Another "big" one, covering none less than 584 pages… One question, of course, is: are they worth the effort. And the answer, as often, is: yes and no. Good news for the lazy reader is that the last 150 pages are appendices and a bibliography and certainly not essential to read. Still, it's a bit strange that one needs 400+ pages to describe the pretty simple concept of STEP, but that this in the end takes less than 25% of the book…
I put the book on my list of books to read because of the fact that one of my employers used STEP (which stands for Sequentially Timed Events Plotting) as the preferred method for finding direct causes of accidents. This immediately underlines the major drawback with STEP: it's a great method to define the events leading to an accident and identifying direct causes, but it's useless for identifying underlying or even root causes, although you may find STEP helpful in showing you what directions to explore further.
The writers do not mention this drawback, instead they go on and on about how innovating and new STEP is and how better it is than other 'frameworks' and how it will solve all your problems and… Well, to be fair they don't actually say the latter, but it comes near and sometimes I almost feel that it should be sold on Tell Sell…
This sounds a bit sarcastic and negative but I'm pretty annoyed by these passages, so my negative tone on their pretention-ness is intended. On the other hand, we should keep in mind that this book is more than 25 years old. These were the days before James Reason’s seminal work, before Tripod, before Piper Alpha, Cullen and Safety Cases… So, maybe we should just ignore the continuing pretentions as much as possible and concentrate on the good parts.
The writers are probably among the first to recognise that an accident (or incident) should be looked upon as a process, and I wholeheartedly agree with this. An incident just cannot be seen as an isolated event. And also the investigation of an incident is definitely a process and must be gone through as such if you want it to reach its goals. Alas the writers get a bit carried away and also treat really tiny details of the preparation of an investigation that it reaches an almost childish level (actually, I think they leave the scope of a book like this here), and it's quite repetitive because chapter 14 brings little new stuff in comparison to chapter 4.
What I really appreciate about the book is that the writers have thought about criteria for conducting a good investigation as well as required qualifications for investigators, and that the STEP methodology has build in a couple of steps (pun not intended, but fine just as well…) to quality check the outcome. Well done!
Very practical, useful and interesting: the parts of dealing with the media (on page 98), and for example chapters 5, 6 and 7 about the actual fieldwork (e.g. dealing with witnesses and the reliability of these persons) and the Four Laws Of Investigation (to which they later add a fifth, by the way). And let's face it: I do like the idea behind STEP, as it is a very practical way to construct a timeline and connections between actors. (something which TopSet has adopted in a smart way, by the way)
Another bit of criticism: the way the writers (deliberately) confuse 'cause' with 'blame' and simply reject 'causes'. I don't know whether this is based on a misunderstanding of the concept of cause, or on some religious/fundamental belief or just another attempt to pose their method against other existing methods and show how unique they are. I have a feeling the latter may have played a role… Quite crap this bit at any rate and maybe this also leads to the authors failing to recognize a bit the limitations of STEP: it is a good tool to describe the accident/incident and define the immediate causes, but it is rather useless to detect underlying or root causes. Because the authors reject concept of causes, they have different stop rules (see chapter 7.3) and may stop their investigation much earlier than one that carries on until the causes have reached a 'system boundary'.
In general this is a good book that gives a very good basis for investigations. Try to look through the pretentiousness here and there and some outdated remarks. And most importantly: do not follow the authors concept (or rather non-concept) of cause. An essential book? If it would be updated and enhanced with a root cause bit, I guess yes, it might be close to essential. As it is: I'm afraid not.
ISBN 0824775104
Likely out of print, but possible to find on Amazon or ebay.
