FOR ACHIEVING EFFICIENT, EFFECTIVE AND TIMELY
INVESTIGATIONS OF ALL KINDS
for use with
MES TECHNOLOGY-BASED INVESTIGATIONS
- - - Daniel J. Boorstin
Guidance to help investigators avoid any illusions of knowledge!
This set of Guides was created to help conscientious investigators and analysts improve the efficiency, effectiveness, timeliness and value of their investigation work products. Software to help implement the guidance during investigations is available at http://www.investigationcatalyst.com/
"Investigated with MES Technology"
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© 1979-2005 by Ludwig Benner, Jr.
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Published by Starline Software Ltd.
TABLE OF CONTENTS
(Blue text indicates internal links)
Multilinear Events Sequencing technology implemented in these Guides makes possible a comprehensive proven investigation system for the examination of any kind of phenomenon. It is best mastered through use. Its true power and value can only be observed through its use. The Guides provide practical instruction in its use during investigations, and for other purposes.
Most of these 10 MES INVESTIGATION TASK GUIDES are based on the Multilinear Events Sequencing (MES) Technology. That technology is based on the systematic acquisition, ordering and linking of data about events that occur during specific phenomena. This Edition updates earlier guides to incorporate the latest thinking and experiences with implementation of MES technology in all types of investigations, and the introduction of Investigation Catalyst software to support its learning and use. Updates include
First a word about the foundation on which MES investigations, or the framework within which it occurs. The foundation consists of the underlying concepts and principles on which the MES technology is built.
Occurrences or System Operations to be investigated are also viewed as processes, consisting of people and objects interacting with each other to produce outcomes. Investigations are undertaken to gain an understanding of occurrences or operations by understanding the dynamic interactions that produced the outcomes - how what you see came to be. Once understood, underlying processes can be analyzed, predicted and managed in the future to produce more desirable outcomes more efficiently, more consistently and with less risk.
To gain understanding, investigators must determine what happened and why it happened during the process, or how it works. The methodology they use must provide for consistency and discipline in the documentation of what happened. It must be research definingto help investigators determine what is known, and point investigators toward the data they still need to acquire. It must provide for the timely organization and progressive analysis of new data to show relationships among events as data is acquired. It must show the logical flow of the events to explain why the process progresses. Then it must facilitate problem discovery by offering an orderly way to examine all interactions during the process. It must lead to the ready, clear communication of the process interactions to encourage their use in the greatest variety of ways. These guides help investigators develop, quickly, efficiently and consistently a valid documented description and explanation of what happened or how it works.
The descriptions produced should meet certain minimum criteria. For example, they must be valid representations of what happened. They should be problem defining by enabling the orderly identification and definition of problem interactions from episodic occurrences. They should facilitate the analysis and evaluation of options for changes that might be expected to achieve better process outcomes. They should minimize subjective opinions to reduce potential controversy about the contents.
Invalid, incomplete or inconsistent descriptions lead to many unnecessary problems: such as misdirected analyses and actions; waste; conflicts; flawed research and others. Therefore, these Guides include Quality Assurance guidance and procedures for both investigation work products, and for the investigations themselves, to help achieve highly valued work products.
Reasoning tasks during investigations.
Logical reasoning is indispensable to good investigation outputs. MES requires investigators to use four kinds of logical reasoning during their investigation tasks. They are:
At the conclusion of necessary and sufficient logic testing, investigators will know what they know and don't know about the occurrence. With that knowledge, they are prepared to report all uncertainties, with an explanation why they could not be resolved. Investigations consume resources. Resource consumption should be managed to achieve the best attainable efficiency, effectiveness and value. Investigation management is not unlike other management tasks. They include, generally, the definition and establishment of objectives, - identifying customers for outputs planning work flows to achieve those objectives, - selecting a process to produce the outputs staffing the work with capable personnel - establishing personnel specifications directing implementation of the planned process - assuring supervision of work ensuring that deliverables achieve desired objectives.
At the conclusion of necessary and sufficient logic testing, investigators will know what they know and don't know about the occurrence. With that knowledge, they are prepared to report all uncertainties, with an explanation why they could not be resolved.
Investigations consume resources. Resource consumption should be managed to achieve the best attainable efficiency, effectiveness and value. Investigation management is not unlike other management tasks. They include, generally, the
definition and establishment of objectives,
- identifying customers for outputs
planning work flows to achieve those objectives,
- selecting a process to produce the outputs
staffing the work with capable personnel
- establishing personnel specifications
directing implementation of the planned process
- assuring supervision of work
ensuring that deliverables achieve desired objectives.
The value of an investigation program depends very heavily on its objectives and the process selected to achieve those objectives. Unfortunately, the determination of cause to prevent similar accidents is almost universally the objective. A far more productive and valuable objective is to determine what happened, and why it happened to improve future process performance, for reasons that are discussed in many works (For more, see http://www.starlinesw.com/lbjr/)
The investigation process selection is equally influential on program success. The MES technology is presented because it provides the most efficient, effective process, and outputs of broader, less controversial value to their users. It helps investigators identify relevance as data are acquired, define what data to seek, avoid unnecessary data gathering, and constantly test the emerging scenario. From a management perspective, it helps investigators define and control work flow efficiently and produce concrete logically tested descriptions of the accident process, and it defines needs for changes systematically to increase their effectiveness. All this reduces the cost/benefits ratio of investigator's efforts, compared to the "find the cause" (or causes or root causes), "eliminate all other possibilities" or facts/ analysis/ conclusions approaches
The investigation and analytical processes described in these Guides have been tested and used successfully for many types of investigation tasks over a twenty five year period. Software to implement them has recently been developed, expediting many of the tasks involved, and expanding the capabilities of the process. The process has proven useful for tasks ranging from discovering hazards and risks in new systems to accident and incident investigations, defining systems for analysis, understanding equipment breakdowns, accident research, documenting human performance in mishaps, scenario modeling, crimes, investigation report quality assurance and assessment, fire investigations and development of improved inter-agency emergency procedures. MES has been used to investigate many sizes of incidents from minor near misses to workplace fatalities and catastrophic accidents of nationwide interest.
With the availability of supporting software and its outputs, MES-based process descriptions with their events sets can help improve designs, operational manuals and procedures, monitoring processes, training, and task analyses, and help with litigation support, change assessment and control, data sharing, and other tasks.
Axioms can help Investigators during their investigations and analyses of different kinds of occurrences. To view what are probably the Top 10 Axioms, click here, or proceed to Guide 1.
These Task Guides are task oriented, presented in the general sequence needed by Investigators. The contents are compatible with the guidance in the Help Menu of the Investigation Catalyst software, and support the software use.
The Guides were designed to be suitable for
Used properly the MES process can serve you well. View Guides 1-10 next.