Systemic usability failures in ECDIS: a Swiss cheese analysis of the Kaami accident

Abstract This paper presents several considerations based on the grounding accident of the small Norwegian bulk carrier Kaami in Scotland 2020, a case which shows surprising deviations in the set-up, pre-voyage use, and the way the Electronic Chart Display and Information System (ECDIS) was subsequently used to monitor the voyage. Using Reason’s Swiss cheese safety barrier perspective, we present and analyse eight safety barriers and how they were breached at the time of the accident. It was not possible to determine if these violations were done wilfully or because the navigators were unaware of the status of the chart system. Assuming the latter, we present design advice that we believe could have averted the accident. Using the Kaami case as an illustration, we advocate that the complexity of modern ECDIS possibly has grown to a point where it is evident that something must be done to address this.