Ivan Alexander Pupulidy


The Transformation of Accident Investigation From Finding Cause to Sensemaking

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.