What can be learnt from the natural context findings?

The insights gained from the natural context research sheds light on the flip side of the epistemological component (as outlined above), and therefore can contribute to the understanding of the system described here, and indirectly to the understanding of ECDIS assisted accidents. Second stories about properties of ECDIS use was indeed possible to extract from the research for this thesis. How the findings connect to the theoretical framework used here will be discussed in the following, to examine what clues they may hold for future design and development of ECDIS.

This research attempted to understand what makes work difficult (e.g. Woods et al., 2010) for any agent or sets of agents during navigation by use of ECDIS. The identification of joint cognitive system demands, helped reveal “how agents have or will adapt and how artifacts have

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affordance” (Woods & Hollnagel, 2006, p. 20). This focus is believed by the researcher to promote a shift in analysis, and design, away from the fallacy of function allocation (Dekker & Woods, 2002) by addressing how integration and co-agency work out during ECDIS navigation. Function allocation, or Man is Better At – Machine is Better At, risks falling prey to a false opposition between people and technology.

The researcher found was that there was a common skepticism towards the ECDIS. The ECDIS represents only part of the input integrated by most mariners to construct their mental model, based on which navigational decisions are made. The mariners were found to be very sensitive to cues derived from the whole operating environment (the experienced mariners). However, at the same time the modern hermeneutic mode of navigation, i.e. “the operator has moved from an experience of the world through the artefact to an experience of the artefact embedding the world.” (Hollnagel & Woods, 2005, p. 33), seems to bear the risk of decreasing this sensitivity. The risk is that silently, imperceptibly, ever more control will be given to the automated system, which relies on the embedded images and algorithms developed at a distance. So much more the reason to try to understand the environment that developers aim to model and engineer into the artifacts, to avoid what has been termed clumsy automation (Wiener, 1989 as cited by Woods & Hollnagel, 2006). This means that “the benefits of the new technology accrue during workload troughs, and the costs or burdens imposed by the technology occur during periods of peak workload, high-criticality, or high-tempo operations” (p. 127). In short, navigation becomes an even more hermeneutic discipline with integrated systems, providing ever more information, which may not seem problematic during normal conditions, but any negative side effects of the disconnection from more basic navigation skills reveal themselves only when operations slide out of their normal operating domains. This could be the case in some ECDIS assisted accidents.

It is of course possible to frame these issues as training and discipline challenges. Training, as a relevant issue, is not disregarded by the author of this thesis. Naturally, advanced technology such as an ECDIS requires a set of taught skills, to operate it. However, there exists a risk that training becomes a universal tool to tweak operator performance. The aspect of co-agency and affordance issues, and an understanding of local rationality and sense making, risk being neglected in this case. Furthermore, training can be dissolved into two dimensions, where the first is, legitimately, concerned with obtaining knowledge and skills in how to operate a device or system. The other dimension represents the enforcement of morale or discipline, i.e. how power and institution wants the device or system to be used (complying with work as imagined). Training as a concept

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seems to be confused in formal accident investigations because while the first dimension is necessary (naturally), to obtain skills, which in some cases is not done well for various reasons, such as financial costs etc., the investigation reports seem to address the second dimension; the undisciplined navigators that should have acted in accordance with how the system was intended to be used (disregarding the context).

The adaptations found on the ships´ bridges, for example silenced acoustic alarms, leave a risk that the clumsy automation is not necessarily noticed until an unexpected event or system anomaly occurs, ultimately as an accident. This was termed the Law of Fluency by Woods & Hollnagel (2006). They assert that:

[…] adaptations often become routinized as a standard part of a task or a role, so that, on the surface, it is difficult to see how these routines are adaptive and to what they have adapted. (p. 37)

Even the informants, the navigators, at times had difficulties to see through their own routinized adaptations and habits. Perry & Wears (2012) also found that the Law of Fluency was relevant in their hospital emergency department study of adaptation (addressed in section 6.3). They noted that:

Because ad hoc adaptations are for the most part tacitly introduced, systems use can easily be misinterpreted by vendors, designers and purchasers as evidence of successful design and implementation unless hidden workarounds are actively sought and studied. (p. 259)

There was a consensus among the informants; that the ECDIS could be improved if customizability is enhanced. This is interpreted here as a manifestation of the point made by for example Hollnagel & Woods (2005) and Norros & Salo (2009), as addressed in section 2.1, that a cognitive system, the human parts of the joint cognitive system, actively seek and interpret rather than passively receive information. Therefore, they may also seek and accept wrong information, and end up going in an incorrect direction if the representation does not correspond to the recipient’s understanding. It is not likely that every navigator´s mental model will be shaped appropriately, if expectations rely on a standard design model aiming to capture a remote reality. For the information offered by the ECDIS to make sense, it is therefore necessary to be able

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customize information representations so that it can be tailored locally to fit the particularities in each situation, and operator preferences. In other words: One size does NOT fit all, in ECDIS use nor should it in ECDIS design.

Furthermore, the above also has implications to the strategies that navigators apply to determine actions. These strategies can be said to consist of a combination of feedback and forward control (Hollnagel & Woods, 2005), which are, thus, highly dependent on the representation of the process to be controlled (navigation), and of how it will behave or develop, to select an appropriate action. ECDIS is clearly a preferred source of feedback information, and a very effective tool in support of forward control, because the information represented is practically real-time information about the environment to be controlled. A great incentive, thus, exists to seek out information from the ECDIS as it effectively enhances the navigator´s ability to anticipate the future conditions that the ship will encounter. However, the mismatches between navigator preferences and machine embedded images, as identified in this study, can increase the likelihood of going in the wrong direction. The issue becomes most apparent in ECDIS assisted accident cases where navigators was misinformed, or not at all informed, by the representation on the ECDIS, due to a mismatch between the operator preferences and corresponding settings, and the machine embedded idea about how the equipment was to be used in the particular context (a prime example is the varying representation of information at different zoom levels).

Basing action on wrong, or incomplete, information has been termed selective use of feedback and it was represented in this model by Hollnagel & Woods:

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To mitigate this potential for misconstruction of mental models, based on information originating from the ECDIS, it is necessary to understand the gap between work as imagined and work as done, and pursue design solutions that align the two dimensions.