I found this a mildly interesting little paper, focused on the maritime industry, exploring:
1. the relationship between design and accidents
2. how control systems contribute to accidents in critical operations
3. what improvements to rules and regulations can improve sensemaking in safety critical maritime operations.
They evaluated accident reports, observed work, literature review and interview data.
Key findings:
- HF experts are rarely involved in the early design phase and key HF principles may be missing in design
- User driven design isn’t often used, where “– decisions are being made between a network of actors not sufficiently involved in the actual operations of ships”
- “Technology driven implementation may not support critical tasks and the users can be subjected to stress, poor sensemaking and conditions leading to accidents”
- Alarm systems are often poorly designed
- Accident investigations are focused on “human errors” and “not based on a system perspective taking into consideration poor design” and more
- Thus, “human error may be seen as a cause and not as a consequence of poor conditions”
- Problems exist with insufficient passage planning, or poor or missing work load assessments, or poor design of bridge layouts
- They provide some suggestions moving forward – one is for the adoption of a contemporary system perspective in maritime accident analysis [** and arguably other areas of prospective design and planning]
Ref: Johnsen, S. O., Kilskar, S. S., & Danielsen, B. E. (2019). Improvements in rules and regulations to support sensemaking in safety-critical maritime operations. In Proceedings of the 29th European Safety and Reliability Conference (ESREL). 22–26 September 2019 Hannover, Germany. ESREL 2019.
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Safety & Performance Research Summaries 
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