The Investigation Process Research Resource Site
A Pro Bono site with hundreds of resources for Investigation Investigators
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. . . .. . . . . . . . last updated 8/8/09


to advance the
State-of-the-Art of
investigations, through
investigation process

Research Resources:

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Launched Aug 26 1996.


The posting of any materials at this site is not intended to imply
endorsement of or concurrence in the contents or ideas they represent.

This index is superseded by the search engine on the home page after September 1, 1999; Jan 1 2000 was last new entry. Some unique links have been updated through 2/1/07, most have not. Do google search for postings.

View PAGE List   View TOPIC index for this site  Click on [ ] to go to page

15 January 2000 update

  • Posted two relevant papers - one about a Theoretical Foundation for Fire Investigation, and another with a model for human factors investigation (Cognitive Failure Analysis of Pilot Error) derived from analyses of accident reports. Comments invited.
  • Press Release about the long awaited Rand research report of its investigation of NTSB investigation process. Download report from
  • 20 Dec 1999 update:(click on box)

  • Press release about the long awaited Rand research report of its investigation of NTSB investigation process - and download report from
  • Posted Book Review of new book about USS Iowa gun explosion, its investigations, and problems with the investigation, with lessons for investigators.
  • Posted new reference to forensic science discussions.
  • 15 October 1999 update:(click on box)

    [ ] Posted new paper describing why of accident investigations undermine statistical safety measurement.
    [ ] Posted Book Review of book by H G Rickover, discusses conflicting findings about explosion, with modern lessons for investigators.
    [ ] See recent paper on post-investigation recommendation implementation issues.

    15 Sept 1999 update:(click on box)

    New policy. Original papers or reports about investigation process research will be posted at this site, Send candidates to Webmaster.
    [ ]Posted new report of research into application of human factors model for investigations.
    [ ]Updated graphics, ToC in Petition for Reconsideration of Probable Cause for high-altitude yaw - roll over -vertical dive aircraft incident.
    [ ]See recent paper on post-investigation recommendation implementation issues.

    15 Aug 1999 update:(click on box)

    [ ] Added new section containing information about the results of two or more investigations of the same accident, fire or incident. Look for potential investigation improvement possibilities.

    [ ] See recent paper on post-investigation recommendation implementation issues.

    25 July 1999 update:(click on box)

    [ ] Added new feature to site, containing information about the results of two or more investigations of the same accident, fire or incident. Focus is on potential insights to improve investigation processes.
    [ ]Added review of new book describing investigations of an explosion aboard a battleship.
    [ ] Set up EDITORIAL PAGES for posting observations and opinion pieces about investigation processes.

    20 June 1999 update:(click on box)

    [ ] Added reference to 24 US Department of Energy documents containing accident investigation policy, orders, guidance, program, etc. and also to International Transportation Safety Association.
    [ ] Added 3 new references to books of interest to investigation process researchers by Schwoebel, Dettmer and Petrosky.

    22 Apr 1999 update:(click on box)

    [ ] Reinvestigation of Lockheed C130A Tanker 82 produces a different outcome.

    6 Mar 1999 update:(click on box)

    [ ] Interesting example of nongovernmental association in New Zealand undertaking accident investigations. Hmmm.
    [ ] Posted reference to Accident Investigation Board of Finland.
    [ ] Just ran across this one: Special Report: Getting Out Alive - Would Smoke Hoods Save Airline Passengers or Put Them at Risk?
    [ ] New Zealand Aircraft Accident Briefs (CAA)

    1 Jan 1999 update:(click on box)

    [ ] Posted reference to research Survey of incident and accident report users to look at alternative ways reports can be created or written.
    [ ] Posted new paper "Investigating Causes" discussing CAUSE origins, problems and suggestions
    [ ] Added excerpts from ICAO Manual of Accident Investigation about the purpose of an inquiry. Also added goals to Annex 13 material previously posted.
    [ ] Posted Definitions section updates
    [ ] Just a reminder to check the papers posted by the GAAG group and other internet locations from time to time to keep abreast of their work.
    [ ] Posted paper titled System Safety's Open Loops about the role of investigations in System Safety programs

    [ ] Posted paper describing application of system safety principles to the safety recommendation process (With presentation slides)
    [ ] Posted slide presentation for paper "Accident Investigations: A Case for New Perceptions and Methodologies", in Accident Causation Papers, SP-461, February 1980, Society of Automotive Engineers

    Oct 21-31 1998 update

    [ ]   Introduced new SECTION titled DEFINITIONS to gather definitions from different investigation fields to identify commonalities and differences, and develop a common language for all investigators.
    [ ] Posted reference to URL for viewing papers about investigation improvement at recent seminars held by the International Society of Air Safety Investigators.
    [ ] Posted reference to recently launched U S Chemical Safety and Hazard Investigation Board.
    October 7 1998 update

    [ ] Posted $400,000 RAND Research Project for NTSB (contract and project description)
    September 18-26 1998 update
    [ ] Posted copy of International Society of Air Safety Investigators' Code of Ethics and Conduct for Investigators.
    August 30 1998 update
    [ ] Added new index of topics at this site to aid navigation around site.
    [ ] Added direct links to Web search engines.
    [ ] Added navigation links at top of pages to expedite navigation around site.
    [ ] Added link to Aviation Archeological Investigation site for historical data.
    [ ] Updated most section files

    July 1-13, 1998 update:

    [ ] Posted new presentation describing research findings from inquiries into investigation issues arising during an investigation..
    [ ] Posted new link to internet sites of general interest to investigation researchers, updated others..
    [ ] Posted new reference to US EPA's site describing EPA chemical accident investigation activities and reports available from EPA for comparison with other investigation activities and outputs. Discussion of Risk Management Plan publication on the Internet is very interesting to investigation researchers.

    May 24 update:

    [ ] Posted paper Ranking Safety Recommendation Effectiveness.
    [ ] Posted numerous references to TWA 800 comments, data and analyses of potential interest to investigation process researchers.

    Apr 17 updates:

    [ ] Posted comparative analysis of 3 reports of same explosion.
    [ ] Added information about Aviation Fire conference
    [ ] Reminder: Abstracts for ISASI Seminar due April 30, 1998.
    [ ] Posted EIR Project Investigation Task List 1 Mod 2
    [ ] Posted partial listing of ANSI investigation standards in Resources - Manuals section
    [ ] Posted paper about theoretical needs of investigation professionals. (22 references)
    ] File with EIR message exchanges available to active participants.

    20-21 March 1998 update

    7 Mar 1998 Update (major)

    • posted investigator vacancy announcement describing desired investigation qualifications at Experimental On-line Investigation Research Project status site, for comments and feedback by EIR participants.
    • more on Junk Science and investigation - of arson fires this time.
    • modified REFERENCE BOOK LIST to enable on-line book store browse and purchase capability, and added several references to recent books.
    • new reference to Clues to a Plane Crash newspaper article article describing what a reporter got out of an investigation (analysis?) training course.
    • moved all book and project reviews to a new Commentaries and Critiques section from the Research Resources section, and added new comments to section.
    • see announcement of ICAO meeting on investigation in Cairo.
    • EIR project message exchanges for Dec 97, Jan 98 and Feb 98 are available to registered EIR participants.
    • modified site structure to speed navigation for regular users, to facilitate E-mail comments, and to accommodate expansion of contents. Please E-mail me if you find any link problems. .

    16 Feb 1998 Update

    • developing new Commentaries and Critiques section new feature where copies or abstracts of investigation research-related papers and critiques or commentaries about the papers are brought together..
    • new Junk Science comments adapted from breast implant investigation comments in a news group.

    30 Jan 1998 Update

    • posted additional link to Glasgow Accident Analysis Group site, to papers sections which includes titles like Improving Accident Reports, etc., some in HTML language.
    • introduced new feature where copies or abstracts of investigation research-related papers are linked directly to comments about the papers.

    23 Jan 1998 Update

    • - Posted new investigation process study report addressing whether psychologists attributed the accident causes to the technical system, while engineers attributed them to the humans.
    • - Posted 1996 paper presented to Federal Aviation Administration proposing changes to FAA's investigation goals, approaches and methods to identify human behavior or decisions that need to be changed to develop effective human error intervention strategies

    16 Jan 1998 Update

    • Posted paper reporting observations of effects of Methodological Bias on investigations in the research reports section.
    • Posted papers reporting multilinear events sequencing approach to investigations Accident Investigation: Multilinear Events Sequencing Methods in investigations in the research reports section, and discussion of the nature of safety regulations to help investigators frame questions during accident investigations..
    • Posted reference to new book which includes section addressing quality control of expert testimony in litigation
    • Posted new links to investigation guides and manuals
    • Posted new conference announcements
    • Posted new National Academy of Sciences report on investigating grain explosions, with recommended procedures and investigator qualifications.
    • Revised Home Page and created Site Directory page with a list of hot links to all the pages and documents posted on the IRR, categorized to facilitate site navigation. Also JAVA browser scrolling list was upgraded to provide alternative access to all posted pages and features with JAVA capable browses. Also added many new hot links to pages to facilitate site navigation speed and ease.
    • Added new ANNOUNCEMENTS page to facilitate public communications access at this site.

    8 Dec 1997 Update

    • Posted extracts from U S Nuclear Regulatory Commission Accident Investigation Directive and Manual 8.9 (1993) for EIR participants.
    • Notice: November Message Traffic files available for EIR participants..

    28 Nov 1997 Update

    • Posted revised project plan and status report information for Experimental on-line Investigation Research project, including list of topics addressed in exchanges among active participants. (EIR)
    • Update forms for applying to participate in EIR and visitor log.
    • Post 2 new EIR resources re international investigation report format and post-crash influences on recommendation development process
    • Changed EIR navigation structure.

    08 Nov 1997 Update

    • Posted revised investigation task matrix for EIR project
    • Made numerous editorial updates, added information about availability of indexed compilation of exchanges re Experimental On-Line Investigation Research Project to Active Participants in project.

    12 Oct 1997 Update

    • - Posted papers describing investigation quality control procedure, with an example showing graphical description of accident, and demonstrating specific investigation and reporting failures, with a discussion of how to find and prevent them. Implications for analyses based on accident reports are readily apparent
    • Posted Updated 6 Mar 98
      Prev update: investigation task matrix for EIR project .

    31 August 1997 Update (Sept)

    • - Posted new item 17 on Research Wish List about Logic required by investigators and new link to internet site of interest to investigation process researchers.
    • - updated, added or fixed links among topics and to other sites. If you encounter problems bringing up linked topics, please let the Webmaster know. The site now uses over 120 files, some with 3 or 4 cross links, and a link sometimes gets changed unintentionally during updates.
    • - Also posted report of research project received in May (oops), re application of root cause analysis to investigations during a safety management project.
    • - coming soon - more exchanges about the Experimental On-line Investigation Research project will be posted.

    18 Aug 1997 Update

    • - Posted 3 investigation guidance documents, ATS Investigation Guide from ISASI, US Department of Energy reporting guidance and Department of Defense reporting requirements in Section 6
      Each document establishes task demands on investigators.
    • - New paper about BAD SCIENCE describing some universal investigation problems for investigators; offers three antidotes.
    • - New book review of OBSERVATION STILL MATTERS for private investigators to help improve observation skills, organize data; shows what some investigators perceive as observation process.
    • - added example of possible process for advancing research inputs for the Experimental On-Line Project Status reports
    • - Research project participant exchanges functioning. Additional contributors invited. Go to sign-up sheet. .
    • -Installed a project description, project plan and project status report/comment section to Experimental On-Line Investigation Research Project at this web site. Participation invited.
      • - Added human decision process model for investigators
      • - added new Food for Thought item (Editorial)

    15 July 97 updates:

    • - Added special 1928 Report on method of accident analysis Prepared by Special Committee on the Nomenclature, Subdivision, and Classification of Aircraft Accidents of the National Advisory Committee for Aeronautics, to show progress in human factors analysis field in past 70 years.
    • Added information about Norwegian research project t to improve investigation methods.
    • - Updated 6 Mar 98
      Prev update: some links , conference references, navigation links.

    5 June 97 updates:

    • - Introduced new draft experimental on-line research project using the Internet to gather data and exchange comments as research project progresses.
    • - Updated 6 Mar 98
      Prev update: some links

    15 April 97 updates:

    • - Added new research report involving recommendation development process observations during investigations, in response to comments and E-mail exchanges
    • - Added new research issue - recommendation development methods.

    1 April 97 (May) updates:

    • - Added new navigation window to enable faster access to each section and topic lists.
    • - Added new DOCUMENT MENU to permit direct access to stored documents if you have a Java-enabled browser
    • - Added new research report describing 5 observed perceptions of accident phenomenon
    • - Updated 6 Mar 98
      Prev update: links to related sites
    • - Added research project report references to Research Projects section
    • - Implemented mailing list among active researchers providing inputs

    March 97 updates:

    • - No major changes

    February 97 updates:

    • - Added Food for Thought note, moved them to Research Wish List
    • - Added 3 new issues to Research Wish List.
    • - Added 4 more investigation reference books and
    • - Added 4 book reviews to Reference Books section
    • - Added 2 research project report references to Research Projects section
    • - Upgraded web site navigation aids, reduced loading times
    • - Updated 6 Mar 98
      Prev update: links to other Inet sites
    • - Established mailing list among active researchers providing inputs

    January 97 updates :

    • : - More new comments posted in Feedback Section. (21 Dec 96)
    • - 2 new conferences posted in Section 7 Conference .
    • - Revised home page to facilitate navigation among sections
    • - Added draft Personals section and sign-up form (under construction)

    December 1996 updates :

    • - Added User SURVEY to get feedback about this experimental internet site to guide future actions.
    • - Added Inet sites
    • - Added 2 additional issues to Research Wish List
    • - Added research report to Research Projects section.
    • - Added feedback about alternative investigation objectives in Canada
    • - More new comments posted in Feedback Section. . (Go to Section 4)
    • - 2 new conferences posted in Section 7 Conference .
    • - Added user SURVEY to help you submit your feedback about this experimental internet site to guide future upgrades.
    • - Added a Report about restructuring investigation agency to separate recommendation development from investigation, etc. in Section 4.
    • - New Feedback about experiences with alternative investigation objectives in Canada (Go to Section)

    November 1996 updates :

    October 1996 updates :

    September 1996 updates :

    • - I just learned today that the US Department of Energy and INEL/EG&G shut down the System Safety Development Center in Idaho Falls, ID over the past several months. The Center, one of the very few organizations to conduct research into investigations and safety processes in the world. I expect to be able to acquire and post some of their last accident investigation process-related research reports over the next several months.
      The Center and its support staff and services made significant contributions to the state of the art in investigations, and this resource will be missed. LB.
    • - A Video investigation research data source section has been added to Section 6, the reference section. The purpose is to provide examples of videos which disclose how investigation are or are intended to be investigated, to enable researchers to model, analyze and evaluate the methodologies described. .ÝÝGo to Video List
    • - Table of contents of proceedings of ISASI 1995 Seminar, listing examples of papers describing investigation experiences, published by the International Society of Air Safety Investigators. Reproduced by permission of ISASI.Go to ToC. (Posted 21 Sept 96)
    • - A mishap investigation manual and proposed revisions are available on-line through the US Department of Defense.(Go to DoD site) From the perspective of investigation objectives, it is interesting to compare the narrow approach to mishap investigation by this organization with the broader approach apparently envisioned by the lessons learned program at the US Department of Energy internet siteÝÝGo to DoE site How do these differences influence the investigative methodology selection process?ÝÝSee the Investigation Program Planning Model.)
    • - Human Factors Intervention Strategies to Prevent Aircraft Accidents: Paradigm Shifts to Exploit Successful Human Factors Interventions for Aircraft Accident Prevention . Position Paper Prepared for FAA Office of System Safety Workshop on? Flight Crew Accident and Incident Human Factors, McLean, VA June 21-23, 1995. Describes current problems with human factors investigations, and proposed 5 paradigm shifts to achieve improved performance.
    • - "Can We Believe What We See, If We See What We Believe? - Expert Disagreement," by Jon J. Nordby, Journal of Forensic Sciences, JFSCA, Vol. 37, No. 4, July 1992, pp.1115-1124. Requests for reprints may be addressed to:
      Professor Jon J. Nordby, Pacific Lutheran University - Knorr 204, Tacoma, WA 98447 USA. Addresses what investigators see; addressed differently from Vaughan's retrospective fallacy arguments, but speaks to similar phenomenon.

      Site launched on August 26, 1996.

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