Development of New Methods to Support Systemic Incident Analysis.
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Explaining incidents as systems is a fast growing area of safety scientific research. The misleading conception of naturalistic human communication in terms of ‘objective information’ remains a pervasive influence on systemic explanation of incidents, despite over a decade of methodological developments in the area. Currently, interested stakeholders are offered with few alternatives for analysing how information systems emerge naturally, and contribute towards the structuring of incident situations. Extant methods are also yet to be widely adopted by the practitioner community, and a research-practice gap has formed. In this PhD research, a new method of systemic incident analysis is developed, to counterbalance against the extant methods being developed in the area. The new method draws on insights from both Distributed Cognition, and linguistics research, in order to present a distributed means of doing systemic incident analysis. The new method de-objectifies the notion of information, to support analysis of how information ‘flow’ is constitutive of the formation of distributed cognitive systems. In embedding an intersubjective component into the core method design, we aim to increase the likelihood of systematic learning from incident situations. The incident analyst is required to explicitly relate past explanations of incident situations, in detail, to data and hypotheses from new incident situations. To increase the potential for theorists in the area to better account for the demands of incident analysis as practiced, data, insights, and method are contributed towards the bridges been built between research and practice. We first develop additional understanding of the practice of incident analysts from the patient safety background. Next, we provide a second new method of analysis, to allow research scrutiny of the empirical phenomena of using systemic incident analysis methods. This second method considers the detailed relationship: from the theory of the systemic incident analysis method into its practice as part of real incident investigation. This provides a new research instrument, for systematically examining how systemic incident analysis methods may afford or constrain elements of their practice.
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