72
Sensemaking in Safety Critical and Complex Situations
control centre communicate. The Accident Investigation Board Norway ( AIBN) published the first of two reports in late 2019 focusing on human aspects related to the
accident. According to the AIBN report, misunderstanding of the situation on the
frigate was the root cause while specific criticism is put forth towards both the tanker
and the shipping control centre.
It is possible to look at the events in Hjelteforden as consisting of actors in a complex sociotechnical system – collaboration being imperative to ensure safety of the
system. In such a system, people are essential when it comes to safeguarding safety.
Such an approach involves analytical focus on what people do, when they do and
how the actions affect other people. The argument is that to manage safety one must
be able to understand how different actors’ dependence on each other’s actions plays
out. Analytically, interdependence is therefore a key issue when analysing social
interaction within complex organizational domains. It is also important to bear in
mind that neither the frigate, the tanker nor the shipping control centre undertook
anything that differed from the usual, which means that the accident occurred during routine and normal operations. An analysis of this type of accident is also about
understanding how something that apparently goes well, paradoxically changes in
a very short time span. Therefore, to learn from the Helge Ingstad accident and in
particular make the findings relevant beyond this accident per se, the argument is that
it is necessary to analyse the events prior to the collision itself in the context of an
empirically grounded ( safety) concept – an analysis this chapter facilitates through
proposing how to operationalize prospective sensemaking.
The properties of prospective sensemaking were elaborated in the article by
Rosness, Evjemo, Haavik and Wærø ( 2015), whereas the AIBN’s investigation report
from 2019 described the sequence and handling of events prior to the collision
between Helge Ingstad and Sola TS. This chapter develops an operationalization of
the properties of prospective sensemaking by exploring the unfolding events prior to
the collision. The following two research questions are elaborated: 1. How can prospective sensemaking be operationalized on the grounds of the KNM Helge Ingstad
accident? 2. What can be learned from an applied operationalization of prospective
sensemaking?
MOTIVATION AND METHOD
The motivation behind operationalization of prospective sensemaking is twofold:
firstly, to better understand how such an ordinary traffic pattern and normal situation could escalate into a collision with the dire consequences that followed. For
this chapter, such an understanding involves a systemic approach to understanding
collaboration, i.e., focusing on the actions the actors perform – more specifically
coordinating and communicative practices and their enabling resources. Particularly,
this chapter views technology use as rooted in local situations and action being in
line with the work of Suchman ( 1987, 2007). Secondly, to explore whether our understanding of this type of accident can be improved by utilizing the concept of prospective sensemaking. The use of prospective sensemaking in this chapter is also
related to traditional accident investigations, which often take as their starting point
an exclusive individual, cognitive approach to human behaviour with an emphasis on
Sensemaking in Safety Critical and Complex Situations
control centre communicate. The Accident Investigation Board Norway ( AIBN) published the first of two reports in late 2019 focusing on human aspects related to the
accident. According to the AIBN report, misunderstanding of the situation on the
frigate was the root cause while specific criticism is put forth towards both the tanker
and the shipping control centre.
It is possible to look at the events in Hjelteforden as consisting of actors in a complex sociotechnical system – collaboration being imperative to ensure safety of the
system. In such a system, people are essential when it comes to safeguarding safety.
Such an approach involves analytical focus on what people do, when they do and
how the actions affect other people. The argument is that to manage safety one must
be able to understand how different actors’ dependence on each other’s actions plays
out. Analytically, interdependence is therefore a key issue when analysing social
interaction within complex organizational domains. It is also important to bear in
mind that neither the frigate, the tanker nor the shipping control centre undertook
anything that differed from the usual, which means that the accident occurred during routine and normal operations. An analysis of this type of accident is also about
understanding how something that apparently goes well, paradoxically changes in
a very short time span. Therefore, to learn from the Helge Ingstad accident and in
particular make the findings relevant beyond this accident per se, the argument is that
it is necessary to analyse the events prior to the collision itself in the context of an
empirically grounded ( safety) concept – an analysis this chapter facilitates through
proposing how to operationalize prospective sensemaking.
The properties of prospective sensemaking were elaborated in the article by
Rosness, Evjemo, Haavik and Wærø ( 2015), whereas the AIBN’s investigation report
from 2019 described the sequence and handling of events prior to the collision
between Helge Ingstad and Sola TS. This chapter develops an operationalization of
the properties of prospective sensemaking by exploring the unfolding events prior to
the collision. The following two research questions are elaborated: 1. How can prospective sensemaking be operationalized on the grounds of the KNM Helge Ingstad
accident? 2. What can be learned from an applied operationalization of prospective
sensemaking?
MOTIVATION AND METHOD
The motivation behind operationalization of prospective sensemaking is twofold:
firstly, to better understand how such an ordinary traffic pattern and normal situation could escalate into a collision with the dire consequences that followed. For
this chapter, such an understanding involves a systemic approach to understanding
collaboration, i.e., focusing on the actions the actors perform – more specifically
coordinating and communicative practices and their enabling resources. Particularly,
this chapter views technology use as rooted in local situations and action being in
line with the work of Suchman ( 1987, 2007). Secondly, to explore whether our understanding of this type of accident can be improved by utilizing the concept of prospective sensemaking. The use of prospective sensemaking in this chapter is also
related to traditional accident investigations, which often take as their starting point
an exclusive individual, cognitive approach to human behaviour with an emphasis on