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Launched Aug 26 1996.



  By Klaus Kosmuder


Investigating Accidents with STEP by Kingsley Hendrick and Ludwig Benner, Jr., Marcel Dekker, New York and Basel 1986, 454 pp. (including 8 appendices) ISBN 0-8247-7510-4

This review was published in the ISASI forum 29:2, October 1996
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

Telephone: (703) 43O9668 FAX: (703) 45O1745

Foreword by Ted Ferry, Ed. D., & William G. Johnson

Please take note, the authors of STEP (Sequentially Timed Event Plotting), the book under review, have been professionally associated with the complex field of accident investigation for many years, and their respective curricula vitae bespeak a glaring knowledge and familiarity with this intricate subject. Predicated on these recognizable proficiencies then, in my humble opinion, both individuals are amply qualified not only to ask 'why the same accidents are being investigated time and again, and why, concomitantly, our archives are brim-full with statistic-accumulating and subjective opinion-enhancing reports, but also to create and advance an innovative methodology of redress for this perpetual problem; hence STEP.

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:

1. The multiple events sequence method is great help to the investigator in sorting through often chaotic evidence and clues to find a coherent story of what really happened.

2. A group of managers, scientists, engineers and safety professionals will find multiple events sequence diagrams to be a very helpful method of assembling their findings and views to attain a consensus.

3. The resulting multiple events sequence diagram is understandable to the public, or at least the technical-minded fraction of the public. It shows clearly the multifactorial nature of the sequences.

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.