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The Challenges of Sensemaking
individually for each system. Collaboration between regulators, industry and classification society should be prioritized to speed up adaption.
KEY ISSUES OF THE HELGE INGSTAD ACCIDENT
We have explored the Helge Ingstad collision based on key elements in the accident report based on the methods as described earlier. Main points of the accident
were: The frigate Helge Ingstad and the tanker Sola TS collided in Hjeltefjorden at
04:01:15. The OOW was in charge from 03:53. The tanker Sola had left the Sture
terminal at 03:36. The traffic in Hjeltefjorden were under surveillance by the Fedje
VTS. The OOW did not identify Sola TS as a ship close by, but had a perception that
what he could observe were a lighted part of the Sture terminal.
We have highlighted the following areas from the accident report:
Positive focus on a broad system perspective, not blaming human errors
Positive focus on sensemaking and situational awareness in the report
Poor analysis and piecemeal design of the bridge – poor task analysis and
assessment of mental workload, and poor design of the totality of the workplace decreasing sensemaking possibility; failure to integrate VHF with
radar and ECDIS equipment
Poor design of work environment – not sufficient focus on noise
Poor design of workload – missing alarm philosophy
Poor operational selection of crew – only 3 of 7 had no visual impairment
Poor operational decisions at m argins – working at margins with high mental workload ( both training and safety-critical operations late night – with
fatigue/slower perceptions)
Breakdown in sensemaking at the Helge Ingstad Bridge and between VTS,
Helge Ingstad and TS Sola
Broad system perspective – The accident report from the AIBN ( 2019) presented
an impressive collection of technical, organizational and HF issues, with a focus
on trying to describe and understand the accident, instead of blaming human actors
( that often perform within a demanding framework that is established prior to the
accident). The accident report presents a sequence of what happened during the accident and a careful analysis of framework conditions and background, with much
more detailed findings and analysis than recent accident reports from similar maritime accidents such as USS John S. McCain ( 2017) and USS Fitzgerald ( 2017). The
accident report was careful not to blame individuals but had a system perspective.
Earlier, there had been different practices. As an example, in 2000, two accident
reports were presented at the same time in Norway: one from the MS Sleipner ( 1999)
maritime accident with a responsible captain in charge of the ship and the other
from the Åstad train accident ( 2000) with a responsible train driver in charge. The
Åstad accident report had a system perspective ( the train driver was not blamed); the
Sleipner accident report blamed the captain and did not focus sufficiently on framework conditions that could be seen as root causes.
The Challenges of Sensemaking
individually for each system. Collaboration between regulators, industry and classification society should be prioritized to speed up adaption.
KEY ISSUES OF THE HELGE INGSTAD ACCIDENT
We have explored the Helge Ingstad collision based on key elements in the accident report based on the methods as described earlier. Main points of the accident
were: The frigate Helge Ingstad and the tanker Sola TS collided in Hjeltefjorden at
04:01:15. The OOW was in charge from 03:53. The tanker Sola had left the Sture
terminal at 03:36. The traffic in Hjeltefjorden were under surveillance by the Fedje
VTS. The OOW did not identify Sola TS as a ship close by, but had a perception that
what he could observe were a lighted part of the Sture terminal.
We have highlighted the following areas from the accident report:
Positive focus on a broad system perspective, not blaming human errors
Positive focus on sensemaking and situational awareness in the report
Poor analysis and piecemeal design of the bridge – poor task analysis and
assessment of mental workload, and poor design of the totality of the workplace decreasing sensemaking possibility; failure to integrate VHF with
radar and ECDIS equipment
Poor design of work environment – not sufficient focus on noise
Poor design of workload – missing alarm philosophy
Poor operational selection of crew – only 3 of 7 had no visual impairment
Poor operational decisions at m argins – working at margins with high mental workload ( both training and safety-critical operations late night – with
fatigue/slower perceptions)
Breakdown in sensemaking at the Helge Ingstad Bridge and between VTS,
Helge Ingstad and TS Sola
Broad system perspective – The accident report from the AIBN ( 2019) presented
an impressive collection of technical, organizational and HF issues, with a focus
on trying to describe and understand the accident, instead of blaming human actors
( that often perform within a demanding framework that is established prior to the
accident). The accident report presents a sequence of what happened during the accident and a careful analysis of framework conditions and background, with much
more detailed findings and analysis than recent accident reports from similar maritime accidents such as USS John S. McCain ( 2017) and USS Fitzgerald ( 2017). The
accident report was careful not to blame individuals but had a system perspective.
Earlier, there had been different practices. As an example, in 2000, two accident
reports were presented at the same time in Norway: one from the MS Sleipner ( 1999)
maritime accident with a responsible captain in charge of the ship and the other
from the Åstad train accident ( 2000) with a responsible train driver in charge. The
Åstad accident report had a system perspective ( the train driver was not blamed); the
Sleipner accident report blamed the captain and did not focus sufficiently on framework conditions that could be seen as root causes.