94
Sensemaking in Safety Critical and Complex Situations
acknowledged that Sola TS departed. Three ships going north and two
ships (Helge Ingstad and Dr No) going south – in addition to Sola TS. Helge
Ingstad was poorly identified as it did not use the automatic information system ( AIS). At 3:59, the VTS discovered a possible collision vector between
Sola TS and Helge Ingstad. The VTS communicated to Sola TS informing at
03:59 that it could be Helge Ingstad. At 04:00:44 the VTS told Helge Ingstad
that they had to do s omething – but no commands from the VTS until the
collision at 04:01:15. The VTS did not understand the situational assessment
of Helge Ingstad and did not intervene through emergency procedures.
• Sola TS was at the brightly lighted Sture terminal and left at 03:36. The
pilot at the bridge informed the VTS about their departure at 03:45. ECDIS
information was updated later and was not communicated to Helge Ingstad
at departure, giving latency and a perception that the ship was at the Sture
terminal. At 03:52, the bridge saw the ship Helge Ingstad. At 3:58, Sola TS
asked the VTS about Helge Ingstad. From 03:59:56, there was communication between Sola TS and the OOW. Sola TS tried to communicate an
impending collision at 04.01.15.
• The responsible OOW at Helge Ingstad changed at 03:53 ( after being
briefed from 03:45 to 03:53). Sola TS was visually observed, but as a part
of the land-based Sture terminal and not as a ship by most of the attending
personnel on the bridge, however, this perception and understanding were
not communicated and shared. Verbal clues and information sharing were
a challenge due to the noise level. At 04:00, the OOW used the VHF radio
away from ECDIS/ radar, thus visual clues could not be shared. The OOW
had a perception that Sola TS was the Sture terminal. Large part of the ship
( 200 m) was not lighted – it was difficult to see Sola TS.
Exploring the accidents in hindsight, we see poor common mental models, poor
emergency procedures but also a set of missing redundancies of cues to help the crew
and the OOW to identify Sola TS as a ship.
CONCLUSIONS AND FURTHER WORK
The Helge Ingstad accident should not come as a surprise when looking at the poor
quality of cognitive ergonomics on the bridge ( i.e. poor task analysis, poor configuration of equipment, poor alarms, poor redundancy of cues). The accident clearly
shows the consequences of performing piecemeal building of control systems instead
of focusing on a unified sensemaking design based on cognitive ergonomics. The
Helge Ingstad accident is in line with the analysis we have performed of the 19 other
accidents where control systems were involved, with poor human-based design, poor
focus on cognitive ergonomics and poor sensemaking in critical operations.
In many ways the crew of Helge Ingstad met a combination of many factors that
reduced the sensemaking capability of the team, such as:
• Time – 4:01 in night 8 minutes after responsibility was changed on the watch;
a time where accidents usually may happen.
Sensemaking in Safety Critical and Complex Situations
acknowledged that Sola TS departed. Three ships going north and two
ships (Helge Ingstad and Dr No) going south – in addition to Sola TS. Helge
Ingstad was poorly identified as it did not use the automatic information system ( AIS). At 3:59, the VTS discovered a possible collision vector between
Sola TS and Helge Ingstad. The VTS communicated to Sola TS informing at
03:59 that it could be Helge Ingstad. At 04:00:44 the VTS told Helge Ingstad
that they had to do s omething – but no commands from the VTS until the
collision at 04:01:15. The VTS did not understand the situational assessment
of Helge Ingstad and did not intervene through emergency procedures.
• Sola TS was at the brightly lighted Sture terminal and left at 03:36. The
pilot at the bridge informed the VTS about their departure at 03:45. ECDIS
information was updated later and was not communicated to Helge Ingstad
at departure, giving latency and a perception that the ship was at the Sture
terminal. At 03:52, the bridge saw the ship Helge Ingstad. At 3:58, Sola TS
asked the VTS about Helge Ingstad. From 03:59:56, there was communication between Sola TS and the OOW. Sola TS tried to communicate an
impending collision at 04.01.15.
• The responsible OOW at Helge Ingstad changed at 03:53 ( after being
briefed from 03:45 to 03:53). Sola TS was visually observed, but as a part
of the land-based Sture terminal and not as a ship by most of the attending
personnel on the bridge, however, this perception and understanding were
not communicated and shared. Verbal clues and information sharing were
a challenge due to the noise level. At 04:00, the OOW used the VHF radio
away from ECDIS/ radar, thus visual clues could not be shared. The OOW
had a perception that Sola TS was the Sture terminal. Large part of the ship
( 200 m) was not lighted – it was difficult to see Sola TS.
Exploring the accidents in hindsight, we see poor common mental models, poor
emergency procedures but also a set of missing redundancies of cues to help the crew
and the OOW to identify Sola TS as a ship.
CONCLUSIONS AND FURTHER WORK
The Helge Ingstad accident should not come as a surprise when looking at the poor
quality of cognitive ergonomics on the bridge ( i.e. poor task analysis, poor configuration of equipment, poor alarms, poor redundancy of cues). The accident clearly
shows the consequences of performing piecemeal building of control systems instead
of focusing on a unified sensemaking design based on cognitive ergonomics. The
Helge Ingstad accident is in line with the analysis we have performed of the 19 other
accidents where control systems were involved, with poor human-based design, poor
focus on cognitive ergonomics and poor sensemaking in critical operations.
In many ways the crew of Helge Ingstad met a combination of many factors that
reduced the sensemaking capability of the team, such as:
• Time – 4:01 in night 8 minutes after responsibility was changed on the watch;
a time where accidents usually may happen.