95
The Challenges of Sensemaking
• High mental workload and high level of disturbances with 12 alarms in the
last 14 minutes (Standards specify 1 important alarm in 10 minutes).: in addition to four moving boats ( three going north), while the closest object Sola TS
( unidentified), where the front of the 200 m long boat was in darkness.
• Poor design of the totality of control systems: the OOW could not see their
own position while communicating via the VHF. The VHF radio was placed
so that the responsible personnel could not see ECDIS chart and radar at the
same time – not accepted as a good design by other ships.
• Poor routines in Sola TS that did not record the cast-off on the ECDIS system, giving wrong information to Helge Ingstad.
• Poor quality of the alarm systems and alarm philosophy at Helge Ingstad.
• Questions continue about high level of background noise at the bridge
• Overview of the total situation and emergency action from the VTS could
have been more proactive, in order to control the development. A total overview as interpreted from the VTS could have been shared among the actors,
in addition to emergency intervention to halt the accident.
Control systems in shipping are mostly developed based on a technology drive and
seldom based on strong involvement from the users. There is an abundance of specific technical standards but poor focus on an unified approach focusing on cognitive
issues and sensemaking during safety-critical operations. The industry should learn
from good practices in the oil and gas industry and the aviation industry, and also
look towards recent accidents in oil and gas industry and the aviation industry to
see what happens when sensemaking is ignored. Technology-driven implementation
may not support safety of critical tasks. When the users are subjected to stress and
complex situations, poor cognitive ergonomics does led to poor sensemaking and
conditions leading to accidents. Our suggestion for the future is to prioritize:
• Sensemaking among all the involved actors, through placing responsibility
of the total traffic picture on the VTS centrals ( so that they can display an
overview of traffic giving the ships “ overview- at- a-glance”).
• Sensemaking on the bridge through a unified bridge system where cognitive
ergonomics is adapted to the critical operations being performed. As a part
of this, focus on alarm design and standards so that alarms are set and really
used within human limitations ( i.e. max six alarms in an hour).
• Verification and validation of design and critical operations through exploration of “ safety-cases” and verification of training periodically.
REFERENCES
Aas, A. L., Johnsen, S. O., Skramstad, T. ( 2009). CRIOP: A human factors verification and
validation methodology that works in an industrial setting. Lecture Notes in Computer
Science 5775, 243–256.
AIBN ( 2019). Part one report on the collision on 8 November 2018 between the frigate
HNOMS Helge Ingstad and the oil tanker Sola TS outside the Sture terminal in the
Hjeltefjord in Hordaland County.
The Challenges of Sensemaking
• High mental workload and high level of disturbances with 12 alarms in the
last 14 minutes (Standards specify 1 important alarm in 10 minutes).: in addition to four moving boats ( three going north), while the closest object Sola TS
( unidentified), where the front of the 200 m long boat was in darkness.
• Poor design of the totality of control systems: the OOW could not see their
own position while communicating via the VHF. The VHF radio was placed
so that the responsible personnel could not see ECDIS chart and radar at the
same time – not accepted as a good design by other ships.
• Poor routines in Sola TS that did not record the cast-off on the ECDIS system, giving wrong information to Helge Ingstad.
• Poor quality of the alarm systems and alarm philosophy at Helge Ingstad.
• Questions continue about high level of background noise at the bridge
• Overview of the total situation and emergency action from the VTS could
have been more proactive, in order to control the development. A total overview as interpreted from the VTS could have been shared among the actors,
in addition to emergency intervention to halt the accident.
Control systems in shipping are mostly developed based on a technology drive and
seldom based on strong involvement from the users. There is an abundance of specific technical standards but poor focus on an unified approach focusing on cognitive
issues and sensemaking during safety-critical operations. The industry should learn
from good practices in the oil and gas industry and the aviation industry, and also
look towards recent accidents in oil and gas industry and the aviation industry to
see what happens when sensemaking is ignored. Technology-driven implementation
may not support safety of critical tasks. When the users are subjected to stress and
complex situations, poor cognitive ergonomics does led to poor sensemaking and
conditions leading to accidents. Our suggestion for the future is to prioritize:
• Sensemaking among all the involved actors, through placing responsibility
of the total traffic picture on the VTS centrals ( so that they can display an
overview of traffic giving the ships “ overview- at- a-glance”).
• Sensemaking on the bridge through a unified bridge system where cognitive
ergonomics is adapted to the critical operations being performed. As a part
of this, focus on alarm design and standards so that alarms are set and really
used within human limitations ( i.e. max six alarms in an hour).
• Verification and validation of design and critical operations through exploration of “ safety-cases” and verification of training periodically.
REFERENCES
Aas, A. L., Johnsen, S. O., Skramstad, T. ( 2009). CRIOP: A human factors verification and
validation methodology that works in an industrial setting. Lecture Notes in Computer
Science 5775, 243–256.
AIBN ( 2019). Part one report on the collision on 8 November 2018 between the frigate
HNOMS Helge Ingstad and the oil tanker Sola TS outside the Sture terminal in the
Hjeltefjord in Hordaland County.