PREFACE
This presentation is one of several graphic instructional materials available from Starline Software, Ltd.¬Ý It is an overview of the first of a three part slide series describing challenges, opportunities and examples for improving the value of investigations.¬Ý Using these materials, one can learn to investigate accidents, fires, explosions, spills, incidents and most other occurrences more efficiently, more effectively and more consistently
For more information about this and other learning tools, visit the Starline web site at
Produced by
Ludwig Benner & Associates for Starline Software Ltd.
Welcome
Exploring the State of the Art
of Investigations:
Part 1 Investigation Challenges
RECOGNIZED INVESTIGATION¬Ý CHALLENGES
Whether it is a large mishap. . .
Or a fire
Or someone fell off a ladder...
How should I prepare myself?
Why investigate?
What are my objectives?
Scope of Investigations?
What should I investigate?
How should I investigate?
or by reconstruction?
What investigation method should I use?
Unknowns and
Unknown Unknowns
During an investigation...
How much data are enough?
¬ÝHow do I recognize when I know enough?
Investigation outputs:
What should I deliver?
Quality assurance
How can I tell if my work is OK?
How will my work be used?
By now you are wondering...
Recognized Challenges
Emerging Challenges
Managerial demands
Improve Effectiveness
Improve Efficiency
Improve Consistency
Improve Timeliness
Assure Quality
Improve Credibility
Emerging Challenges
USER-DRIVEN CHALLENGES:
User challenges:
Research origins
Main research data sources
2 kinds of investigation deficiencies
Hidden deficiencies
Investigation’Äôs Hidden Defects
Symptoms of problems
Next research step:
Problems with current technology
Research disclosed a useful surprise:
-time for a¬Ý break ...
Conceptual differences
WHAT IS BEING INVESTIGATED?
Concept 1
Concept 2
Concept 3
Reason’Äôs example of Stochastic Model
Concept¬Ý 4
Fault Tree Model
MORT Tree Example
Concept¬Ý 5
MES-based Event Pairs and Sets for analyses
They can’Äôt all be right!
Models drive investigation tasks
Chain of Events Model
Stochastic Model
Branched tree model
Multilinear Model
Finding preferred model
Field applications disclosed
-time for a another break
A false premise
Role of Investigation Models
Research challenges were to...
More¬Ý research challenges
Investigation Process Criteria
Investigation Process Criteria
Search for Investigation Models
Investigation Process Models
Models in use did not satisfy these criteria:
Models for Investigation Process
Investigation Process Frameworks
Attributes of processes within the LEGAL framework
Processes within SCIENCE framework
Processes with SAFETY framework
Scientific Model most attractive:
Importance of Observations
Observation limits
Understanding as an objective:
Prediction as a Goal
Control as a Goal
Other models
New Investigation Goals
The Research challenge:
Technical Challenges
Investigation data variations
Technical Challenges II
New technology needs
Broader challenges
Output Use Challenges
Functional Integration Challenge
Investigation Process
Quality Control Challenges
Investigation Paradigms
The ’ÄúOpportunity’Äù paradigm
The ’ÄúAttitude’Äù paradigm.
The ’ÄúMethodology’Äù
The ’ÄúData’Äù paradigm.
The ’ÄúAnalysis’Äù paradigm.
Investigators’Äô response?
End of Overview
REFERENCES slide