89
The Challenges of Sensemaking
Poor redundancy/ alternatives ( in nine accident reports) in terms of poor organizational redundancy of coastguard; poor backup of equipment; no contingency
planning; poor route planning not cross-checked; undue reliance on the ECDIS;
practice of operating with watertight doors open; not using at least two independent
sources to verify position; no installed navigation autopilot with alarm when discrepancies were detected. In summary, there is a need to establish resilience in critical
operations such as planning and navigation.
Alarm-related issues ( in ten accident reports) including disabling of alarms
and thus removing necessary barriers of imminent danger; alarm system silenced,
missing entering of passage plan; ECDIS not utilized effectively as navigation aid
and audible alarm disabled; ECDIS safety setting not appropriate – audible alarm
inoperative – and defect of alarm system not being reported; system giving alarm
per minute and overwhelming the watchkeeper; poor understanding of the system
and relationship of alarms; navigation equipment ineffective and not set-up to use all
safety features; no installation of alarm comparing position from multiple independent positions. In summary, alarm design is a key issue.
Insufficient training ( in 15 accident reports) in terms of no emergency preparedness training; operator not qualified and not supervised; untrained in the use
of the ECS and unaware of user support; no training in use of ECDIS and no safety
procedures established; marked differences in ECDIS systems such as menus, terminology and interfaces; poor training of electronic support systems/ main engine control systems; poor training in use of the integrated navigation system; poor training
in crew resource management and emergency communication; poor focus on continuous professional development and skill retainment. In summary, poor training
seems to be a key issue in many accidents using electronic systems ( ECDIS, voyage
management system, etc.). The accident reports raise the issue of usability and user
involvement from design through acceptance of these electronic s ystems – are the
systems so poorly made that they are a challenge to use?
Lacking or insufficient passage planning ( in eight accident reports) including
poor passage planning and poor checking and approval of the route ( i.e. grounding
was inevitable due to vessel draught and depth of water); poor utilization of ECS or
ECDIS for passage planning – the system would have given alarms early. In summary, the quality of planning is poor and the support from the ECDIS is often missing ( either due to poor training or poor design).
Poor or missing work load assessment ( in eight accident reports), the sole
bridge watch-keeper having to undertake passage planning and chart corrections
and bridge manning was insufficient; the coastguard being distracted and did not
send warning due to chronic manpower shortages; the bridge team having to provide
administrative information when they should focus on safety of vessel passage; the
bridge missing an appropriately certified third person; a widespread deselection of
automated functions in ECDIS to reduce workload ( indicative of wider problems
with the ECDIS design). In summary, organizational factors as well as design issues
contribute to work load and fatigue.
Poor ( safety) management ( in 14 accident reports) including the harbour not
having a risk assessment or safety management plan in the pilotage area; the crew
seeing no value in safety management; the master providing insufficient safety
The Challenges of Sensemaking
Poor redundancy/ alternatives ( in nine accident reports) in terms of poor organizational redundancy of coastguard; poor backup of equipment; no contingency
planning; poor route planning not cross-checked; undue reliance on the ECDIS;
practice of operating with watertight doors open; not using at least two independent
sources to verify position; no installed navigation autopilot with alarm when discrepancies were detected. In summary, there is a need to establish resilience in critical
operations such as planning and navigation.
Alarm-related issues ( in ten accident reports) including disabling of alarms
and thus removing necessary barriers of imminent danger; alarm system silenced,
missing entering of passage plan; ECDIS not utilized effectively as navigation aid
and audible alarm disabled; ECDIS safety setting not appropriate – audible alarm
inoperative – and defect of alarm system not being reported; system giving alarm
per minute and overwhelming the watchkeeper; poor understanding of the system
and relationship of alarms; navigation equipment ineffective and not set-up to use all
safety features; no installation of alarm comparing position from multiple independent positions. In summary, alarm design is a key issue.
Insufficient training ( in 15 accident reports) in terms of no emergency preparedness training; operator not qualified and not supervised; untrained in the use
of the ECS and unaware of user support; no training in use of ECDIS and no safety
procedures established; marked differences in ECDIS systems such as menus, terminology and interfaces; poor training of electronic support systems/ main engine control systems; poor training in use of the integrated navigation system; poor training
in crew resource management and emergency communication; poor focus on continuous professional development and skill retainment. In summary, poor training
seems to be a key issue in many accidents using electronic systems ( ECDIS, voyage
management system, etc.). The accident reports raise the issue of usability and user
involvement from design through acceptance of these electronic s ystems – are the
systems so poorly made that they are a challenge to use?
Lacking or insufficient passage planning ( in eight accident reports) including
poor passage planning and poor checking and approval of the route ( i.e. grounding
was inevitable due to vessel draught and depth of water); poor utilization of ECS or
ECDIS for passage planning – the system would have given alarms early. In summary, the quality of planning is poor and the support from the ECDIS is often missing ( either due to poor training or poor design).
Poor or missing work load assessment ( in eight accident reports), the sole
bridge watch-keeper having to undertake passage planning and chart corrections
and bridge manning was insufficient; the coastguard being distracted and did not
send warning due to chronic manpower shortages; the bridge team having to provide
administrative information when they should focus on safety of vessel passage; the
bridge missing an appropriately certified third person; a widespread deselection of
automated functions in ECDIS to reduce workload ( indicative of wider problems
with the ECDIS design). In summary, organizational factors as well as design issues
contribute to work load and fatigue.
Poor ( safety) management ( in 14 accident reports) including the harbour not
having a risk assessment or safety management plan in the pilotage area; the crew
seeing no value in safety management; the master providing insufficient safety