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INVESTIGATING
INVESTIGATIONS to advance the State-of-the-Art of investigations, through investigation process research. Research Resources: Search site for:: Launched Aug 26 1996. |
By Klaus Kosmuder
Copyright 1996 by the International Society of Air Safety investigators Reproduced by permission of ISASI Permission to preprint material in this work, without fee, is hereby granted contingent on giving full and appropriate credit to the author and to the International Society of Air Safety Investigators on any reprints. For permission to reproduce and disseminate the material in other forms, please contact ISASI at its Sterling, VA USA office. ISASI Technology Trading Park Five Export Drive Sterling VA 20164-4421 USA
As Ted Ferry in one of the two 'Forewords' of the book writes: "This badly needed book makes a call for 'new investigators', people able to accept new accident investigation concepts and Ideas. The 'new investigator' will understand tomorrow's needs for accident information and be able to foresee the need for tomorrow's Investigation.
The greatest deficiency in present-day accident investigation is the lack of a systematic investigation approach called by the authors the 'unmet Need.' In developing a definitive system of accident investigation, they have done all safety-oriented persons a great service.
The authors, through most of their working lives, have sought to advance the field of accident investigation. In previous and present position they have had an opportunity to observe and test nearly every recognized investigation process, all the while developing the Ideas that have resulted in the STEP technique."
William G. Johnson states in the other 'Foreword' that "Three values are especially significant in my experience:
My own appraisal of the book, and the Sequentially Timed Event Plotting or STEP methodology of accident investigation, is that both are long overdue. This publication, 15 chapters plus 8 appendices between hard covers, is a comprehensive delineation of old versus new, of obsolescence versus avant-garde, and should be read by every safety-oriented person and every investigator, the seasoned veteran of yore, as well as the ab initio novice of tomorrow.
In a detailed manner and comprehensible diction, this book addresses a new and viable methodology of accident investigation. It covers everything from the mandate to investigate, via such quintessential processes as accident delineation, report writing and recommendation developing, to the one person investigation of minor interest, or the team investigation of a major tragedy with considerable interest.
To a corresponding degree the book elucidates not only why present-day accident investigation practices and techniques have glaring shortcomings, and why doubts and objections as to their efficacy have been about for some years. It also addresses the controversy surrounding causation of an accident, and the innate biases of purpose and methodology of an investigation. This publication can, and should, for ever alter this profession and field. Kingsley and Ludi, good luck!
Klaus Kosmider
P.S. The opinions expressed herein are those of the author; they are not those of the Canadian Transportation Safety Board.
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