Safety Science
Causality is central to accident investigation, shaping how events are reconstructed, accountability is assigned, and systemic improvements are identified. However, conventional investigations often emphasise procedural and technical sequences, overlooking relational and interpretive dynamics crucial for understanding how systems drift towards failure through the gradual erosion of shared understanding. To examine what this framing may overlook, we revisit the 2018 collision between the Norwegian frigate Helge Ingstad and the tanker Sola TS. We first used FRAM to reconstruct Work-as-Imagined (WAI) and then conducted a sensemaking-informed content analysis to examine Work-as-Done (WAD) based on official reports. While FRAM effectively clarified system function coupling and where variability arose, it offered limited insight into how interpretations diverged or why
shared understanding was difficult to sustain. This two-stage analysis revealed critical discrepancies between formal expectations and actual meaning-making. These insights, together with theoretical considerations, informed the development of a four-layer maturity model. The four-layer maturity model, consisting of (i) technical causality, (ii) human performance, (iii) socio-technical interdependencies, and (iv) relational sensemaking grounded in Human Readiness Levels (HRL). This model, with its distinctive fourth analytical layer (iv), shifts attention from functional interactions to how coherence forms—or fails—under pressure. The case was then revisited solely to illustrate how the model reveals relational and interpretive dynamics not captured by functional analysis, thereby avoiding methodological circularity. It highlights silence, saturation, and fragmentation as indicators of a system losing its capacity to adapt its understanding, even when information is available and routines continue.