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Sensemaking in Safety Critical and Complex Situations
Focus on sensemaking – In the Helge Ingstad report, the AIBN explored the concept of situational awareness as describe by Endsley ( 2016), team collaboration and
the concept of sensemaking. This framework and understanding of team actions and
collaboration must be in place before further causes can be explored, such as technology and organizational issues.
Piecemeal design – The design of command facilities on the bridge should be
based on a systematic task analysis of all necessary tasks. The task analysis is used
as a basis for responsibilities, designing interfaces and layout decisions, i.e. to understand how equipment such as radar, ECDIS and VHF radio should be placed to support the tasks. The AIBN remarked that the design of the bridge was not optimal to
ensure common situational awareness on the bridge. As an example of the missing
focus on human factors, the installation of the VHF can be mentioned. The VHF
radio had been installed at a later stage, via separate piecemeal installation procedure. At Helge Ingstad, the VHF radio was placed in a corner, making it difficult
to get information from the radar and ECDIS when using the VHF. In the minutes
before the collision, the OOW was using the VHF and talking to Sola TS and had
not easy access to the radar and ECDIS. When the VHF was installed at one of the
other ships, an experienced officer was on the watch, and based on his awareness of
critical tasks he managed to get the VHF placed besides the radar and the ECDIS,
in order to get an overview of the radar and ECDIS at the same time as communication via the VHF took place. The task analysis is also used as a basis for manning
and an assessment of workload in all s afety-critical operations. The manning of the
bridge had been influenced by a high-level strategy called LMC ( lean manning concept), implemented primarily to reduce costs. There was no workload assessment
of performing training at the same time as performing s afety-critical tasks such as
navigation. The design was not based on task analysis ( i.e. good design practices),
had not performed systematic task analysis of new equipment when it was placed on
the bridge and operations were not based on appropriate work load analysis when
performing safety-critical tasks. The quality and usability of the ECDIS system
seems poor, based on a review of prior accidents. Data from ECDIS indicate that
TS Sola updated its status from “ at quay” to “ under way” 30 minutes after actual
cast-off, a status information that could have impacted the sensemaking of the OOW.
The poor usability, quality and support from the systems ( radar and ECDIS) during
this accident support the prior accident analysis. There were some adaptations in
practices and equipment on the bridge that were mentioned in the accident reports,
such as changes in routes and adaptations of night vision. After implementation of
the ECDIS system, the ships are more often using the direct route plotted into the
ECDIS system; thus they are no longer using the traditional sea routes, close to land
on starboard side that ensured that ships were separated when going in the fjord. One
adaptation mentioned that some of the lights on the bridge had been taped over in
order to preserve “ the night vision” of the officers on the watch., i.e. indicting poor
consideration of user needs during night time.
Working e nvironment – Noise: The ergonomics of the working environment
is the key to ensure that communication supporting sensemaking can take place.
Working environment is influenced by many factors such as noise, lightning level,
and temperature. Team communication and teamwork on the bridge is dependent on
Sensemaking in Safety Critical and Complex Situations
Focus on sensemaking – In the Helge Ingstad report, the AIBN explored the concept of situational awareness as describe by Endsley ( 2016), team collaboration and
the concept of sensemaking. This framework and understanding of team actions and
collaboration must be in place before further causes can be explored, such as technology and organizational issues.
Piecemeal design – The design of command facilities on the bridge should be
based on a systematic task analysis of all necessary tasks. The task analysis is used
as a basis for responsibilities, designing interfaces and layout decisions, i.e. to understand how equipment such as radar, ECDIS and VHF radio should be placed to support the tasks. The AIBN remarked that the design of the bridge was not optimal to
ensure common situational awareness on the bridge. As an example of the missing
focus on human factors, the installation of the VHF can be mentioned. The VHF
radio had been installed at a later stage, via separate piecemeal installation procedure. At Helge Ingstad, the VHF radio was placed in a corner, making it difficult
to get information from the radar and ECDIS when using the VHF. In the minutes
before the collision, the OOW was using the VHF and talking to Sola TS and had
not easy access to the radar and ECDIS. When the VHF was installed at one of the
other ships, an experienced officer was on the watch, and based on his awareness of
critical tasks he managed to get the VHF placed besides the radar and the ECDIS,
in order to get an overview of the radar and ECDIS at the same time as communication via the VHF took place. The task analysis is also used as a basis for manning
and an assessment of workload in all s afety-critical operations. The manning of the
bridge had been influenced by a high-level strategy called LMC ( lean manning concept), implemented primarily to reduce costs. There was no workload assessment
of performing training at the same time as performing s afety-critical tasks such as
navigation. The design was not based on task analysis ( i.e. good design practices),
had not performed systematic task analysis of new equipment when it was placed on
the bridge and operations were not based on appropriate work load analysis when
performing safety-critical tasks. The quality and usability of the ECDIS system
seems poor, based on a review of prior accidents. Data from ECDIS indicate that
TS Sola updated its status from “ at quay” to “ under way” 30 minutes after actual
cast-off, a status information that could have impacted the sensemaking of the OOW.
The poor usability, quality and support from the systems ( radar and ECDIS) during
this accident support the prior accident analysis. There were some adaptations in
practices and equipment on the bridge that were mentioned in the accident reports,
such as changes in routes and adaptations of night vision. After implementation of
the ECDIS system, the ships are more often using the direct route plotted into the
ECDIS system; thus they are no longer using the traditional sea routes, close to land
on starboard side that ensured that ships were separated when going in the fjord. One
adaptation mentioned that some of the lights on the bridge had been taped over in
order to preserve “ the night vision” of the officers on the watch., i.e. indicting poor
consideration of user needs during night time.
Working e nvironment – Noise: The ergonomics of the working environment
is the key to ensure that communication supporting sensemaking can take place.
Working environment is influenced by many factors such as noise, lightning level,
and temperature. Team communication and teamwork on the bridge is dependent on