The transformation of accident investigation: From finding cause to sense making (2015)

Summary

This dissertation from Ivan Pupulidy, Tilburg University, introduces a network of practices that transformed the United States Department of Agriculture (USDA) Forest Service accident investigation. 

This dissertation uses case studies to show the interweaving of organisational 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 sense making at both the field and organisational leadership levels of the organisation.