86
Sensemaking in Safety Critical and Complex Situations
personnel fatalities were recorded as a consequence of the collision, but the frigate
Helge Ingstad sank. The cost of the frigate was initially 4,000 Mill NOK, and the
cost of a new frigate is estimated to 11,000 to 13,000 Mill NOK.
This is an accident in a complex environment, with several involved actors that
has to collaborate and being dependent on critical control systems such as radar
and map systems ( Electronic Chart Display and Information System, ECDIS), thus
control and a continuous sensemaking process are important. Automation and control systems relieves people of tasks, but automation challenges sensemaking and
requires more, not less interaction design, interface design and attention to training
( Parasuraman & Riley, 1997). Thus, to understand accidents in an environment of
more automation and control systems, we have explored several maritime accident
reports with reliance on automation and control systems on the bridge, in order to
identify general challenges of sensemaking and HF.
By sensemaking, in this chapter, we build on Kilskar et al. ( 2020), defining sensemaking as a dynamic iterative process of observing ( cues), orienting and acting in
a social setting, thereby creating a shared understanding. Sensemaking is influenced
by HF. The three major ergonomic areas in the HF discipline are organizational, cognitive and physical, Karwowski ( 2012). Organizational ergonomics refers to responsibilities, work process, operational philosophies, Crew Resource Management
( CRM), etc. Cognitive ergonomics refers to task analysis, workload, interaction
design, human–machine interfaces ( HMI), alarm philosophies, etc. Finally, physical ergonomics refers to issues relevant to workplace layout, working environment
( climate, noise), etc. These areas are the foundation of the science of human factors,
as described in Lee et al. ( 2017).
As in all accidents, the root causes of the accident are a combination of technical,
human and organizational issues. We see the accident as a consequence of deeper
challenges with the whole system, i.e. combination of issues such as poor design
of control systems, poor training, mental overload and fatigue ( Dekker, 2005). The
focus of this chapter has been the sensemaking among the different actors (Sola TS
and the VTS) and on the Helge Ingstad bridge prior to this accident, how the sensemaking process was influenced by factors from the environment, clues from the
systems, and how sensemaking could have been more robust.
We use the term safety critical to denote situations or operations that, if they go
wrong, have a large potential for causing harm to people, property or environment.
Critical operations on the bridge include voyage planning, navigation, positioning
and manoeuvring the ship during the voyage. Key systems used on the bridge are DP
systems ( dynamic position) and navigation systems ( radar and ECDIS).
Outside the maritime domain, there are some useful lessons to be learned from
industries with a high focus on safety and reliability. Exploring the Macondo Accident
from the oil and gas industry and the Boeing Max accidents from aviation, there are
key lessons to be learned related to focus on HF in design and operations to build
sensemaking.
The Macondo blowout in 2010 killed 11 workers, released 4.9 million barrels of oil
and generated expenditures of more than 61.6 Billion USD (Washington Post 15th of
June 2016). In the accident report CSB ( 2016), HF were highlighted, i.e. “ Industry’s
focus must shift from correcting individual ‘ errors’ identified post-incident to a
Sensemaking in Safety Critical and Complex Situations
personnel fatalities were recorded as a consequence of the collision, but the frigate
Helge Ingstad sank. The cost of the frigate was initially 4,000 Mill NOK, and the
cost of a new frigate is estimated to 11,000 to 13,000 Mill NOK.
This is an accident in a complex environment, with several involved actors that
has to collaborate and being dependent on critical control systems such as radar
and map systems ( Electronic Chart Display and Information System, ECDIS), thus
control and a continuous sensemaking process are important. Automation and control systems relieves people of tasks, but automation challenges sensemaking and
requires more, not less interaction design, interface design and attention to training
( Parasuraman & Riley, 1997). Thus, to understand accidents in an environment of
more automation and control systems, we have explored several maritime accident
reports with reliance on automation and control systems on the bridge, in order to
identify general challenges of sensemaking and HF.
By sensemaking, in this chapter, we build on Kilskar et al. ( 2020), defining sensemaking as a dynamic iterative process of observing ( cues), orienting and acting in
a social setting, thereby creating a shared understanding. Sensemaking is influenced
by HF. The three major ergonomic areas in the HF discipline are organizational, cognitive and physical, Karwowski ( 2012). Organizational ergonomics refers to responsibilities, work process, operational philosophies, Crew Resource Management
( CRM), etc. Cognitive ergonomics refers to task analysis, workload, interaction
design, human–machine interfaces ( HMI), alarm philosophies, etc. Finally, physical ergonomics refers to issues relevant to workplace layout, working environment
( climate, noise), etc. These areas are the foundation of the science of human factors,
as described in Lee et al. ( 2017).
As in all accidents, the root causes of the accident are a combination of technical,
human and organizational issues. We see the accident as a consequence of deeper
challenges with the whole system, i.e. combination of issues such as poor design
of control systems, poor training, mental overload and fatigue ( Dekker, 2005). The
focus of this chapter has been the sensemaking among the different actors (Sola TS
and the VTS) and on the Helge Ingstad bridge prior to this accident, how the sensemaking process was influenced by factors from the environment, clues from the
systems, and how sensemaking could have been more robust.
We use the term safety critical to denote situations or operations that, if they go
wrong, have a large potential for causing harm to people, property or environment.
Critical operations on the bridge include voyage planning, navigation, positioning
and manoeuvring the ship during the voyage. Key systems used on the bridge are DP
systems ( dynamic position) and navigation systems ( radar and ECDIS).
Outside the maritime domain, there are some useful lessons to be learned from
industries with a high focus on safety and reliability. Exploring the Macondo Accident
from the oil and gas industry and the Boeing Max accidents from aviation, there are
key lessons to be learned related to focus on HF in design and operations to build
sensemaking.
The Macondo blowout in 2010 killed 11 workers, released 4.9 million barrels of oil
and generated expenditures of more than 61.6 Billion USD (Washington Post 15th of
June 2016). In the accident report CSB ( 2016), HF were highlighted, i.e. “ Industry’s
focus must shift from correcting individual ‘ errors’ identified post-incident to a