90
Sensemaking in Safety Critical and Complex Situations
focus/ culture; poor clarity in responsibility during watch; inefficient safety audits
based on ISM code; poor risk assessment prior to work on ballasting; poor passage
planning – not cross- checked – and mitigating actions not performed. In summary,
risk-based focus of operations is sometimes missing, and there is variability.
Poor system design or display layout ( in eight accident reports) in terms of
deficiencies in design and implementation of the integrated bridge system and in
the procedures for its operation; widespread de-selection of automated functions in
ECDIS that is indicative of wider problems with ECDIS; ECDIS not used as expected
by the regulators or equipment manufacturer; ECDIS safeguards intended to prevent
grounding were overlooked, disabled or ignored; MAIB chief inspector said: “ 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 inter-face, and little evidence that a common approach is developing.” In summary, there is a need for standardization, improved user-based design and user-based
acceptance testing in normal operations and during critical operations.
key finDingS
The ability to understand the status at a glance ( and get an understanding of key
risks) is missing in some of the bridge systems. When focusing on sensemaking, the
usability qualities of the control systems ( ECDIS, Bridge systems, DPS) are poor and
should improve. The poor usability also influences the needed training regime, since
training and competence development seems challenging ( due to system complexity)
and sometimes missing ( due to costs, poor practice and missing regulation of training). Passage planning seems poor due to poor usability and missing operational
procedures – thus the systems do not support sensemaking as they should. The alarm
systems have not been adapted to the users’ workload and system understanding, thus
alarms seem a disturbance and not an input to improved sensemaking.
Design of organizational procedures and work should be performed together with
the seafarers to ensure usability of procedures and checklists; and clarity in responsibility and proper work load. Too high work load may lead to stress and challenges
sensemaking and understanding.
Designing of alarms should be performed to ensure that alarms are designed to
support sensemaking and not stress the operators with too many alarms, i.e. more
than six alarms each hour as specified by EEMUA-191 ( 2013).
There is a need to increase focus on user-centric design principles. Poor design is
a significant contributor to maritime accidents. There is a need for improved regulations and standards related to use of integrated bridge systems and ECDIS. Design of
bridges and control systems should be based on user-centric design principles, involvement from HF experts and should be subject of inspections, regulators and workforce
attention. Benefits of user-centric design should be highlighted through research.
The quality of alarm systems is poor, and alarm guidelines and standards should
be established based on industry best practices considering human limitations. An
integrated alarm philosophy must be established for all systems on the bridge – not
Sensemaking in Safety Critical and Complex Situations
focus/ culture; poor clarity in responsibility during watch; inefficient safety audits
based on ISM code; poor risk assessment prior to work on ballasting; poor passage
planning – not cross- checked – and mitigating actions not performed. In summary,
risk-based focus of operations is sometimes missing, and there is variability.
Poor system design or display layout ( in eight accident reports) in terms of
deficiencies in design and implementation of the integrated bridge system and in
the procedures for its operation; widespread de-selection of automated functions in
ECDIS that is indicative of wider problems with ECDIS; ECDIS not used as expected
by the regulators or equipment manufacturer; ECDIS safeguards intended to prevent
grounding were overlooked, disabled or ignored; MAIB chief inspector said: “ 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 inter-face, and little evidence that a common approach is developing.” In summary, there is a need for standardization, improved user-based design and user-based
acceptance testing in normal operations and during critical operations.
key finDingS
The ability to understand the status at a glance ( and get an understanding of key
risks) is missing in some of the bridge systems. When focusing on sensemaking, the
usability qualities of the control systems ( ECDIS, Bridge systems, DPS) are poor and
should improve. The poor usability also influences the needed training regime, since
training and competence development seems challenging ( due to system complexity)
and sometimes missing ( due to costs, poor practice and missing regulation of training). Passage planning seems poor due to poor usability and missing operational
procedures – thus the systems do not support sensemaking as they should. The alarm
systems have not been adapted to the users’ workload and system understanding, thus
alarms seem a disturbance and not an input to improved sensemaking.
Design of organizational procedures and work should be performed together with
the seafarers to ensure usability of procedures and checklists; and clarity in responsibility and proper work load. Too high work load may lead to stress and challenges
sensemaking and understanding.
Designing of alarms should be performed to ensure that alarms are designed to
support sensemaking and not stress the operators with too many alarms, i.e. more
than six alarms each hour as specified by EEMUA-191 ( 2013).
There is a need to increase focus on user-centric design principles. Poor design is
a significant contributor to maritime accidents. There is a need for improved regulations and standards related to use of integrated bridge systems and ECDIS. Design of
bridges and control systems should be based on user-centric design principles, involvement from HF experts and should be subject of inspections, regulators and workforce
attention. Benefits of user-centric design should be highlighted through research.
The quality of alarm systems is poor, and alarm guidelines and standards should
be established based on industry best practices considering human limitations. An
integrated alarm philosophy must be established for all systems on the bridge – not