FINDING ACTORS

During any process, the outcome is determined by what people, objects or energies do during the process. Their actions produce progressive changes as the process progresses. The investigator's goal is to identify the "change makers" and what they did to advance the process, and then explain why they did it.

The change makers can be people, objects or energies. Tracking what people, objects and energies did may be impeded by changes that were obliterated by subsequent changes. However investigators should still try to track them from whatever data survives. The tracking should cover the entire process, form the initial state before the phenomenon began, through the last harmful occurrence. In practice, it can proceed from any point in the process either forward or backward.

Finding actors for EBs

Investigators can learn about people directly involved in the incident from anyone injured, other people who were there, and any other sources that might have observed the particular incident. The second approach is to use logical reasoning to identify actors that had to do something to produce the EBs already recorded. The latter will lead to individuals who had less obvious involvement in what occurred, like designers, trainers, regulators or budgeters ‚ the programmers whose actions influenced what happened. The main point is to pursue any potential change makers until the full scenario is understood.

Finding objects for EBs.

Investigators can learn about objects involved at the site where the process took place by observing and assigning names to each object they see. Occasionally, a lot of time may have elapses before the effects of an objects action become evident, as when an automobile windshield is chipped by a stone, and a crack grows from that point until the windshield must be replaced, or when a hazardous material is spilled and works its way into the ground water. Investigators should be open to discovering the involvement of new objects as the investigation continues.

Finding energies for EBs

Investigators can identify energies involved from knowledge of work that occurs in a system, and the energies that do that work, and from the work done (changes made) in creating what remains after an accident. Thinking in terms of "stressors" as the actors that produced changes in people (injuries, for example) or objects (deformation, for example), and thinking of people or objects affected by stressors as "stressees" is a useful technique for identifying energies involved.

For more specific guidance about finding and working with energies during investigations, see a description of the Energy Trace and Barrier Analysis process and a comprehensive list of energy sources, see
http://www.starlinesw.com/product/Guides/MESGuide05.html.