Monash University
20170307-Trotter-Thesis.pdf (18.88 MB)

A systems perspective on improvisation in safety-critical situations: Applications in the led outdoor activity context

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posted on 2017-03-15, 23:37 authored by Margaret Joyce Trotter
Improvisation is a form of performance variability that can provide the adaptation necessary to make systems resilient in the face of unanticipated, unprepared-for disruptions and disturbances. While the systems perspective on safety is now widely accepted in many areas, no research has examined improvisation from this perspective and there is currently no framework or methodology available to do so. To address these gaps, this thesis has aimed to: develop a methodology to support the examination of improvisation in safety-critical situations, consistent with a systems perspective; determine the occurrence, nature and conceptualisation of safety-related improvisation in a specific domain—the led outdoor activity (LOA) domain; identify the systemic factors influencing improvisation in safety-critical situations in LOAs; determine the factors of greatest importance to the occurrence of appropriate, effective improvisation in safety-critical situations; and develop a set of practical recommendations/guidelines for organisations in order to support appropriate, effective improvisation to positively enhance safety outcomes. To accomplish these aims, five studies have been conducted.
   The appropriateness of such a systems perspective and the usefulness of a newly adapted systems perspective methodology (Impromaps) have been demonstrated using improvisation case studies (Study 1). The nature and importance of improvisation to safety in the LOA domain has been determined via a survey of LOA practitioners (Study 2). An Impromap analysis of in depth interview data from LOA leaders (Study 3) and managers (Study 4) has identified the factors and interactions across the LOA system that influence safety-related improvisation. Finally, social network analysis techniques have been applied (Study 5) to identify the key factors in the system. This programme of studies has provided the means through which to develop a systems perspective model of safety-related improvisation, to determine that the concept meets all predictions for a system phenomenon, and to develop a network of solutions or measures that LOA providers can take in order to support appropriate, effective improvisation.


Campus location


Principal supervisor

Michael Lenné

Additional supervisor 1

Paul Salmon

Year of Award


Department, School or Centre

Monash University Accident Research Centre (MUARC)


Doctor of Philosophy

Degree Type



Monash University Accident Research Centre

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