INVESTIGATING INVESTIGATIONS
to advance the
State-of-the-Art of investigations, through
investigation process research.
Research Resources:
Search site for::
Launched Aug 26 1996.
| |
Human Factors in the Field: A Field Study of Accident
Investigation at the Transportation Safety Board of Canada |
Doctor of
Philosophy 2003
Leo Donati
Department of
Mechanical and Industrial Engineering
University of
Toronto
Abstract
The goals of this
research are twofold. First in the sense of direct applicability to
investigative bodies, the goal is to identify the cognitive strategies used by
accident investigators to uncover human factors issues and to actively manage
accident information. This information is pertinent to training and job aid
design. Second, in an academic sense, the goal is to identify and conceptualize
the factors affecting information management in a complex work environment.
The field study is
based on grounded theory and involved participant observation carried out over
a three and a half year period, in addition to the documentary review of
investigation records. Three major classes of strategies employed by accident
investigators to manage information were revealed; information minimizing,
information creation, and information balancing. The field study also
identified a number of constraints affecting the use and flow of information
during the investigation process. Methods used in this study are demonstrated
as useful tools for researchers examining cognitive activities, analyzing
patterns of behaviour, and the management of information between the various
interacting players in a complex, real world, work system.
Results of the field
study lead to the development of a conceptual model of information management
called Ñthe funnels of investigation and the investigation trajectoryæ. The
model captures three levels of constraints imposed on information. Information
is constrained: a) by the organization, b) by contextual factors and investigator
perspective, and c) through the control of information by accident
investigators as they employ information management strategies and causal
interpretations to the information. The proposed model of information
management provides a framework to help direct future research in this area.
The conceptual model
proposed highlights the times during the investigation process when information
is constrained, and suggests where efforts can be placed to reduce those
constraints. The information management strategies identified, particularly
those that create information, can assist in broadening the information
observable by accident investigators.
A number of prescriptive recommendations are made to improve investigator
training. These findings should be
of use to those developing training programs or support tools for
practitioners.
|
|