methodology
• Slide 24 Configuration of event blocks
• Slide 25 Teaching simulations
• Slide 26 Does it work?
• Slide 26a Teaching model
• Slide 27 What should investigators do about this?
• Slide 28 Look for best investigation technology
• Slide 29 IDEAL One report to serve all users
• Epilogue:
• Presentation Package Information

Slide 1 Presentation purposes

THE PURPOSES OF THIS PRESENTATION ARE TO

• PRESENT ACCIDENT INVESTIGATION PROBLEMS THAT PROMPTED EXTENSIVE RESEARCH INTO ACCIDENT INVESTIGATION SYSTEMS,
• SHARE WHAT THE RESEARCH DISCLOSED, AND
• DESCRIBE ACTIONS SUGGESTED BY THE RESEARCH

Slide 2 Presentation promises

THE PRESENTATION WILL

• LOOK AT THE ACCIDENT INVESTIGATION PROBLEMS IN DETAIL,
• DISCUSS THE RESEARCH FINDINGS,
• EXPLORE SOME APPLICATIONS AND FUTURE ACTIONS SUGGESTED BY THE RESEARCH.

Slide 3 List of investigation problem areas

THE MAJOR PROBLEM AREAS INCLUDE ACCIDENT INVESTIGATION:

• OBJECTIVES
• SCOPE
• METHODS
• OUTPUTS, and
• USES

TO EXPLAIN THESE PROBLEMS IN A MEANINGFUL WAY, WE WILL HAVE TO TALK ABOUT ACCIDENT THEORY, TOO. MORE ABOUT THAT LATER.

Slide 4 (A local accident Slide can be used here to personalize questions)

LET'S BEGIN BY ASSUMING YOU AND I ARE ACCIDENT INVESTIGATORS.

YOU ARE ORDERED TO JOIN ME IN AN INVESTIGATION OF THIS ACCIDENT:

WHY SHOULD WE INVESTIGATE THE ACCIDENT?

• IN OTHER WORDS, WHY BOTHER INVESTIGATING THIS ACCIDENT?

Slide 5 Objectives for investigations?

WHAT SHOULD BE THE OBJECTIVES OF OUR INVESTIGATION?

• WHAT SHOULD WE BE TRYING TO ACCOMPLISH BY INVESTIGATING THIS ACCIDENT?
• ARE OUR OBJECTIVES VALID? DO OUR OBJECTIVES TELL US HOW TO MEASURE THE SUCCESS AND WORTH OF OUR INVESTIGATION AND ITS OUTPUTS?
• EVEN MORE FUNDAMENTALLY, WHAT SAFETY CONCEPTS AND PRINCIPLES GIVE US THE BASIS FOR OUR ANSWERS?

Slide 6 (A local accident Slide can be used here to personalize questions)

SUPPOSE YOU AND I HAVE TO INVESTIGATE THIS ACCIDENT

* WHAT SHOULD BE THE SCOPE OF OUR INVESTIGATION?

Slide 7 Beginning and end

SAID ANOTHER WAY,

• WHEN WILL WE SAY THE ACCIDENT BEGINS AND ENDS?
• WHAT SHOULD WE COVER DURING THE INVESTIGATION?

AGAIN, A MUCH MORE CRUCIAL QUESTION:

• WHAT CONCEPTS AND PRINCIPLES - OR THEORY - FORM THE BASIS FOR OUR ANSWERS?

NOW LET'S SHIFT GEARS FOR A MOMENT.

Slide 8 (A local accident Slide can be used here to personalize questions)

YOUR OPERATION IS INVOLVED IN THIS ACCIDENT.

• WHAT METHODS WOULD YOU WANT ME USE TO INVESTIGATE AND ANALYZE THE ACCIDENT FOR YOU, TO ENSURE THAT YOU GET A GOOD INVESTIGATION?

Slide 9 Selection criteria for best method

TO ANSWER THAT QUESTION COMPETENTLY, SHOULDN'T YOU KNOW

• THE NAME OF THE METHOD YOU USE NOW?
• WHAT CHOICES OF METHODS ARE AVAILABLE TO YOU?
• WHICH METHOD IS THE BEST?

WHAT ARE YOUR SELECTION CRITERIA FOR THE "BEST METHOD?"

• IS ANY ONE METHOD REALLY BETTER THAN ANOTHER? AND WHY?
• WILL THE METHOD YOU SELECT LEAD TO OUTPUTS THAT WILL SATISFY YOU?

Slide 10 (A Slide showing a local accident report can be used here)

AT THE END OF THE INVESTIGATION,

WHAT WORK PRODUCTS DO YOU WANT ME TO DELIVER TO YOU?

Slide 10A Work product specifications

WHAT ARE YOUR SPECIFICATIONS FOR MY INVESTIGATION WORK PRODUCTS?

• WHERE DO WE FIND THE SPECIFICATIONS DOCUMENTED?
• DO THEY REALLY TELL WHAT I SHOULD PRODUCE?

WHY DO YOU WANT ME TO INVESTIGATE WHEN YOUR INSURER, THE LOCAL CORONER, A GOVERNMENT AGENCY, SUPPLIER OR OTHERS WILL ALSO BE INVESTIGATING AND REPORTING ON THE ACCIDENT?

• HOW WILL YOU ACTUALLY JUDGE THE ACCEPTABILITY OF MY WORK PRODUCTS? OTHERS' WORK PRODUCTS?
• ARE YOUR CRITERIA CONSISTENT FROM DAY TO DAY?

ONCE AGAIN, WHAT CONCEPTS LEAD TO YOUR CRITERIA FOR ANSWERS TO THESE QUESTIONS?

Slide 11 Work product usage

AFTER YOU HAVE MY INVESTIGATION WORK PRODUCTS, HOW DO YOU PLAN TO USE THEM?

• WHICH REPORT - MINE, THE POLICE'S, INSURANCE COMPANY'S - WILL HELP YOU UNDERSTAND THE ACCIDENT BETTER? WHY?
• WHY ARE THERE STILL SOME PEOPLE WHO WILL COMPLAIN TO YOU THAT THEY NEED MORE OR `BETTER' DATA?
• WHAT EXACTLY IS WRONG WITH MY DATA, AND HOW CAN WE DECIDE WHAT ADDED DATA WOULD BE WORTH GETTING?

ONCE AGAIN, WHAT CONCEPTS PROVIDE THE CRITERIA FOR YOUR ANSWERS?

Slide 11A Lots of questions: Answers?

LOTS OF QUESTIONS AND PROBLEMS FOR INVESTIGATORS!!!!! ARE THERE REALLY GOOD ANSWERS??

BE ASSURED THAT THESE ARE NOT JUST RHETORICAL QUESTIONS. THEY ARE REAL, AND DEMAND DECISIONS BY EVERY THOUGHTFUL INVESTIGATOR WHO HAS EVER INVESTIGATED AN ACCIDENT.

THE ANSWERS ARE RARELY FOUND IN INVESTIGATION BOOKS OR TAUGHT IN TRADITIONAL ACCIDENT INVESTIGATION COURSES; OTHERWISE YOU WOULD ALREADY HAVE ALL THE ANSWERS AT THE TIP OF YOUR TONGUE!

STILL, THEY HAVE TO BE ANSWERED - BY EVERY INVESTIGATOR IN EVERY ACCIDENT INVESTIGATION.

• HOW??

Slide 12 Personalized investigations

EVERY INVESTIGATOR RESOLVES THESE QUESTIONS BY PERFORMING THE INVESTIGATION IN HIS OR HER OWN WAY, DOING THE INVESTIGATION THE WAY THEY KNOW AND THINK BEST.

• IN THE ABSENCE OF GUIDANCE, MANY INVESTIGATORS ARE FORCED TO USE THEIR OWN PERSONALIZED METHODOLOGIES AND INTERPRETATIONS.

THE CONSEQUENCES?

• THESE PERSONALIZED METHODOLOGIES RESULT IN PERSONALIZED INVESTIGATION DECISIONS, AND IN WIDELY DIFFERING, PERSONALIZED ACCIDENT INVESTIGATION WORK PRODUCTS AND ACCIDENT DATA.

Slide 13 Adverse effects for investigators

SO WHAT, YOU ASK? A FAIR QUESTION. . .

THINK ABOUT THE EFFECTS OF PERSONALIZED PRACTICES ON THE NATURE OF ACCIDENT REPORTS:

• HOW CAN WE AVOID REPORTS DOMINATED BY INVESTIGATOR'S PERSONAL CONCLUSIONS AND EXPERIENCE, OR WORSE A DOMINATING INVESTIGATOR'S CONCLUSIONS ON A TEAM INVESTIGATION?

THINK ABOUT THE REPLICABILITY OF REPORT CONTENTS:

• HOW CAN WE EXPECT REPRODUCIBLE RESULTS FROM INVESTIGATION TO INVESTIGATION OR AMONG INVESTIGATORS?

THINK ABOUT ATTEMPTS TO CONTROL QUALITY:

• HOW CAN WE CONTROL THE QUALITY OF ACCIDENT REPORTS RELYING ON PERSONAL CONCLUSIONS, WITHOUT CONSISTENT INVESTIGATION METHODS AND SOUND, OBJECTIVE QUALITY ASSURANCE CRITERIA?

THINK ABOUT THE WORTH OF THE INVESTIGATIONS:

• HOW CAN YOU LINK WORK PRODUCTS TO PREVIOUSLY PREDICTED SAFETY PERFORMANCE PROMISED IN SAFETY APPROVAL DOCUMENTS OR REGULATIONS, OR DERIVED FROM SAFETY ANALYSES?

Slide 14 Adverse effects on others

GOING BEYOND THE EFFECTS ON YOUR OWN OPERATIONS, CONSIDER THE RAMIFICATIONS OF PERSONALIZED INVESTIGATIVE OUTPUTS ON

• YOUR ORGANIZATION'S AND OTHERS' SAFETY POLICIES - OR REGULATIONS,
• YOUR ORGANIZATION'S, OR YOUR INDUSTRY'S OR OTHERS' SAFETY PROGRAM STRATEGIES AND TACTICS,
• YOUR EMPLOYEES' AND THE PUBLIC'S OPINIONS ABOUT THE ADEQUACY OF YOUR SAFETY LEVELS, OR ON
• ANALYSIS AND RESEARCH EFFORTS THAT USE THOSE DATA TO DEFINE AND SOLVE SAFETY PROBLEMS , AND
• IN PRACTICAL $, THINK ABOUT COSTS OF LITIGATION STEMMING FROM DIFFERENT REPORTS ABOUT AN ACCIDENT!

Slide 15 Safety's hidden defect iceberg

THE EFFECTS INCLUDE DELAYS, MISDIRECTION, INJUSTICES, DAMAGED REPUTATIONS, WASTE AND MORE.

THESE PROBLEMS ARE NOT READILY VISIBLE TO MOST PEOPLE. THE SUBTLE ONES ARE LIKE THE BOTTOM OF AN ICEBERG. THEY ARE THERE, AND THEY CREATE LOTS OF DIFFICULTIES, BUT THEY ARE HIDDEN. MOST PEOPLE DON'T LINK THESE PROBLEMS TO INADEQUATE INVESTIGATIONS OR INVESTIGATION FAILURES.

BUT THEY ARE LINKED, AND THAT IS WHY TRADITIONAL INVESTIGATIONS ARE

Slide 16 Investigation methods research

LITTLE ACCIDENT INVESTIGATION METHODS RESEARCH (AS CONTRASTED WITH ACCIDENT RESEARCH ON ACCIDENT DATA) HAS BEEN PERFORMED, AND WHAT HAS BEEN DONE HAS NOT BEEN WELL FUNDED, OR DONE WITH GREAT FORMALITY, ESPECIALLY IN THE UNITED STATES.

ONE RESEARCH INITIATIVE HAS BEEN UNDER WAY FOR OVER 20 YEARS. ITS DISCOVERIES WERE ROUTINELY TESTED DURING ACTUAL INVESTIGATIONS ALONG EACH STEP OF THE WAY. AS EACH FINDING EMERGED, IT WAS TESTED AND REFINED IN THE NEXT SUBSEQUENT INVESTIGATION. WHEN THE WORK WAS APPLIED, IT HELPED RESOLVE THE PROBLEMS JUST DESCRIBED.

Slide 17 List of findings

WHAT EXACTLY WAS DISCOVERED?

ONE FINDING WAS THE GREAT DIVERSITY OF THINKING AND REASONING AMONG INVESTIGATORS, THEIR BOSSES AND THE USERS OF THEIR REPORTS. THE WORK DISCLOSED

* 5 DIFFERING GENERAL PERCEPTIONS OF THE NATURE OF THE ACCIDENT PHENOMENON

* 44 DIFFERING REASONS FOR INVESTIGATING ACCIDENTS

* 7 DIFFERENT ACCIDENT INVESTIGATION PROCESSES

* 6 DISTINCTIVELY DIFFERENT METHODOLOGICAL APPROACHES AND

* 3 DIFFERING TYPES OF DELIVERABLES

MOST IMPORTANTLY, THERE WAS AND STILL IS ALMOST COMPLETE LACK OF AGREEMENT ABOUT WHAT AN ACCIDENT IS AND HOW TO DETERMINE THE BEGINNING AND END OF THE ACCIDENT. THUS THE SCOPE OF WHAT WILL BE INVESTIGATED AND REPORTED IN SPECIFIC ACCIDENTS VARIES WIDELY.

IS IT ANY WONDER WE HAVE QUESTIONS, DELAYS, DISPUTES, AND LOTS OF LITIGATION AFTER ACCIDENT INVESTIGATIONS - BIG AND SMALL- ARE REPORTED?

Slide 18 Perceptions of accident phenomenon

PROBABLY THE MOST SIGNIFICANT FINDING WAS THE VARIATION IN PEOPLE'S PERCEPTIONS OF ACCIDENTS.

BRIEFLY, THE 5 MAIN PERCEPTIONS INCLUDE THE

1. SINGLE EVENT, VIEWING ACCIDENTS AS A SINGLE EVENT LIKE A LIGHTNING BOLT OR ACT OF GOD; THIS INCLUDES MUCH REGULATORY COMPLIANCE/VIOLATION THINKING.

2. CHAIN-OF-EVENTS, OR LINEAR SEQUENCE MUCH LIKE A ROW OF TOPPLING DOMINOS.

3. FACTORIAL VIEW, OR AN OCCASION INVOLVING `FACTORS' WHICH CAN BE IDENTIFIED BY STATISTICAL ANALYSIS METHODS.

4. BRANCHED CONVERGING EVENTS CHAIN, ILLUSTRATED BY CONVERGING FAULT TREE CHARTS; AND

5. MULTILINEAR EVENTS SEQUENCES, THINKING OF AN ACCIDENT AS A PROCESS INVOLVING CONCURRENT ACTIONS BY VARIOUS ACTORS TO PRODUCE AN UNINTENDED OUTCOME.

KNOWING THESE DIFFERENCES CAN HELP YOU UNDERSTAND WHY OTHERS SAY AND DO WHAT THEY DO DURING INVESTIGATIONS. BUT BY ITSELF, THIS KNOWLEDGE WILL NOT PRODUCE BETTER INVESTIGATIONS.

REALIZING ALL THIS, WAS IT POSSIBLE TO DEVELOP SOMETHING BETTER?

Slide 19 Findings led to synthesis, etc.

THAT'S WHAT THE RESEARCH FOCUSED ON NEXT. THE FINDINGS ABOUT DIFFERENT PERCEPTIONS WERE USED TO DISTINGUISH RESULTS FLOWING FROM EACH, IN TERMS OF WORK PRODUCTS AND THEIR WORTH.

THEIR WORTH WAS JUDGED BY THE SAFETY PERFORMANCE IMPROVEMENTS WHICH FOLLOWED.

THAT WORK LED TO

1. SYNTHESIS OF A PERCEPTUAL FRAMEWORK THAT WOULD HELP RESOLVE ALL THE QUESTIONS INVESTIGATORS FACED, AND TIE INVESTIGATIONS TO PREDICTIVE ANALYSES.

2. ISOLATION OF PRINCIPLES TO HELP PRODUCE "BETTER" INVESTIGATIONS.

3. DEVELOPMENT OF A COMPREHENSIVE METHODOLOGY THAT COULD GIVE REPRODUCIBLE OUTPUTS.

4. DEVELOPMENT OF TRAINING TECHNIQUES TO SIMULATE INVESTIGATIONS SO THE METHODS COULD BE TAUGHT.

Slide 20 Conceptual glue

THE RESEARCH REQUIRED DEVELOPMENT OF A CONCEPTUAL "GLUE" TO TIE ALL THE INVESTIGATION PRACTICES TOGETHER INTO A CONGRUENT GENERAL FRAMEWORK.

IN ESSENCE IT REQUIRED `A SYSTEM OF ASSUMPTIONS, ACCEPTED PRINCIPLES AND RULES OF PROCEDURE DEVISED TO ANALYZE, PREDICT OR OTHERWISE EXPLAIN THE NATURE AND BEHAVIOR OF PHENOMENA THAT WE CALL ACCIDENTS.'

SUCH A GLUE WAS DEVELOPED. LET'S EXAMINE THAT GLUE NOW.

Slide 21 Tape transcript I

TO DO THAT, WE HAVE TO SHIFT GEARS.

PLEASE TURN TO THE HANDOUT. IT HAS A MUSICAL SCORE ON IT. TRACK WHAT FOLLOWS ON THAT PAGE.

[Note to instructor: Turn on audio cassette here. The text of the cassette tape follows.]

YOU ARE ABOUT TO HEAR FIVE MUSICIANS AND FIVE INSTRUMENTS. LET'S THINK OF THEM AS 10 ACTORS. THESE TEN ACTORS WILL EACH ACT, STEP BY STEP, ACCORDING TO CERTAIN TIMING, PITCH AND OTHER MUSICAL SPECIFICATIONS SHOWN BY THE SCORE. THEIR ACTIONS WILL PRODUCE A MELODIOUS SONG. EVEN IF YOU DON'T READ MUSIC, YOU WILL PROBABLY RECOGNIZE THE TUNE.

(MUSIC - harmonious band music)

YOU HEAR 10 ACTORS MAINTAINING A STATE OF DYNAMIC HARMONIOUS EQUILIBRIUM OVER TIME. EACH NEW NOTE CHANGES A STATE, ALMOST EVERY MOMENT. THESE COMBINED STATE CHANGES PRODUCE AN OVERALL STATE OF DYNAMIC EQUILIBRIUM OR BALANCE, WHICH WE WILL CALL STASIS. AS LONG AS THE ACTORS' ACTIONS BLEND TOGETHER WITHIN CERTAIN TOLERANCES, THEIR DYNAMIC EQUILIBRIUM OR STASIS IS MAINTAINED, EVEN WHEN SOME OF THE ACTORS START TO ADD THEIR VOICES.

(MUSIC- voices join band music)

AS EACH NEW WORD AND NOTE INTRODUCES A NEW STATE DURING THE SONG, THERE IS SOME RISK OF A SOUR NOTE. WHEN SEVERAL NOTES DO NOT FOLLOW WITHIN NEEDED TIME, PITCH OR OTHER TOLERANCE RANGES, THE RISK OF TROUBLE GROWS. OFF-SPEC NOTES CAN DISRUPT OUR DYNAMIC EQUILIBRIUM, AND TRANSFORM THE SONG INTO NOISE. LISTEN TO HOW THAT CAN HAPPEN.

(MUSIC- disharmony, confusion, audience shouting)

Slide 21A Tape transcript II

NOTICE HOW THE SONG WAS TRANSFORMED FROM MUSIC INTO NOISE. THE CHANGED PITCH OR TIMING BY SOME OF THE ACTORS STARTED THE PROCESS THAT BROUGHT THE MUSIC TO AN END. DISHARMONY WAS OBVIOUS TO THE EAR OF THE LISTENER.

OUT-OF-TOLERANCE INTERACTIONS PRODUCE ACCIDENTS IN ESSENTIALLY THE SAME WAY. FOR INVESTIGATION PURPOSES, THIS ANALOGY IS ESPECIALLY HELPFUL. IF YOU WANT TO UNDERSTAND WHAT HAPPENED DURING THE SONG, YOU CAN FIND OUT AS FOLLOWS.

YOU HAVE A RECORD IN YOUR MINDS AND ON THIS CASSETTE TAPE, OF THE ACTIONS TAKEN BY EACH OF THE ACTORS. USING BOTH, YOU CAN TRACK THE ACTIONS BY EACH ACTOR TO LOCATE THE FIRST EVENT THAT WAS OUT OF TOLERANCE, AT THE BEGINNING OF THIS TRANSFORMATION PROCESS. AS WE TRACK EACH ACTOR'S ACTIONS, WE CAN ORGANIZE THE DATA AND DOCUMENT IT BY RECONSTRUCTING THE SCORE AS IT WAS ACTUALLY PLAYED DURING THIS MISHAP. THIS CAN BE DONE USING THE SAME KINDS OF BUILDING BLOCKS USED TO DOCUMENT THE ORIGINAL SCORE. USING THESE TECHNIQUES, ONE CAN RECONSTRUCT AND DISPLAY THE SCORE OF AN ACCIDENT, TOO.

THINK OF AN ACCIDENT SCORE AS A PLOT OF INTERACTING EVENTS, OR AN EVENTS FLOW CHART.

YOU CAN RECONSTRUCT THE ACCIDENT SCENARIO FROM THE DATA STORED IN PEOPLE AND THINGS AFTER THE ACCIDENT, BY USING THE SAME EVENTS TRACKING AND DOCUMENTATION APPROACH FOR EACH OF THE ACTORS INVOLVED IN THE OUTBURST OF DISHARMONY.

IF YOU THINK ABOUT THE MUSIC ANALOGY, YOU WILL RECOGNIZE HOW

* MANAGEMENT RELATES TO THE COMPOSER,

* SUPERVISORS COMPARE WITH CONDUCTORS,

* WORKERS COMPARE WITH MUSICIANS,

* THE WORKERS' TOOLS COMPARE WITH MUSICAL INSTRUMENTS,

* WORK PROCEDURES RELATE TO THE MUSICAL SCORE,

* OUTCOMES RELATE TO THE MUSIC PRODUCED,

* WITNESSES ARE THE AUDIENCE THAT OBSERVED THE THE MUSIC PRODUCED,

* THE MUSIC NOTATION SYSTEM CAN BRING ORDER TO ONE'S SEARCH FOR DATA, AND ITS ORGANIZATION, AND

* IT CAN HELP TEST THE DATA RELEVANCE AS DATA BECOMES AVAILABLE DURING ACCIDENT INVESTIGATIONS.

NOR IS IT DIFFICULT TO RECOGNIZE HOW THE "SCORE" FROM ONE ACCIDENT CAN HELP YOU INVESTIGATE FUTURE SIMILAR ACCIDENTS MORE EFFICIENTLY. OR DESIGN FUTURE OPERATIONS BETTER. OR TRAIN WORKERS WITH A CORRECTED NEW SCORE.

APPLYING THESE IDEAS AND THE RESULTANT IMPLEMENTING METHODS DEVELOPED BY THE RESEARCH, INVESTIGATION EFFICIENCY AND VALUE HAS BEEN FOUND TO IMPROVE DRAMATICALLY WITH EACH SUCCESSIVE ACCIDENT INVESTIGATION.

[Instructor: Turn cassette recorder off here, and resume Slide presentation]

Slide 22: 4 Key principles

WITHIN THIS CONCEPTUAL FRAMEWORK, 4 KEY INVESTIGATIVE PRINCIPLES WERE ISOLATED;

THINK EVENTS BUILDING BLOCKS

*THAT IS, TRANSFORM ALL YOUR ACCIDENT INFORMATION INTO SINGLE ACTIONS BY INDIVIDUAL ACTORS, BREAK DOWN WHAT THEY DID TO FASHION BASIC BUILDING BLOCKS CALLED `EVENTS'- THE KEY TO REPLICABILITY AND CONSISTENCY

THINK EVENTS SEQUENCES

* THAT MEANS SEQUENTIAL, RATHER THAN DEDUCTIVE OR INDUCTIVE LOGICAL APPROACHES. YOU DOCUMENT AND ASSEMBLE THE BUILDING BLOCKS INTO SEVERAL SEQUENTIAL, TIMED STRINGS OF PARALLEL EVENTS FOR EACH ACTOR YOU ARE TRACKING DURING THE ACCIDENT- BOTH ANIMATE AND INANIMATE.

MAKE MENTAL MOVIES

* THAT MEANS YOU TRY TO ORGANIZE THE STRINGS OF EVENTS INTO `FRAMES' OF A MENTAL MOVIE TO "SEE" THOSE INTERACTIONS DURING THE ACCIDENT WHICH DETERMINED ITS OUTCOME; THIS FORCES RECOGNITION AND USE OF GAPS!

ESTABLISH RELATIVE TIMING OF EVENTS

* THAT MEANS YOU HAVE TO SHOW WHEN EACH EVENT OCCURRED RELATIVE TO EACH OTHER RELATED EVENT IN YOUR FLOW CHARTS.

THIS LAST POINT IS IGNORED IN MOST ACCIDENT INVESTIGATIONS, REPORTS AND WORK PRODUCTS. AND MOST ACCIDENT RESEARCH! A FATAL DEFECT IN OUTPUTS!

Slide 23 Synthesized investigative methodology

TO APPLY THESE PRINCIPLES, AN INVESTIGATIVE METHODOLOGY WAS SYNTHESIZED, BASED ON GRAPHIC MODELING OF ACCIDENT EVENTS.

* THE 4 KEY ELEMENTS OF THAT TECHNOLOGY ARE

1 A TIME LINE TO DISCIPLINE THE TESTING OF RELATIONSHIPS AMONG EVENTS IDENTIFIED DURING AN INVESTIGATION,

2 AN ACTOR-ACTION MATRIX SYSTEM TO DISPLAY AND SEQUENTIALLY ARRANGE THE EVENTS BUILDING BLOCKS INTO A MODEL OF THE ACCIDENT,

3 AN ARROW CONVENTION TO SHOW THE AGREED-UPON CAUSE-EFFECT LOGIC OF THE EVENTS RELATIONSHIPS DURING THE ACCIDENT, AND

4 A SYSTEM FOR IDENTIFYING AND TABBING COUNTERMEASURES TO INDICATE WHERE THE FLOW OF EVENTS DEMONSTRATED A PROBLEM, SUBJECT TO FUTURE CONTROL BY SOME CHANGE IN THE DESIGN, A NEW SAFEGUARD, PROCEDURE, WARNING, OR OTHER SAFETY ACTIONS.

Slide 24 Configuration of event blocks

THIS SLIDE SHOWS THE GENERAL CONFIGURATION OF THE BUILDING BLOCKS AND LINKS FORMING THE MULTILINEAR EVENTS SEQUENCING MATRIX. WITH COUNTERMEASURE TABS SHOWING PROBLEM RELATIONSHIPS. EVENTS EVIDENCED BY CHANGED CONDITIONS COULD BE TRACKED THE SAME WAY.

Slide 25 Teaching simulations

SIMULATIONS OF THIS INVESTIGATIVE PROCESS WERE DEVELOPED SO IT CAN BE TAUGHT. THE SIMULATIONS INCLUDE

* DEVELOPMENT OF AN INVESTIGATIVE PLAN THAT TAKES INTO ACCOUNT THE INTERESTS OF ALL PARTIES WITH A STAKE IN THE INVESTIGATION, AND HOW THEY MIGHT BE MANAGED.

* WAYS TO USE THE PRINCIPLES AND TECHNIQUES TO PRODUCE VASTLY IMPROVED WITNESS INTERVIEWS,

* DEVELOPMENT OF PLANS FOR TESTING DEBRIS AFTER AN ACCIDENT TO AVOID WASTING A LOT OF TIME, MONEY OR DATA, AND

* HANDS-ON EXPERIENCE WITH WAYS TO TRANSFORM AND ORGANIZE ACCIDENT DATA SO THE ANALYTIC TASKS ARE FASTER, MORE EFFICIENT, CONSISTENT AND REPRODUCIBLE, AND POINT DIRECTLY TO DATA STILL REQUIRED

Slide 26 Does it work?

DOES IT WORK?

YES, WITHOUT QUALIFICATION.

BEFORE, DURING AND AFTER ACCIDENT INVESTIGATIONS.

THE EVENTS ANALYSIS METHODOLOGY WAS USED TO MODEL FIREFIGHTERS' EMERGENCY DECISION MAKING PROCESSES AND HAZARDOUS MATERIAL ACCIDENT BEHAVIOR. DURING SUBSEQUENT INVESTIGATIONS, THESE MODELS WERE TESTED AND REFINED, AND NOW PROVIDE GUIDANCE TO INVESTIGATORS, FIREFIGHTERS AND TRAINERS IN FEMA COURSES.

IN THE AVIATION COMMUNITY, THE APPROACH IS BEING APPLIED TO THE PRIVATE PILOT DECISION MAKING PROCESS. WHERE WILL IT LEAD NEXT?

THE EFFECT ON RECOMMENDATION DEVELOPMENT AND EVALUATION HAS BEEN DRAMATIC, TOO - THOSE CHANGES MERIT A SEPARATE PRESENTATION!

Slide 26a Teaching model

HERE IS AN EXAMPLE OF THE RESULTANT TEACHING MODEL. IT HAS APPLICATIONS IN MANY FIELDS.

SAFETY IMPROVEMENTS IN THE FIELD HAVE BEEN DRAMATIC; THERE HAVE BEEN NO FATAL INJURIES AMONG FIREFIGHTERS TRAINED WITH THIS MODEL SINCE 1979 AS FAR AS IS KNOWN TODAY.

Slide 27 What should investigators do about this?

SO WHAT DOES ALL THIS MEAN TO YOU?

IN A WORD, YOU AS AN INVESTIGATOR ARE VULNERABLE TO TECHNICAL AND PROFESSIONAL OBSOLESCENCE IF YOU DON'T KEEP UP WITH FAST MOVING DEVELOPMENTS IN THIS FIELD.

YOUR MANAGERS AND CO-WORKERS ARE VULNERABLE TO WASTE OF RESOURCES AND REPETITION OF LOSSES. FURTHER, THEY ARE BEING DENIED THE RESULTS YOUR INVESTIGATIONS SHOULD BE ACHIEVING.

WHAT SHOULD YOU DO? AT LEAST 3 THINGS.

REEXAMINE YOUR OWN WORK AND METHODS. AND THE RESULTS THEY ARE ACTUALLY ACHIEVING, AND DEVELOP CRITERIA FOR WHAT YOU NEED.

Slide 28 Look for best investigation technology

REVIEW, SELECT AND THEN MASTER THE BEST AVAILABLE INVESTIGATION TECHNOLOGY AND METHODS TO HELP YOU DO YOUR INVESTIGATIONS EFFECTIVELY, PROMPTLY, CONSISTENTLY, AND IN THE MOST PRODUCTIVE WAY.

FINALLY, LOOK ON ANY ACCIDENT OR INCIDENT YOU INVESTIGATE AS WORTH INVESTIGATING PROPERLY AND COMPLETELY.

Slide 29 IDEAL One report to serve all users

IF YOU ACCEPT THESE CHALLENGES, YOU CAN HELP OTHERS TO STRIVE TOWARD AN EMERGING IDEAL FOR INVESTIGATORS:

END

Epilogue:

Subsequent to the original 1980 report, further research disclosed a way to achieve this ideal. The key change was to separate the production of a description of causally related interactions during the accident process from subsequent uses of that information. This means the investigation output is the description of what happened, which requires different data, knowledge and skills than developing problem statements, remedial actions and post-implementation monitoring plans. These findings are applied in "Investigating Accidents with STEP" by Hendrick and Benner, Marcel Dekker, New York, 1986 and subsequent publications by this author.

Presentation Package Information

The presentation consists of four components:

1. The presentation script for ACCIDENT INVESTIGATION: SAFETY'S HIDDEN DEFECT

2. A audio segment with a discussion of the background for the presentation and the musical score analogy that is used to demonstrate the timed multilinear events sequencing concepts and procedures during presentations of the set.

3. A set of slides matched to the script.

4. The one-page handout, which presenters may reproduce and distribute to each attendee at each presentation, for their use during the musical score presentation.

The presentation set is fully integrated with

a) the book "INVESTIGATING ACCIDENTS WITH STEP" by Kingsley Hendrick and Ludwig Benner, Jr., published by Marcel Dekker, Inc., 270 Madison Avenue, New York, NY 10016 (1986)

b) instructional aids found in the publications "Four Accident Investigation Games" student manual and instructor's manual, published by Starline Software Ltd., 12101 Toreador Lane, Oakton, Va. 22124 (1984, 1986), and 10 MES Guides also available from Starline Software Ltd.

c) a series of four new publications including Introduction to Investigation, Investigating Accidents, Hazardous Materials Investigation, and Fire Investigation, published by Fire Protection Publications, Oklahoma State University, Stillwell, OK.

Anyone presenting this A/V presentation should familiarize themselves with the investigation system resulting from the timed multilinear events sequencing technology. MES is sometimes described as one of several analytic methods for investigators. It is not an analytic method, or data gathering method, or recommendation development method, or a disjointed bag of techniques; It is an investigation system. Don't be misled: this system is a comprehensive system for investigation that can be broadly used to gain understanding of accident and non-accident processes.

THANK YOUR FOR YOUR HELP IN PROMOTING BETTER INVESTIGATIONS!