Transparency within automated engine control systems: The case of the Savannah Express

Paper i proceeding, 2015

© 2015 Organising Committee NAV 2015. This paper is a case study that elucidates upon the root causes of a collision MS Savannah Express with a link span while inbound to the Southampton Docks because of an engine failure. The poorly documented engine design and installation, an unanticipated crew change, lack of spare parts, in part, accounted for the accident that was primarily attributed to human error during the initial investigation. Reason's Swiss Cheese Model clearly provides a framework that describes the accident and the inherent latent failures that turned the crews' actions to active failures. This paper will elaborate upon the complexity, and consequently ambiguity, of automated systems and how the lack of transparency within such systems led to crew decision failures. The conclusions made in the accident report stated that "The ship's engineers did not have a sufficiently good knowledge of the ME control system or specific system engineering training to successfully diagnose faults". As the complexity of the Engine Control Systems increases and the transparency decreases, the technology, to a higher extent, needed to support the decision making process of the engineers becomes even more critical. This gap cannot be replaced solely by training but needs to be supported by user-centered design.