© 1979-2003 by Ludwig Benner, Jr. .All rights reserved.

MES Guide for


For Improving Investigation Performance

Prepared Ludwig Benner, Jr.

Table of Contents

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This document contains numerous self-help references to varoius resources to give investigators opportunities to improve their understanding of investigation concepts and practices, and build their investigative and analytical skills. Live links are to accessible materials on the Internet.


NOTE: This list does not include any resources which conflict with the the non-causal approach of the MES investigation system because they impede needed progress.


  • The book INVESTIGATING ACCIDENTS WITH STEP, by Hendrick and Benner, published by Marcel Dekker, 1986 New York, NY (490 p) is a comprehensive reference source for studying the MES investigation process. Serious learners will benefit from its study.

  • Additional guidance is provided in four Investigation Guides accompanying four video training films with same names:


    These Guides, designed primarily for the fire fighting community, include several models to help investigations. They are available from the Emergency Film Group, 140 Cooke St. Edgartown MA 02539 (508 627 8844) or Starline Software.

  • Hayakawa, S.I., LANGUAGE IN THOUGHT AND ACTION, (4th Edition), Harcourt Brace Janovich, Inc. New York NY 1972. Must reading to understand the abstraction issues faced by investigators, and how his ladder of abstraction helps investigators address them when using MES process.

Internet resources

The Internet contains many self-help resources for investigators. The following is a list of resources that pertain to the MES investigation system or compatible practices of value.

  • Process Research Roundtable and Library. This pro bono site offers access to noteworthy research activities involving investigation processes. Updated monthly, numerous links to related sites; site search engine available.
  • Starline Software's web site offers training and support resources for investigators, ranging from slide sets, CDs, handouts, Tutorials and Investigation Guides. Site search engine available. (Commercial site.)
  • Personal Archives of Ludwig Benner. This pro bono site provides acces to papers that report the evolution of the MES system over time for those interested in its history. Site search engine available.

Software support

Starline Software offers the Investigatioin Catalyst software to support the MES investigation process. This software supports the preparation of MES Matrixes and their analysis for incident investigation, hazard analysis, evidence organization, investigation quality assurance, among others.

Instruction Materials

These Guides provide a convenient way to get acquainted with the e MES investigation tasks and practices. Reading through the entire set provides a thorough grounding in the MES process. Contact Starline Software for information about additional MES training aids such as course course outlines, tailored school solutions, etc.

The Investigation Catalyst software also includes 5 tutorials.


The following list of papers a suggested readings for students of improved investigaiton methods.

Rimson, I.J., INVESTIGATING "CAUSES" AND ASSIGNING "BLAME", Paper present to AIChE symposium, Texas A&M, September 29 2003.

Benner, L., INVESTIGATING INVESTIGATION METHDOLOGIES NASA/CP-2003-212642, NASA Langley Research Center, Hampton VA 2003

Rimson, Ira J. and L Benner, MISHAP INVESTIGATIONS: TOOLS FOR EVALUATING THE QUALITY OF SYSTEM SAFETY PROGRAM PERFORMANCE, Proceedings of 14th System Safety Conference, Albuquerque, NM

Benner, L., ACCIDENT THEORY AND ACCIDENT INVESTIGATION, Proceedings of the Annual Seminar of the Society of Air Safety Investigators, Ottawa, Canada, 1975.

Benner, L., HYPOTHESIS GENERATION IN RARE EVENTS RESEARCH, Workshop on Rare Events Research Methodologies, National Bureau of Standards, Gaithersburg MD 1976. (NBS Special Publication 482)

Benner, L., FOUR ACCIDENT INVESTIGATION GAMES: INSTRUCTORS' MANUAL, Lufred Industries, Inc., Oakton, VA 22124, 1979.

Benner, L., UNDERSTANDING ACCIDENTS: A CASE FOR NEW PERCEPTIONS AND METHODOLOGIES, Accident Causation, Special Publication SP-461, Society of Automotive Engineers, Inc., Warrendale, PA February, 1980.

Driver, E.T. and Benner, L., EVALUATING DANGEROUS GOODS EMERGENCY RESPONSE WITH TIME/LOSS ANALYSES, Proceedings of 6th International Symposium-Packaging and Transportation of Radioactive Materials, November 10-14, 1980, Berlin(West), Federal Republic of Germany

Benner, L., METHODOLOGICAL BIASES WHICH UNDERMINE ACCIDENT INVESTIGATIONS, The International Society of Air Safety Investigators 1981 International Symposium, Sept 1981

Benner, L. and McDevitt, J., WHITE PAPER NO. 1: SYSTEM SAFETY METHODOLOGY, for Conference on The State Of The Art of System Safety, System Safety Society, Arlington, Va. Nov 4, 1981, Hazard Prevention

Benner, L. ACCIDENT MODELS: HOW UNDERLYING DIFFERENCES AFFECT WORKPLACE SAFETY, Proceedings of International Seminar on Occupational Accident Research, September 5-9, 1983, Saltsjöbaden, Sweden, Vol. 1

Benner, L. and Sweginnis,R. SYSTEM SAFETY'S OPEN LOOP, Hazard Prevention, Nov. 1983,

Benner, L. WHAT IS THIS THING CALLED A SAFETY REGULATION?, Journal of Safety Research, 14:4 Winter 1983

Benner, L. NEW ROLES FOR INVESTIGATIONS, National Fire Protection Association 88th Annual Meeting, New Orleans, LA. May 1984

White L. and Benner, L. CORRECTIVE ACTION EVALUATION, Proceedings of Seventh Int'l. System Safety Conference, System Safety Society July 1985

Benner, L. RATING ACCIDENT MODELS AND INVESTIGATION METHODOLOGIES, Journal of Safety Research, 16:3, Fall 1985 Chicago, IL

Hendrick, K.M., Benner, L. and Lawton, R. A METHODOLOGICAL APPROACH TO THE SEARCH FOR INDIRECT HUMAN ELEMENTS IN ACCIDENT INVESTIGATIONS, Fourth International Symposium on Aviation Psychology, Ohio State University, April 29, 1987

Lawton, R.L., Benner, L,. Clarke, R., Jensen, R., Adrion, A., and Maresh, J., THE DECIDE APPROACH TO TRAINING PILOTS IN PILOT DECISION MAKING, AOPA Air Safety Foundation, June 1987.

Benner, L. "FIRE RISKS IN CARLOAD/TRUCKLOAD TRANSPORTATION OF CLASS A EXPLOSIVES", Report to Department of Transportation, OHMT, Contract No. DTRS57-88-P-82656, March, 1989

Benner, L., "APPLYING SYSTEM SAFETY TO THE SAFETY RECOMMENDATION PROCESS", Proceedings of the 10th International System Safety Conference, Irving TX July 1991

Benner, L ON CAUSE (Guest Editorial on determination of cause), International Society of Air Safety Investigators forum, Volume 24:3 1991

Benner, L. and Rimson, I., "QUALITY MANAGEMENT FOR ACCIDENT INVESTIGATIONS" (in 2 Parts) International Society of Air Safety Investigators FORUM, 24:3, 25:1, OCTOBER 1991, FEBRUARY 1992

Benner, L. RANKING SAFETY RECOMMENDATION EFFECTIVENESS, International Society of Air Safety Investigators, Proceedings of 1992 conference, Dallas TX

Knox, N.W. and Eicher, R.W., MORT USERS MANUAL, SSDC 4 Rev 3, , EG&G Idaho, Idaho Falls, ID 1992

Benner, L., SYSTEM SAFETY ANALYSIS PITFALLS, Proceedings of 15th System Safety Conference August 13-17, 2000, System Safety Society, Sterling, VA

.Benner L. and Rimson, I. PARADIGM SHIFTS TOWARD EXPLOITING SUCCESSFUL HUMAN FACTORS INTERVENTION STRATEGIES TO PREVENT AIRCRAFT ACCIDENTS, Proceedings of FAA Office of System Safety Workshop on Flight Crew Accident and Incident Human Factors, McLean, VA June 21-23, 1995.

Benner, L. and Rimson, I.J., PREVENTING FLIGHT CREW ERRORS: PRIMARY DATA MUST DRIVE ANALYSES prepared for the FAA Office of System Safety Workshop on Flight Crew Accident and Incident Human Factors, McLean, VA June 21+23, 1996

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