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The Challenges of Sensemaking
systematic approach for managing human factors.” Furthermore, the report highlights
that “ the lack of effective integration of human factors into the design, planning, and
execution of drilling and completions activities … and it illustrates a demonstrable
gap in US offshore regulation and guidance to incorporate more robust management
of human factors.” Specific areas mentioned were the importance of HF engineering
in design of s afety-critical systems; the need for focus on non-technical skills ( such
as communication, teamwork and decision-making between different actors) and
assessment of safety-critical tasks and identification of controls that could maximize
the likelihood of successful human performance through improved sensemaking.
( HF design activity includes the design of HMI as a part of cognitive ergonomics.)
The Boeing Max 737 was grounded worldwide in March 2019, after 346 people
died in two crashes, i.e. Lion Air Flight 610 on October 29, 2018, and Ethiopian
Airlines Flight 302 on March 10, 2019. The Boeing Max 737 disasters were caused
by many factors, among others complex control systems, failures of sensors, challenges of sensemaking during critical operations and poor design. In a hearing to the
US Congress, Endsley ( 2019) pointed out that development of the critical control systems should be in compliance with HF design standards ( ensuring that design should
support cognitive ergonomics); professionals trained in HF Engineering should be
included on the design team and robust human user testing should be conducted to
validate system design.
RESEARCH QUESTION
Key issues to be explored in this chapter has been the sensemaking process among
the different actors involved in these accidents and how the sensemaking process
could have been improved, i.e. the two research questions are:
What are the key issues influencing the sensemaking process during operations
of safety-critical operations?
What are the key issues influencing the sensemaking process in design of control systems used in safety-critical operations?
METHOD AND APPROACH
We have based our approach on review of the accident reports from Helge Ingstad,
supplied with interviews with actors involved in the accident analysis in addition to a
review of 19 accident reports focusing on control systems on the bridge.
To help analyse the accidents, we have structured our review based on the CRIOP
method, Sintef ( 2011). CRIOP is an internationally accepted method that is being
used as a good practice guideline when designing control facilities, Aas et al. ( 2009).
CRIOP is focusing on HF supporting sensemaking when using control systems. Key
issues from CRIOP that has been explored are:
Safety-oriented design based on a task analysis. Exploring on how tasks must
be designed through a balance between automated operations and human
operated tasks supported by HMI, i.e. conditions supporting cognitive
The Challenges of Sensemaking
systematic approach for managing human factors.” Furthermore, the report highlights
that “ the lack of effective integration of human factors into the design, planning, and
execution of drilling and completions activities … and it illustrates a demonstrable
gap in US offshore regulation and guidance to incorporate more robust management
of human factors.” Specific areas mentioned were the importance of HF engineering
in design of s afety-critical systems; the need for focus on non-technical skills ( such
as communication, teamwork and decision-making between different actors) and
assessment of safety-critical tasks and identification of controls that could maximize
the likelihood of successful human performance through improved sensemaking.
( HF design activity includes the design of HMI as a part of cognitive ergonomics.)
The Boeing Max 737 was grounded worldwide in March 2019, after 346 people
died in two crashes, i.e. Lion Air Flight 610 on October 29, 2018, and Ethiopian
Airlines Flight 302 on March 10, 2019. The Boeing Max 737 disasters were caused
by many factors, among others complex control systems, failures of sensors, challenges of sensemaking during critical operations and poor design. In a hearing to the
US Congress, Endsley ( 2019) pointed out that development of the critical control systems should be in compliance with HF design standards ( ensuring that design should
support cognitive ergonomics); professionals trained in HF Engineering should be
included on the design team and robust human user testing should be conducted to
validate system design.
RESEARCH QUESTION
Key issues to be explored in this chapter has been the sensemaking process among
the different actors involved in these accidents and how the sensemaking process
could have been improved, i.e. the two research questions are:
What are the key issues influencing the sensemaking process during operations
of safety-critical operations?
What are the key issues influencing the sensemaking process in design of control systems used in safety-critical operations?
METHOD AND APPROACH
We have based our approach on review of the accident reports from Helge Ingstad,
supplied with interviews with actors involved in the accident analysis in addition to a
review of 19 accident reports focusing on control systems on the bridge.
To help analyse the accidents, we have structured our review based on the CRIOP
method, Sintef ( 2011). CRIOP is an internationally accepted method that is being
used as a good practice guideline when designing control facilities, Aas et al. ( 2009).
CRIOP is focusing on HF supporting sensemaking when using control systems. Key
issues from CRIOP that has been explored are:
Safety-oriented design based on a task analysis. Exploring on how tasks must
be designed through a balance between automated operations and human
operated tasks supported by HMI, i.e. conditions supporting cognitive