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Tilburg University the Transformation of Accident Investigation Pupulidy Tilburg University The transformation of accident investigation Pupulidy, Ivan Document version: Publisher's PDF, also known as Version of record Publication date: 2015 Link to publication Citation for published version (APA): Pupulidy, I. (2015). The transformation of accident investigation: From finding cause to sensemaking S.l.: s.n. General rights Copyright and moral rights for the publications made accessible in the public portal are retained by the authors and/or other copyright owners and it is a condition of accessing publications that users recognise and abide by the legal requirements associated with these rights. ? Users may download and print one copy of any publication from the public portal for the purpose of private study or research ? You may not further distribute the material or use it for any profit-making activity or commercial gain ? You may freely distribute the URL identifying the publication in the public portal Take down policy If you believe that this document breaches copyright, please contact us providing details, and we will remove access to the work immediately and investigate your claim. Download date: 09. apr. 2016 The Transformation of Accident Investigation From Finding Cause to Sensemaking Proefschrift ter verkrijging van de graad van doctor aan Tilburg University op gezag van de rector magnificus, prof.dr. E.H.L. Aarts, in het openbaar te verdedigen ten overstaan van een door het college voor promoties aangewezen commissie in de Ruth First zaal van de Universiteit op dinsdag 1 september 2015 om 10.15 uur door Ivan Alexander Pupulidy geboren op 30 mei 1958 te Weissenburg, Duitsland Promotores: Prof.dr. J.B. Rijsman Prof.dr.ir. G. van Dijk Copromotor: Dr. D. Whitney Overige leden promotiecommissie: Prof.dr. J. Goedee Prof.dr. L. Bibard Prof.dr. J.A.J. Luijten Prof.dr.em. E. Schein Prof.mr. L. Witvliet Dr. P. Spierings Table of Contents Abstract ........................................................................................................................................... i Acknowledgements ........................................................................................................................ ii Introduction ................................................................................................................................... 1 Chapter 1: History of the USDA Forest Service .............................................................................. 9 Chapter 2: The Evolution of Accident Investigation ..................................................................... 27 Chapter 3: The Serious Accident Investigation Guide—Pressure to Standardize the Investigation Process ......................................................................................................................................... 40 Chapter 4: The Norcross Case Study ............................................................................................ 54 Chapter 5: The Panther Case Study ............................................................................................. 68 Chapter 6: The Importance of Sensemaking Communities to Accident Prevention .................... 87 Chapter 7: Learning from Error .................................................................................................... 95 Chapter 8: Agreeing to the Concepts of the Coordinated Response Protocol and Learning Review ........................................................................................................................................ 111 Chapter 9: The Saddleback Case Study ...................................................................................... 120 Chapter 10: Reflections on Transformation through the Lens of Social Construction ............... 149 Chapter 11: Summary and Conclusions ..................................................................................... 162 Bibliography of References ........................................................................................................ 185 Appendix .................................................................................................................................... 199 TRANSFORMATION OF ACCIDENT INVESTIGATION FROM FINDING CAUSE TO SENSEMAKING Abstract This dissertation introduces a network of practices that transformed the United States Department of Agriculture (USDA) Forest Service accident investigation. This is an exceptionally important topic to the Forest Service for several reasons. First, the Chief of the Forest Service has committed to creating a “zero fatality organization,” and the organizational response to accidents is believed to play a significant role in achieving this goal (Tidwell, 2013). Second, the previous method of investigation created second victims; these were workers who were blamed or cited as having caused the accident. This outcome was not intentional; however, the process demanded the identification of cause, and cause was translated into blame. Third, the linear traditional method of investigation was overly simplistic and eroded the confidence that the workforce had concerning the organization. Fourth, the fatality accident rate for wildland firefighting operations was “unacceptable” (Tidwell, 2013)—the wildland1 firefighting community lost 1,075 firefighters between 1910 and 2014 (this number does not include off duty deaths). Under the traditional method of accident investigation, the accident rate increased. This dissertation uses case studies to show the interweaving of organizational and individual journeys, each of which began with the strength to inquire and to challenge assumptions. The case studies show how constructed realities, including my own, were challenged through inquiry and how four practices emerged that supported sensemaking at both the field and organizational leadership levels of the organization. The application of a single one of these practices can improve investigative processes; however, as the last case study demonstrates, together they form a network that transformed Forest Service investigations. There is also a realization that this was—and in many ways—still is a learning journey. The process of change spanned eight years and the journey is not yet complete. In that eight- year period, the Forest Service has accepted new processes for the review of accidents and incidents. The Learning Review process, which replaced accident investigation, embraces four practices designed to engage a wide range of participants through targeted learning products. Where we used to construct accident investigation reports to place the incidents behind us, these new learning products are designed to invigorate communities of practice to discuss, question, and explore the incidents in ongoing dialogues that add perspectives, knowledge, and experience in order to develop applicable lessons learned. I did not begin my journey as a social constructionist and only discovered this orientation once I was well along the path. I realized almost all the organizational and individual transformation practices represented the application of constructionist concepts. 1 Wildland firefighting is differentiated from structural firefighting. Wildland fires burn in forest and grasslands, whereas the term structural firefighting is specific to houses and other manmade structures. Ivan Pupulidy i TRANSFORMATION OF ACCIDENT INVESTIGATION FROM FINDING CAUSE TO SENSEMAKING Acknowledgements When I first began to write this dissertation I did not understand that the transformation I was about to expose was as much about me as it was about the USDA Forest Service. I learned that change can be so incremental as to be imperceptible. I also learned the importance of an emerging sense that we should be less drawn to finding specific solutions to problems in complex systems. Instead, the focus of our effort should be to facilitate collaboration across hierarchical boundaries through dialogues that result in creative pathways that fit specific situations. Then we must dedicate effort to reflect— only in reflection can we learn. I want to thank those who helped conceptually, spiritually, and technically; that list would likely fill the page. It would not be reasonable to continue without mentioning some of the most critical members of the cast of people who supported me and contributed to this dissertation: Crista, my wife, best friend, and editor; Heather, my dear Canadian friend and conceptual cohort; John, for challenging my ideas and being really clever about it; Ben, for beginning his journey with me and for trusting; Curtis, Heath, Wayne, Gwen, and Jay for helping to bring ideas into practice; Sidney, for lighting a fire that would not go out; Todd, for changing me and changing with me; Diana, for holding my feet to the fire; and every person who challenged my ideas, ran small experiments, provided feedback, and otherwise agreed or disagreed—we have all come a long way. There is a greater thanks that must be offered—to my mom—she already knows what she did to inspire the drive that I needed just to get this thing done! There is another group of people who deserve the utmost recognition: the lost friends who, in the pursuit of their dreams, were with me at dinner one night and were gone the next. Alongside them are all the other firefighters, frontline operators, and pilots who have been made into second victims by a process from which justice cannot be achieved and learning is of little or no interest. In particular is Pete, whose story about the
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