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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


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 —the funnels of investigation and the investigation trajectoryś. 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.