Sensemaking in safety-critical situations

The ability to handle demanding maritime operations safely is increasingly dependent on IT- based control systems (e.g. control systems on the bridge, Electronic Charting-ECDIS, dynamic positioning, and ballasting/stability and alarm systems). Such systems play a crucial role in the handling of critical situations, by presenting information that allows operators to make sense of the situation. The growing dependence on systems changes the design process, the work processes, competence requirements, and above all it introduces new opportunities and challenges to improve for the handling of risk in demanding maritime operations. This is the topic of the SMACS project. The term sensemaking refers to the way actors combine the bits and pieces of information they have and make decisions on this basis, i.e. the process of getting situational awareness. This process involves tight interaction between humans and technology. It also places high demands on the quality of technology, the experience of the operator, and the education and training of seamen and operators. We have identified the bridge systems, electronic charting, the use of autonomous systems such as dynamic positioning and ballasting systems in critical situations as our key cases. These are operations with much energy involved, where situations may change quickly from normal operations to critical situations, and where the consequences may be devastating, as illustrated by the Helge Ingstad accident in 2018, and the USS J. McCain accident in 2017. The goal of the SMACS project is to develop new knowledge about how to design systems for safety-critical operations and how to improve the training of the seafarers. We have started with a literature review of sensemaking in safety-critical situations, and an exploration of 19 accidents in the maritime sector to get better insight in the root-causes and causes for the missing sense-making. In some of the accidents the accident investigators identify the root causes as poor quality of technical systems (such as ECDIS). In the Shipping Industry the old concept of "Human Error" (blaming the human) is still used. In other industries the understanding is that accidents are caused by the whole system (with less blame on the humans). The results of our work have been documented in several papers and in an open access (OA) book. We have studied the use of bridge control systems, dynamic positioning systems, how training is performed, and we have performed observation-studies of old and new bridge control systems based on different development philosophies. We have performed an in-depth study of the Helge Ingstad accident, to explore accident investigation techniques and root causes of the accident. We have found that the systems seldom have been developed based on user centred design, the consequences has been that some users are confused by the number of alarms, too much information and poor design. We have arranged collaboration meetings with the users (such as the Captain-forum in Equinor with 100 captains), authorities, the maritime industries and consultants/academia. Principles to support sensemaking were also discussed in an session with the academies of Science/Marine Board Meeting in the US. We have arranged HFC meetings to present results (www.hfc.sintef.no), "state-of the art", and to build network between authorities, research institutions, and the actors developing these systems. Findings are that user-centred design must be used more, sensemaking should be used as a design principle and explored in accident investigations, and that the systems should be designed and developed in collaboration with the actual users. We have developed design principles to be used in safety critical design, (principles of how to get status at a glance) and are suggesting how to impact regulations and certification processes in order to sustain sensemaking and user centred design. We have published eight conference papers and two journal articles that have been peer reviewed and an Open Access Book (with 15 articles), published in July 2021. As a part of the PhD study, two journal articles will be published in 2021. HFC conference was arranged as two web sessions in 2020, (100-150 participants) with an excellent discussion of sensemaking and need for better understanding of sensemaking in accident analysis. We have had collaboration related to the investigation of the H. Ingstad accident, and we have suggested increased focus on sensemaking from the surrounding systems, such as integrations of systems used to establish positions (VHF, Radar, Ecdis) based on Human Factors. Key issues in accident investigations has been adopted by the Norwegian Safety Forum (i.e. Involvement of Human Factors in accident investigations, and use of sensemaking in accident analysis). The principle of Human Centered Design is going to be implemented in regulations.

Formålet med prosjektet er å bygge kunnskap om menneskelige og organisatoriske forhold for å håndtere sikkerhetskritiske situasjoner i maritim sektor. Vi har brukt sensemaking som begrep. Konsekvensene av dårlig sensemaking kan være alvorlige, som Helge Ingstad ulykken. Vi har analysert litteratur og ulykker for å forstå årsaker. Analysene peker på dårlig brukersentrert design. Begrepet "Human Error" (som straffer mennesket) brukes som forklaring i skipsindustrien i stedet for et systemperspektiv. Vi har gjennomført observasjons-studier av brosystemer. Vi har arrangert møter for å bygge ut nettverket mellom myndigheter, forskere og de som lager systemene. Funnene peker på viktigheten av brukersentrert design og sensemaking. Funnene er presentert i bok (OA CC BY 4.0) og artikler. Resultatene er formidlet til Sikkerhetsforum, som sier at ulykkes-granskinger skal vurdere menneskelige faktorer og sensemaking. Prinsipper om brukersentrering skal komme i regelverket for å støtte sensemaking.

The operation of ships and mobile drilling units are increasingly dependent on ICT based control systems (e.g. dynamic positioning and ballasting/stability. Such systems play a crucial role in the handling of critical situations, by presenting safety-critical information that allows operators to make sense of the situation. The growing dependence on such systems changes work processes, competence requirements, and above all, it introduces new types of risk into maritime operations. This is the topic of this project. We will study and improve the technical, human and organizational capabilities The term sensemaking refers to the way actors combine the bits and pieces of information they have, and make decisions on this basis. Importantly, this process involves tight interaction between humans and technology that places high demands on the quality of technology, the experience of the operator, and the education and training of seamen and operators. Our key cases are the design and use of dynamic positioning and ballasting systems in critical situations. Anchor handling operations of drilling rigs in the high north is given particular attention, as these are operations with huge amounts of energy involved and where situations may switch quickly from normal operations to critical situations. The vision of SMACS is to create knowledge on how to enhance the technological, human and organizational capabilities needed to be able to handle safety critical situations. The project's research questions are the following: 1) What are the characteristics of sensemaking and resilience in safety-critical situations? 2)What are the needed human, technological and organisational factors to support sensemaking and resilience in safety-critical situations? 3)What are the characteristics of an HMI that facilitates sensemaking and resilience in safety-critical situations 4)What are the characteristics of training methods that promote the development of sensemaking?