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Sensemaking in Safety Critical and Complex Situations
ergonomics. Support from regulations to perform necessary safety-oriented
design.
Design of control and safety systems to support sensemaking and cues,
design of HMI and support of sensemaking, supporting cognitive ergonomics through high-performance HMI and clues that can support the operators.
Alarms, design and handling of alarms to understand and handle critical
situations – avoiding undue cognitive workload.
Job organization and planning, based on safety-critical tasks, cognitive and
physical workload ( describing responsibilities of operations and high-level
work procedures) planning, i.e. safety management.
Procedures and work descriptions, based on task analysis and established
together with the users.
Physical layout of work place and working environment, based on systematic task analysis and how jobs are organized, supporting all tasks
( especially safety critical).
Competence and training of the involved actors in their different roles using
control and safety systems and appropriate procedures.
We have performed a review of 19 maritime accident reports related to control systems on the bridge. ( To focus our review on systems used on the bridge, we have
selected accidents that involved onboard control systems, i.e. accidents which
involved onboard electronics/ control systems in some shape or form.)
We have tried to structure root causes based on the above taxonomy from CRIOP,
i.e. loss of situational awareness ( i.e. poor sensemaking process), poor cognitive
ergonomics design ( poor redundancy, poor cues), poor planning, poor work load
assessment, alarm issues, poor competence and training, poor safety management,
poor support from regulation and poor ergonomic layout,.
The 19 accident reports were selected in collaboration with an expert within the
area of maritime safety. The review included 14 Marine Accident Investigation Branch
( MAIB) investigation reports from accident occurring in the period 2005–2016 as well
as 5 other investigation reports from accidents occurring in the period 1995–2008.
ANALYSIS OF CONTROL SYSTEMS ON THE BRIDGE
In the following, we have summarized the experiences from our review of 19
maritime accident reports related to control systems on the bridge. The issues are
described in more detail in Johnsen et al. ( 2019). A key statement from the chief
inspector of MAIB in one of the reports was: “ this is the third grounding investigated
by the MAIB where watchkeepers’ failure to use ECDIS properly has been identified as one of the causal factors. In 2014 there are over 30 manufacturers of ECDIS
equipment, each with their own designs of user interface, and little evidence that a
common approach is developing,” Johnsen et al. ( 2019).
Loss of situational awareness ( in ten accident reports) due to poor monitoring of position; distraction due to workload; unsafe navigation practices; poor passage planning; insufficient understanding of control system; misinterpretation of the
nature of malfunctions.
Sensemaking in Safety Critical and Complex Situations
ergonomics. Support from regulations to perform necessary safety-oriented
design.
Design of control and safety systems to support sensemaking and cues,
design of HMI and support of sensemaking, supporting cognitive ergonomics through high-performance HMI and clues that can support the operators.
Alarms, design and handling of alarms to understand and handle critical
situations – avoiding undue cognitive workload.
Job organization and planning, based on safety-critical tasks, cognitive and
physical workload ( describing responsibilities of operations and high-level
work procedures) planning, i.e. safety management.
Procedures and work descriptions, based on task analysis and established
together with the users.
Physical layout of work place and working environment, based on systematic task analysis and how jobs are organized, supporting all tasks
( especially safety critical).
Competence and training of the involved actors in their different roles using
control and safety systems and appropriate procedures.
We have performed a review of 19 maritime accident reports related to control systems on the bridge. ( To focus our review on systems used on the bridge, we have
selected accidents that involved onboard control systems, i.e. accidents which
involved onboard electronics/ control systems in some shape or form.)
We have tried to structure root causes based on the above taxonomy from CRIOP,
i.e. loss of situational awareness ( i.e. poor sensemaking process), poor cognitive
ergonomics design ( poor redundancy, poor cues), poor planning, poor work load
assessment, alarm issues, poor competence and training, poor safety management,
poor support from regulation and poor ergonomic layout,.
The 19 accident reports were selected in collaboration with an expert within the
area of maritime safety. The review included 14 Marine Accident Investigation Branch
( MAIB) investigation reports from accident occurring in the period 2005–2016 as well
as 5 other investigation reports from accidents occurring in the period 1995–2008.
ANALYSIS OF CONTROL SYSTEMS ON THE BRIDGE
In the following, we have summarized the experiences from our review of 19
maritime accident reports related to control systems on the bridge. The issues are
described in more detail in Johnsen et al. ( 2019). A key statement from the chief
inspector of MAIB in one of the reports was: “ this is the third grounding investigated
by the MAIB where watchkeepers’ failure to use ECDIS properly has been identified as one of the causal factors. In 2014 there are over 30 manufacturers of ECDIS
equipment, each with their own designs of user interface, and little evidence that a
common approach is developing,” Johnsen et al. ( 2019).
Loss of situational awareness ( in ten accident reports) due to poor monitoring of position; distraction due to workload; unsafe navigation practices; poor passage planning; insufficient understanding of control system; misinterpretation of the
nature of malfunctions.