The human factor in accident analysis : the Kronprins Harald case

Several recent maritime accidents suggest that modern technology sometimes can make it difficult for mariners to navigate safely. A review of the literature also indicates that the technological remedies designed to prevent maritime accidents at times can be ineffective or counterproductive. To understand why, problem-oriented ethnography was used to collect and analyse data on how mariners understand their work and their tools. Over 4 years, 15 ships were visited; the ship types studied were small and large archipelago passenger ships and cargo ships. Mariners and others who work in the maritime industry were interviewed. What I found onboard were numerous examples of what I now call integration work. Integration is about co-ordination, co-operation and compromise. When humans and technology have to work together, the human (mostly) has to co-ordinate resources, co-operate with devices and compromise between means and ends. What mariners have to integrate to get work done include representations of data and information; rules, regulations and practice; human and machine work; and learning and practice. Mariners largely have to perform integration work themselves because machines cannot communicate in ways mariners see as useful. What developers and manufacturers choose to integrate into screens or systems is not always what the mariners would choose. There are other kinds of ‘mistakes’ mariners have to adapt to. Basically, they arise from conflicts between global rationality (rules, regulations and legislation) and local rationality (what gets defined as good seamanship at a particular time and place). When technology is used to replace human work this is not necessarily a straightforward or successful process. What it often means is that mariners have to work, sometimes very hard, to ‘construct’ a cooperational human-machine system. Even when technology works ‘as intended’ work of this kind is still required. Even in most ostensibly integrated systems, human operators still must perform integration work. In short, technology alone cannot solve the problems that technology created. Further, trying to fix ‘human error’ by incremental ‘improvements’ in technology or procedure tends to be largely ineffective due to the adaptive compensation by users. A systems view is necessary to make changes to a workplace. Finally, this research illustrates the value problem-oriented ethnography can have when it comes to collecting information on what users ‘mean’ and ‘really do’ and what designers ‘need’ to make technology easier and safer to use.