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Sensemaking in Safety Critical and Complex Situations
unexpectedly and repeatedly pushed the nose of the plane down. To make matters
worse, it was designed in a way that made manual intervention difficult even when
the pilots finally understood what was happening ( National Transportation Safety
Board, 2019).
In this chapter, we look at this challenge from the perspective of a modern ship
bridge, and more specifically the operation of dynamic positioning systems ( DP systems). This technology is utilized for automatic station keeping and is becoming
ubiquitous in the maritime domain in a wide variety of operations such as drilling,
cargo loading, diving operations and p ipe-laying. As such, various industries increasingly depend on the safe operation of these systems, and the considerable number of
incidents and accidents that have occurred in recent years are causing concern.
The work presented in the following is the result of a study performed within the
sensemaking in safety-critical situations ( SMACS) research project ( SINTEF, 2018)
supported by the Norwegian Research Council and industry partners Human Factors
in Control ( HFC) forum and Kongsberg Maritime, focusing on human–machine
interfaces ( HMIs). Sensemaking refers to the ability of operators to perceive and
understand situations and act accordingly in complex environments ( Kilskar et al.,
2018; Weick, 1988). It is closely related to “ Situation Awareness” ( SA) as described by
Endsley and Jones ( 2012). The purpose of this study has been to identify the factors
that challenge the sensemaking of DP operators ( DPOs) and to propose new design
principles for effective h uman–automation interaction that may improve safety.
This has been a mixed-method feasibility study with a strong focus on end-user
involvement and learning from related safety-critical domains that Institute for
Energy Technology ( IFE) has worked with. The study first identified key challenges
through semi-structured interviews with instructors and experienced DPOs, observations during simulator-based DP training, discussions with Equinor “ Captains forum”
and analysis of incident and accident reports, summarized in Hurlen, Skjerve & Bye
( 2019). Design opportunities was then explored and exemplified through mock-ups
( Hurlen & Bye, 2020) and finally evaluated with end-users, summarized at the end
of this chapter.
DYNAMIC POSITIONING ( DP)
To understand the context, let us first look at DP operations, how the system works
and how it is used. The system itself works by automatically controlling thrusters
and rudders to keep a predetermined position, using input from a variety of reference
systems – position reference systems ( such as radar, GPS, hydroacoustic and laser
systems) and sensors measuring external forces acting on the vessel ( wind and current) – to compute and execute the force necessary for station-keeping. DP systems
are classed 1–3 according to their level of technical redundancy. Class 3 is generally
required for s afety-critical operations and involves the capability of no single fault in
an active system causing the system to fail and is also being able to withstand fire or
flood in any one compartment without the system failing ( see IMO publication 645).
For many types of operations, this is increasingly becoming a preferred way of
maintaining position as an alternative to anchoring. Depending on the operation, DP
systems are used more or less prevalently. A cargo vessel may use it for only a few
Sensemaking in Safety Critical and Complex Situations
unexpectedly and repeatedly pushed the nose of the plane down. To make matters
worse, it was designed in a way that made manual intervention difficult even when
the pilots finally understood what was happening ( National Transportation Safety
Board, 2019).
In this chapter, we look at this challenge from the perspective of a modern ship
bridge, and more specifically the operation of dynamic positioning systems ( DP systems). This technology is utilized for automatic station keeping and is becoming
ubiquitous in the maritime domain in a wide variety of operations such as drilling,
cargo loading, diving operations and p ipe-laying. As such, various industries increasingly depend on the safe operation of these systems, and the considerable number of
incidents and accidents that have occurred in recent years are causing concern.
The work presented in the following is the result of a study performed within the
sensemaking in safety-critical situations ( SMACS) research project ( SINTEF, 2018)
supported by the Norwegian Research Council and industry partners Human Factors
in Control ( HFC) forum and Kongsberg Maritime, focusing on human–machine
interfaces ( HMIs). Sensemaking refers to the ability of operators to perceive and
understand situations and act accordingly in complex environments ( Kilskar et al.,
2018; Weick, 1988). It is closely related to “ Situation Awareness” ( SA) as described by
Endsley and Jones ( 2012). The purpose of this study has been to identify the factors
that challenge the sensemaking of DP operators ( DPOs) and to propose new design
principles for effective h uman–automation interaction that may improve safety.
This has been a mixed-method feasibility study with a strong focus on end-user
involvement and learning from related safety-critical domains that Institute for
Energy Technology ( IFE) has worked with. The study first identified key challenges
through semi-structured interviews with instructors and experienced DPOs, observations during simulator-based DP training, discussions with Equinor “ Captains forum”
and analysis of incident and accident reports, summarized in Hurlen, Skjerve & Bye
( 2019). Design opportunities was then explored and exemplified through mock-ups
( Hurlen & Bye, 2020) and finally evaluated with end-users, summarized at the end
of this chapter.
DYNAMIC POSITIONING ( DP)
To understand the context, let us first look at DP operations, how the system works
and how it is used. The system itself works by automatically controlling thrusters
and rudders to keep a predetermined position, using input from a variety of reference
systems – position reference systems ( such as radar, GPS, hydroacoustic and laser
systems) and sensors measuring external forces acting on the vessel ( wind and current) – to compute and execute the force necessary for station-keeping. DP systems
are classed 1–3 according to their level of technical redundancy. Class 3 is generally
required for s afety-critical operations and involves the capability of no single fault in
an active system causing the system to fail and is also being able to withstand fire or
flood in any one compartment without the system failing ( see IMO publication 645).
For many types of operations, this is increasingly becoming a preferred way of
maintaining position as an alternative to anchoring. Depending on the operation, DP
systems are used more or less prevalently. A cargo vessel may use it for only a few