The greatest obstacle to discovering the shape of the earth, the continents and
the oceans was not ignorance, but the illusion of knowledge.

- - - - Daniel J. Boorstin

• encourages harmopnious collaboration among everyone involved in the investigation
• provides continuous status updates of an investigation progress
• produces blameless descriptions of what happened
• facilitates discovery of new knowledge about what happened
• uses standardized building blocks for developing descriptions of what happened
• enables objective logical quality assurance and truth tests
• offers compatibility with pre-incident analyses.

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  Reading time is about 50 minutes.

  TABLE OF CONTENTS
  (Blue text = linked soures)
  
  

  Part 1. INTRODUCTION TO GUIDES PREFACE STEP-MES INVESTIGATION SYSTEM DESIGN BASIS STEP-MES Foundation STEP-MES Investigation System Overview Investigation Reasoning Tasks Sequential logic Input-output logic Deductive logic Necessary-sufficient logic Investigation Management What can everyone expect 10 Axioms for Investigators GUIDE DESIGN Design approach to Guides Intended use READINGS AND REFERENCES

  Part 2 THE 11 INVESTIGATION TASK GUIDES UNDERSTANDING EPISODIC PHENOMENA Guide 1. Developing STEP-MES Building Blocks (BB Guide) Guide 2. Building STEP-MES matrix arrays (MATRIX Guide) Guide 3. Filling Gaps in STEP-MES arrays (BackSTEP Guide) Guide 4. Acquiring STEP-MES input data BBs (SOURCES Guide) Guide 5. Using Energy Trace & Barrier Analyses (ETBA Guide) Guide 6. Investigation Test Planning (TEST Plan ) Guide 7. Management Oversight And Risk Tree (MORT Guide) Guide 8. Using Time/Loss Analysis (T/LA Guide) USING VALID DESCRIPTIONS OF OCCURRENCES Guide 9. User Action Needs Development (NEEDS Guide) Guide 10.User Action Development (ACTION Guide) INVESTIGATION AND WORK PRODUCT QUALITY ASSURANCE Guide 11 Quality Assurance Procedures (QA Guide)

This set of Guides was created to help conscientious investigators 1) understand and develop valid descriptions of episodic phenomena efficiently and quickly, 2) help investigators communicate that understanding to users needing the description to determine their response to the episode, and 3) illustrate how users can utilize the data building blocks in investigators descriptions to determine their response actions. The Guides are based on he Simultaneous Timed Events Plot/Multilinear Events Sequencing (STEP-MES) technology created from extensive investigation process research and analyses, and tested over many years.

The STEP-MES technology makes possible a comprehensive proven investigation system for developing descriptions of any kind of episodic phenomenon. It can be mastered reasonably quickly through use by following the rules presented. Its true power and value can only be observed and appreciated through its use. The Guides provide practical instruction in its use during investigations and user analyses of the descriptions, and for other purposes.

These 11 GUIDES lead investigators through the systematic identification of investigation input data, its acquisition, ordering, integrating and linking to produce a description of what happened during specific episodic phenomena. This Edition updates earlier Guides to incorporate the latest research, thinking and experiences with implementation of STEP-MES technology in all types of investigations. Updates incorporate

• new information from research about the STEP-MES investigation process, and a summary of steps at beginning of each Guide.
  
  
• a summary STEP-MES procedural rules in Guides.
  
  
• updated investigation logic tasks,
  
  
• differentiation between investigator and analyst task knowledge and skill needs.
  
  
• new Guides for determining user action needs statements and proposed actions for user responses to more kinds of epidoses.
  
  
• more links to investigation web sites where supplemental information can be found.
  
  
• more task illustrations for STEP-MES-based Matrix array development and use to accommodate different types of investigations.
  
  
• updated User's Action Development process tasks for systematically identifying data users need from the episode description to develop actions to achieve their objectives.
  
  
• upgraded investigation quality assurance task section.

First, a word about the foundational thinking or framework on which the STEP-MES investigation system is built. The foundation consists of concepts, principles and insights for the STEP-MES system design which have evolved for me over the years of study and experimentation.

Episodic phenomena are processes, consisting of people, objects and energies interacting with each other over time to produce observed outcomes. Investigations are undertaken to gain an understanding of episodes by understanding the interactions that produced the outcomes. Once understood and documented, the episodic process descriptions can be analyzed to satisfy investigation data users' specifici needs for actions they should undertake in response to the episode..

2. Every investigation is a process. All investigations involve many tasks, each task requiring specialized investigation knowledge, skills and methods. Those common tasks, and the knowledge, skills and methods required to perform them, are addressed in these Guides. Investigators need to produce valid new understanding and information on which individuals and organizations can act to satisfy their specific needs. That is accomplished by developing scenarios representing what happened, constructed with data "building blocks" (BBs) derived empirically from sources involved with the episode. The procedures are applicable to investigations of any kind and level of episode complexity.

They are also relevant to development of scenarios of hypothetical episodes for predicting future behaviors.

3. Understanding what happened requires investigators develop a description that meets certain criteria. Descriptions must be valid representations of what happened. The description must describe what happened in ways which readily communicate the investigators' understanding of what happened to users who need to act on that description. The description should strive for consistent structure and content to facilitate comparisons of episodes. As it is developed, the description must be research defining to help investigators recognize what is unknown, and point investigators toward the data they still need to acquire to complete the description. To do so, their descriptions must be developed as each new data input BB is acquired and "progressively integrated" to show investigators the status of their investigation, and what input data they still need to acquire. Investigators' descriptions must show the logical flow of the actions and interactions that produced the outcome, to enable objective quality control. The description must facilitate user's identification of dat they need to support development of their actions in response to the episode by offering an orderly way to consider all described episode actions and interactions. Descriptions must be as complete as possible to encourage their use in the greatest variety of activities.Descriptions should be as specific as possible to minimize the need for more data, interpretation or disambiguation by users. Descriptions should avoid investigator-originated subjective opinions, judgments, allegations and characterizations to minimize potential controversy about described actions; save them for other reports. These 11 guides help investigators develop a trustworthy description of what happened;quickly, efficiently and consistently.

4. The description of an episode should be explanatory. A distinction is often made between describing what happened and explaining what happened. An underlying premise of these guides is that a competent description of what happened should also explain why it happened. STEP-MES investigations strive to accomplish that by pursuing all input actions by specific actors that were necessary(essential) and sufficient to produce a subsequent action or interaction during an episodic occurrence. That includes "programmer" actions by any entity of any kind that influenced what people subsequently did, and design decisions and actions that influenced what an object or energy did during the episode, as well as an individual's prior experiential influences.

5. Developing user action proposals is a different type of "investigation" function than determining what happened. Therefore that function should be reported separately. Understanding of what happened is essential to users' discovery and definition of behaviors during episodes requiring user action to satisfy user's duty. User also need a definition of expected interactions (norms.) User actions build on valid knowledge of what happened, but also require analytical and predictive knowledge, skills and methods. The Guides describe how the two investigations task areas overlap and support each other. The specialized knowledge, skills and methods required to meet both challenges are also addressed.

6. Inaccurate, incomplete or otherwise flawed descriptions have led to many observed unnecessary problems. Those problems include misdirected analyses and user actions; wasted resources, biased judgments, conflicts; injustices, unbridled conjecture and speculations, inappropriate characterizations, and flawed research, among others. Therefore, these Guides include quality assurance guidance and procedures for both the investigation and the investigation work products, to help achieve accurate, complete and trustworthy investigation work products for users.

WHY USE STEP-MES INVESTIGATION System?

Many different investigation systems exist, so selection of an investigation process involves a choice. Use the 4 step, 5 steop, 7 step, 8 step or 12 step scientific method? Use one of the 30 accident investigation methods? Use a forensic scence methods?

After analyzing available methods and their results, and experimenting with them, I have synthesizing their most useful features, innovative personal insights and ideas from the music domain to create the STEP-MES investigation system.

The result is that STEP-MES investigations presented here can produce unexcelled descriptions of episodic phenomena to serve users' needs. Additionally, STEP-MES investigations can produce their quality tested descriptions more quickly, efficiently and reliably than other investigation methods.

STEP-MES also provides users with readily transferable, consistently structured "data building blocks" with which users can confidently and efficiently build their response actions.

STEP-MES System Overview

• principles and procedures for finding and documenting input data acquired during investigations in a timely, consistent, and disciplined way,
  
• principles and procedures for managing any data acquired during an investigation, sequentially ordering it and integrating it in real time,
  
• timely direction to guide the acquisition of additional data still needed as the investigation progresses,
  
• procedures to differentiate the actions needed to produce the outcome from those that were not involved, and
  
• procedures to ensure high quality investigation processes and work products.
  

SEQUENTIAL LOGIC - the reasoning process applied to data to organize it into the proper temoral and spatial sequence in which actions by people, objects or energies occurred. For example, the investigator must reason whether data BB A happened before data BB B, or B before A by determining their relative timing and spatial logic.

INPUT/OUTPUT LOGIC - the reasoning process applied, after actions or behaviors have been ordered sequentially, to determine if an input/output relationship among them exists, and to test relevance of new data. Input/output logic reasoning is documented with linking arrows between BBs, to show the flow of interactions. For example, when A occurred during a process, was it an input to B, kn the sense that it had to happen for B to occur. ? If so draw an input/output arrow pointing from A to B. Sometimes A led to several other actions. If so, draw linking arrows from A to the outputs it produced. Other times several actions (A1, A2 and A3) all were needed inputs to B. If so, show this by drawing an" input/output links" from input action A to outputs B1, B2, B3, etc. If you think there may be an input/output relationship but need more data, display a dashed arrow with an empty arrowhead or an arrow with a ? on it between these actions.Details are described in Guide 2 about building matrix arrays.

Another way to illustrate this reasoning is to compare it to if/then reasoning. "If A occurred, then B occurred" describes a complete input/output coupling of two actions. "If A, then maybe B" but you need more As (A1, A2.... ) to produce B, you have to keep adding more A's until all the "If A1 and A2 and A3 then B" describes the BBs it takes to make B happen every time the A's occur.

This is the basis for ensuring the completeness of the description, including the explanatory aspects of an episode, to the extent permitted by surviving data..

DEDUCTIVE LOGIC - the reasoning process applied to objects to 1) infer actions that must have occurred to produce the changed states observed during investigations, and 2) fill gaps in an investigator's understanding of what happened with hypothetical candidate scenarios. By applying natural laws and scientific principles to infer possible specific actions of people, objects or energies that must have occurred to produce the observed state, or to fill gaps in input/output flows between known actions, an investigator can pinpoint data which should be sought to verify each assumed scenario. Deductive logic can utilize reasoning aids such as BackSTEP and logic trees.

NECESSARY AND SUFFICIENT LOGIC (N/S)- the reasoning process applied to linked actions, to determine what and only what had to occur to produce a subsequent action or outcome, and to test the completeness of a process description. Is A always necessary for B to occur? If so, it remains part of the linked set. Next, determine sufficiency by determining if B will always occur if A and only if A occurs? If so, the investigator has a complete input/output relationship pair or set. If not, what other actions must occur to produce B with reasonable certainty? N/S logic helps investigators find and define unknown unknowns, or unk-unks.that may not be discovered by other reasoning processes. Deductive logic is used to discover the unknowns.

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.