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The books listed provide either data, ideas, guidance, descriptions of experiences, points of view or other information to investigation process researchers
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|Book References for Investigation Process Researchers
Ten Questions About Human Error by Sidney Dekker, ISBN 0 8058 4744 8 2005: poses ten questions about human factors and system safety as disciplines, to engender vigorous debate about underlying theory of human factors.
The Field Guide to Human Error Investigation, by Sidney Dekker, ISBN 0 7546 1917-6 (HBK) 2003: offers a "new view" of human error, based on premise that if you really understand evolving situation involving people's behavior, you will understand the behavior that took place within it.
Learning from Failure, The Systems Approach by Fortune, J and Peters G ISBN 0 471 94420 3 1995: proposes a reliability-oriented "systems failure method" for analyzing failures to find lessons learned.
Root Cause Analysis: Improving Performance for Bottom-Line Results, Third Edition 2006 offers a broad look at the various types of approaches to root cause analysis (RCA), comparing the pros and cons while supplying practical tools for implementing or improving current RCA initiatives.
Shaping public safety investigations of accidents in Europe, Edited by S. Roed-Larson, J. Stoop, E. Funnermark, and ESReDA Working Group Report, Det Norkse Veritas, Hovik, Norway 2005, describes the development, state of the art and challenges and recommendations for future developments.
TapRooTĘ The System for Root Cause Analysis, Problem Investigation, and Proactive Improvement, by Mark Paradise and Linda Unger, System Improvements, Inc. Knoxville TN 2000 ISBN 1-893130-02-09 describes investigation tools.
Human Error by James Reason, Cambridege University Press, 1990, ISBN 0521 31419 4. Presesnts views of human error that influenced investigation practices and mehtods, including managing errors. Viewed by some as a seminal work.
Normal Accidents, by Charles Perrow, Princeton University Press, Princeton, NJ 1984, ISBN 0-691-00412-9 analyzes the social side of technical risk, with perspective on accidental occurrences in close-coupled complex systems.
Handbook of Industrial Automation, Edited by Richard L. Shell and Ernest L. Hall, Marcel Dekker, Inc. New York 2000. Chapter. 8 Investigation Programs covers the elements of an accident investigation program, program planning and conducting investigations. See chapter Table of Contents.
Fire on the Mountain by John N. Maclean, William Morrow and Company, New York, NY (1999) ISBN 0-668-14477-2. Describes a mountain forest fire, and the investigation that followed, problems and all. See review.(1999)
Young Men and Fire, by Norman Maclean, University of Chicago Press, Chicago, IL, (1992) ISBN: 0226500616. A writer spends 14 years trying to reconstruct how 11 firefighters died in a mountain fire "blowout" in 1949, in part because the original investigations were inadequate.See review. (1992)
A Glimpse of Hell: The Explosion On The USS Iowa And Its Cover-up, by Charles C. Thompson II,, W. W. Norton & Company, Inc. New York NY 1999 ISBN 0-393-04714-8. See Review. Extensive discussion of the explosion aboard the battleship USS Iowa and the many problems with the investigation of the explosion. (11/99)
How the Battleship Maine Was Destroyed by H.G. Rickover, US GPO, 1976, LC 76-600007 [no ISBN shown], View book review. Offers concepts that should interest today's "investigators": and researchers:
Sabotage Syndrome from a century ago,
hypothesis-bias motivated by desires to protect a "corporate" image,
Explosion aboard the Iowa, by Dr. Richard L. Schwoebel. Annapolis, U.S. Naval Institute Press, 1999. ISBN 1-55750-810-0. View book review. Look at reader comments, and (6/99)
- Goldratt's theory of Constraints by W. William Dettmer. ISBN 0-87389-379-0 Goldratt's continuous improvement ideas in comprehensible English with examples. Cause-effect diagrams, etc. (6/99)
To Engineer Is Human, The Role of Failure in Successful Design by Henry Petroski , St. Martin's Press, NY 1985, ISBN 0-312-80680-9. Petoski states "I believe that the concept of failure-mechanical and structural in the context of this discussion is central to understanding engineering, for engineering has as its first and foremost objective the obviation of failure." These words can also apply directly to the profession of accident investigation. < (john richardson 6/99)
"Why Things Bite Back, Technology and the Revenge of Unintended Consequences",by Edward Tenner, Knopf, NY 1996, ISBN 0-679-42563-2. An interesting follow-on to Perrow's book and another take on the Complexity theory issue. I suggest that it provides an interesting philosophical view of modern technology and the problems in engenders. Certainly, there is food for thought here for those of us faced with identified causes. (John Richardson 3/99)
LANGUAGE IN THOUGHT AND ACTION, by S. I. Hayakawa, Alan R. Hayakawa 5th Edition Paperback, Harcourt Brace 1991 Absolutely must reading for investigators and accident analysts who have to develop descriptions and explanations of occurrences, and prepare reports on what happened and why it happened. Shows language pitfalls for investigators and analysts, and how to work with concrete, objective, non-judgmental language. Super value. Look
Establishing Quality Controls for Forensic Expertise." In Bohan, T. L., Ed., Forensic Accident Investigation: Motor Vehicles - 2 . Charlottesville, VA Lexis Law Publishing, 1997. Includes discussion of need for quality controls for forensic witness testimony. Chapter 6 ( by Ira Rimson), Establishing Quality Controls for Forensic Expertise, subtitled Case-Hardening by the Scientific Method: multilinear Events Sequencing. Provides overview and method for ensuring forensic quality controls.
INVESTIGATING ACCIDENTS WITH STEP, 1986, by Hendrick and Benner, published by Marcel Dekker, New York/Basel. ISBN 0-8247-7510-4. Introduces research-defining multilinear events sequencing-based investigation system and procedures, based on position that accidents are processes. Focus is on understanding, describing and explaining phenomena, and then developing and assessing actions to improve future performance. Contains comparative analyses of accident models and investigation methodologies, references to 20+ investigation manuals, plus investigation tools and models.
GUIDELINES FOR INVESTIGATING CHEMICAL PROCESS ACCIDENTS, 1992 by Center for Chemical Process Safety, of the American Institute of Chemical Engineers (AICHE), New Your, NY USA. Focus is on cause determination and prevention. Prepared by a committee, this investigation guide includes a comparison of available investigation systems, and describes rationale for experientially-based choice presented; presents examples of cases.
OBSERVATION STILL MATTERS, How to Increase Your Posers of Observation by Ronald L. Mendell, CLI Describes his view of the process of observation, and how investigators can improve their observational skills. Discusses five ways to organize data, and ways to improve people observation skills. Go to review:
FUNDAMENTALS OF CRIMINAL INVESTIGATION, O'Hara and O'Hara, 1989, Charles C Thomas, Springfield, IL USA ISBN 0-398-05460-6 Describes criminal investigation process fundamentals. Community college textbook. Focus is on methods for investigating most frequent types of offenses, with many references to techniques and procedures to help user pursue other crimes. Responds to demands of US legal system. /font>
A GUIDE TO HISTORICAL METHOD, 1974, Shafer, published by Dorsey Press, Homewood IL USA, ISBN 0-256 -01525-2. An example of historical investigation methods. Describes historical research method, including concepts and methodologies of the social and behavioral sciences, and the function of inference in historical reasoning. Provides numerous bibliographic leads to background readings.
AIRCRAFT ACCIDENT INVESTIGATION, 1996, Wood and Sweginnis, Endeavor Books, Casper WY USA. Focus is on techniques used in aircraft accident investigation and how selected aviation-related systems function. Describes and documents current techniques for developing description of accident phenomena very comprehensively. Reflects legal investigation concepts and needs, and the conventional wisdom in this field. ISBN 0-9629524-3-5 E-mail publisher.
THE CHALLENGER LAUNCH DECISION , 1996, Vaughan, University of Chicago Press, Chicago, IL Revises findings of the Presidential Commissions investigation in areas of the production of culture, culture production including normalization of deviations into risk taking decisions, interactions influenced by organizational culture, dissociation of assumptions over time and other human behavior insights for investigators. Author describes and discusses investigation process used.
IMPROBABLE CAUSE, 1991, Filotas, L., McClelland-Bantam, Toronto, Ontario Canada ISBN 0-7704-2488-0. Describes in a narrative autobiographical form the course of events involved in an aircraft accident investigation, including the handling of data, and possible influences on the investigation process. Informative for investigation program designers.
FIRE INVESTIGATION BACKGROUND BOOKS
La Formation de l'Esprit Scientifique , Gaston Bachelard,, Librairie J. Vrin, Paris, 1938 and
La Psychanalyse du feu , Gaston Bachelard, Gallimard, Paris, 1949. Fire was either a tool we needed not understand, or an ancillary phenomenon, until thermodynamics started to develop with Lavoisier et alia. Bachelard (a philosopher and science professor) recounts and analyses some of the prescientific notions about fire and electricity.
Fire Fighting Tactics, Lloyd Layman, NFPA International, Boston, 1953,
Attacking and Extinguishing Interior Fires , Lloyd Layman, NFPA International, Boston, 1955. Important titles in the contemporary fire literature. They present enduring descriptions of fire behavior in structures and are widely presented, mostly without credit to Layman. Fire investigators must understand the concepts presented.
NFPA 921 Fire and Explosion Investigation. National Fire Protection Association, 1995 Prevailing fire and explosion investigation guidance in fire investigation field.
ABC de police scientifique , Jean Gayet, Bibliothque scientifique Payot, Paris, 1973. Only the second part of this book deals with fire investigation. The interest lies in a sound scientific description of fire ignition and fire development. Contact H. Chicoine for information
THE INVESTIGATION OF FIRES, 1981, Roblee and McKechnie, published by Prentice-Hall, Englewood Cliffs, New Jersey USA ISBN 0-11-503169-9. Focuses on determination of fire origin and cause by fire investigators. Example of textbook approaches that present information about phenomenon and its investigation, with strong emphasis on illustrations to support techniques presented.
- BEYOND AVIATION HUMAN FACTORS: SAFETY IN HIGH TECHNOLOGY SYSTEMS by Daniel Maurino, James Reason, Neil Johnston and Rob Lee, Avebury Aviation, Aldershot, Hants, England (~1995) Suggests new view of organization systems, supported by case studies of past investigations. Of special interest for investigation process researchers who would have to provide the requested data about the decision making process throughout aviation investigations.
SAFEWARE: SYSTEM SAFETY AND COMPUTERS, by Nancy G. Leveson, Paperback, 680 pages Published by Addison-Wesley Pub Co 1995 This book examines what is currently known about building safe electromechanical systems and looks at past accidents to see what investigation lessons can be applied to new computer-controlled systems. Case studies alone worth the price! .
- <NORMAL ACCIDENTS, Living With High Risk Technologies by Charles Perrow, Basic Books, 1985. Interesting observations that help investigators understand risk taking issues in histology incidents.
GUIDE 1-INTRODUCTION TO INVESTIGATION, by Ludwig Benner, Fire Protection Publications, Oklahoma State University, Stillwell, OK 1997. New series also includes GUIDE 2 - ACCIDENT INVESTIGATION, GUIDE 3-HAZMAT INVESTIGATION and GUIDE 4 - FIRE INVESTIGATION. Guides describe general preparations for investigation, knowledge needed, how investigators should investigate, developing performance improvement recommendations, and a summary of investigation tasks, with 9 appendices containing detailed tools. Support video training films. Get purchase information.
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