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The Challenges of Sensemaking
coordinating mechanisms such as shared mental modes, c losed-loop communication
and mutual trust ( Salas et al., 2005). To ensure closed-loop communication, the noise
level should be assessed. In the accident report, it is pointed out that “ Bridge ventilation system is so noisy that it is difficult for the bridge team to communicate in a normal manner. Excessive levels of noise interfering with voice communication, causing
fatigue and degrading overall system reliability, shall be avoided. ( noted during visit
on-board).” In Sunde et al. ( 2015), they pointed out that “ All vessel classes, except the
coast guard vessels, had noise levels exceeding the Royal Norwegian Navy ( RNoN)
standard’s recommended maximum noise levels.” The background noise level should
be below 45 db when performing safety-critical tasks ( ref SINTEF, 2011), but the
noise level was higher in Helge Ingstad, impacting sensemaking.
Workload – alarm philosophy: Mental workload is dependent on alarms and
alarm handling. No alarms were given related to the impending collision with Sola
TS. However, in the accident report, it was mentioned that the bridge handled 12
alarms in the last 14 minutes; this is almost one alarm each minute. ( These were
alarms related to objects that the bridge were aware of and thought they could control, no alarms from Sola TS that they collided with.) This is a fairly high mental
workload, even if it seems a controllable environment. The international recognized
alarm standard EEMUA-191 ( 2013) specifies that the maximum number of important
alarms that can be handled is 6 alarms in 1 hour, i.e. 10 minutes between each alarm.
Thus, the alarm philosophy should have been discussed further.
Poor operational selection of c rew – 3 of 7 had no visual impairments. In the
AIBN report, it was mentioned that 3 of the 7 persons on the bridge had no visual
impairment, i.e. some of the crew on the bridge had some sort of visual impairment. It is uncertain if this impacted the accident, but team cognition could have
been impacted, and these facts should have been known when responsibilities were
planned on the bridge.
Poor design impacting operational decisions at margins – The Helge Ingstad performed fairly critical operations at night time, where resources were allocated to
training and navigating in an area with several ships. This environment creates fairly
high mental workload, and it is know that many disasters happen during night time,
i.e. this is a period of operational risks. A systematic task analysis, analysis of mental workload and operational risk analysis should have been a part of design of the
manning, the design of procedures to enable safe operations during the training task.
These procedures were missing and are due to missing design of operational procedures based on a systematic task analysis.
Breakdown of sensemaking between key actors during the collision – If we look
on the extended team of key actors ( involving Helge Ingstad, the VTS and TS Sola),
the mental models were not shared ( i.e. common perception among the actors about
position and course) and the closed-loop communication during the emergency was
poor ( i.e. clarity of responsibilities, communication procedures during an emergency
and understanding of who was speaking).
• The VTS got a call from Helge Ingstad at 02:38 informing the VTS that
they would enter the area of the VTS. At 2:50 Helge Ingstad entered the
area, but the VTS did not plot Helge Ingstad on its radar. At 3:45, the VTS
The Challenges of Sensemaking
coordinating mechanisms such as shared mental modes, c losed-loop communication
and mutual trust ( Salas et al., 2005). To ensure closed-loop communication, the noise
level should be assessed. In the accident report, it is pointed out that “ Bridge ventilation system is so noisy that it is difficult for the bridge team to communicate in a normal manner. Excessive levels of noise interfering with voice communication, causing
fatigue and degrading overall system reliability, shall be avoided. ( noted during visit
on-board).” In Sunde et al. ( 2015), they pointed out that “ All vessel classes, except the
coast guard vessels, had noise levels exceeding the Royal Norwegian Navy ( RNoN)
standard’s recommended maximum noise levels.” The background noise level should
be below 45 db when performing safety-critical tasks ( ref SINTEF, 2011), but the
noise level was higher in Helge Ingstad, impacting sensemaking.
Workload – alarm philosophy: Mental workload is dependent on alarms and
alarm handling. No alarms were given related to the impending collision with Sola
TS. However, in the accident report, it was mentioned that the bridge handled 12
alarms in the last 14 minutes; this is almost one alarm each minute. ( These were
alarms related to objects that the bridge were aware of and thought they could control, no alarms from Sola TS that they collided with.) This is a fairly high mental
workload, even if it seems a controllable environment. The international recognized
alarm standard EEMUA-191 ( 2013) specifies that the maximum number of important
alarms that can be handled is 6 alarms in 1 hour, i.e. 10 minutes between each alarm.
Thus, the alarm philosophy should have been discussed further.
Poor operational selection of c rew – 3 of 7 had no visual impairments. In the
AIBN report, it was mentioned that 3 of the 7 persons on the bridge had no visual
impairment, i.e. some of the crew on the bridge had some sort of visual impairment. It is uncertain if this impacted the accident, but team cognition could have
been impacted, and these facts should have been known when responsibilities were
planned on the bridge.
Poor design impacting operational decisions at margins – The Helge Ingstad performed fairly critical operations at night time, where resources were allocated to
training and navigating in an area with several ships. This environment creates fairly
high mental workload, and it is know that many disasters happen during night time,
i.e. this is a period of operational risks. A systematic task analysis, analysis of mental workload and operational risk analysis should have been a part of design of the
manning, the design of procedures to enable safe operations during the training task.
These procedures were missing and are due to missing design of operational procedures based on a systematic task analysis.
Breakdown of sensemaking between key actors during the collision – If we look
on the extended team of key actors ( involving Helge Ingstad, the VTS and TS Sola),
the mental models were not shared ( i.e. common perception among the actors about
position and course) and the closed-loop communication during the emergency was
poor ( i.e. clarity of responsibilities, communication procedures during an emergency
and understanding of who was speaking).
• The VTS got a call from Helge Ingstad at 02:38 informing the VTS that
they would enter the area of the VTS. At 2:50 Helge Ingstad entered the
area, but the VTS did not plot Helge Ingstad on its radar. At 3:45, the VTS