Counter-Errorism in Diving: Applying Human Factors to Diving

Gareth Lock at The Human Diver

Human factors is a critical topic within the world of SCUBA diving, scientific diving, military diving, and commercial diving. This podcast is a mixture of interviews and 'shorts' which are audio versions of the weekly blog from The Human Diver. Each month we will look to have at least one interview and one case study discussion where we look at an event in detail and how human factors and non-technical skills contributed (or prevented) it from happening in the manner it did.

  1. 22h ago

    SH303: The Structure of This Diving Tragedy Was Not Abnormal. The Scale Was.

    This episode explores why diving accidents are so often explained by individual mistakes instead of the wider conditions that made those mistakes possible. Using the case of a fatal medication error in healthcare alongside the recent Maldives cave diving tragedy, it examines how hindsight, blame, and our natural tendency to focus on people rather than systems can prevent meaningful learning. The discussion highlights how unsafe practices can become normal when they repeatedly appear to work, and why serious accidents often reveal long-standing weaknesses that existed long before the final event. Rather than asking "Who is at fault?", the episode argues that the better question is "What conditions made these decisions seem reasonable at the time?"—because understanding those conditions offers the best chance of preventing similar tragedies in the future. Original blog: https://www.thehumandiver.com/post/the-structure-is-normal-the-scale-is-not Links: Martin Anderson’s write-up: https://humanfactors101.com/2022/05/08/is-human-error-a-crime/ Andrzej Gornicki’s Eight Question Review: https://www.thehumandiver.com/post/eight-questions-about-maldives-accident Gareth’s blog about accountability: https://www.thehumandiver.com/post/we-want-accountability Assumptions and worn paths: https://www.thehumandiver.com/post/why-rules-get-broken Consensus is because people don’t want to disagree: https://www.thehumandiver.com/post/beyond-the-floor Conditions produce outcomes: https://www.thehumandiver.com/post/what-conditions Useful illegality in action: https://www.thehumandiver.com/post/why-rules-get-broken Tags: THD-English| THD-Learning, Incidents & Just Culture

    SH303: The Structure of This Diving Tragedy Was Not Abnormal. The Scale Was.

  2. Aug 5

    SH302: Why Rules Get Broken. Does It Matter Who Is Breaking Them?

    This episode explores why rule-breaking in diving is often more complicated than simply “breaking the rules.” It looks at the difference between shortcuts that organisations quietly depend on to keep operating and personal shortcuts taken for convenience or ego. Through real-world examples, the discussion explains how hindsight can unfairly turn system-wide problems into individual blame after an incident occurs. The episode also examines why teams often stay silent when they notice problems, how social pressure affects decision-making, and why genuine learning requires understanding the reality of how diving actually works rather than relying on simple explanations. Ultimately, it challenges divers, instructors, and leaders to recognise the difference between necessary adaptations and risky personal shortcuts before something goes wrong. Original blog: https://www.thehumandiver.com/post/why-rules-get-broken Links: Blog about how conditions shape actions: https://www.thehumandiver.com/post/what-conditions Master thesis about storytelling to learn: https://www.thehumandiver.com/post/msc-part-1-the-problem-space Guide to speaking truth to power: https://www.thehumandiver.com/resources Tags: THD-English| THD-Learning, Incidents & Just Culture

    SH302: Why Rules Get Broken. Does It Matter Who Is Breaking Them?

  3. Aug 1

    SH301: Eight Questions About the Maldives Dive Accident

    This episode examines the deaths of five Italian divers in the Maldives and a Maldivian military diver who later died during the recovery operation, using the tragedy to explore how Just Culture approaches accidents in high-risk environments. Rather than rushing to blame individuals, the discussion walks through the Eight-Question Review framework, which looks first at the wider system: authority, procedures, training, resources, organisational culture, operational norms, and the pressures influencing decisions. The episode highlights how experienced scientific divers can still face hidden competence gaps when moving into technical cave environments, how commercial and research pressures can shape risk-taking, and how safety rules may drift away from everyday practice over time. It also explores the dangers of hindsight bias and why meaningful investigations must focus on understanding how decisions made sense to those involved at the time, not simply judging outcomes after the fact. The central message is that accidents rarely come from one bad decision alone, but from interacting conditions within a wider system—and that real learning only happens when we are willing to ask difficult questions before assigning blame. Original blog: https://www.thehumandiver.com/post/eight-questions-about-maldives-accident Links: Blog about the Chac Mool deaths: https://www.thehumandiver.com/post/chac-mool-triple-diving-fatality Further reading on The Human Diver: Change your Language, Change the World They Lost Situation Awareness The Eight-Question Review — LFEO course Tags: THD-English| THD-Learning, Incidents & Just Culture

    SH301: Eight Questions About the Maldives Dive Accident

  4. Jul 29

    SH300: "We want accountability."

    This episode reflects on the tragic deaths of five Italian divers in the Maldives and a Maldivian military diver who died while trying to recover them, using the event to explore what real accountability should look like after a diving accident. Rather than rushing to blame or making assumptions based on limited information, the discussion challenges the diving community to resist quick judgement and focus instead on understanding the conditions, decisions, and systems that may have shaped the outcome. It examines the difference between backward-looking accountability, which seeks someone to blame, and forward-looking accountability, which asks better questions about training, equipment, oversight, environmental conditions, and the support given to those involved in both the original dive and the recovery effort. At a time when facts are still emerging, the episode argues that meaningful learning begins with humility, patience, and a commitment to understanding what really happened—because only then can the diving community improve and better protect those who dive and those asked to rescue others. Original blog: https://www.thehumandiver.com/post/we-want-accountability Tags: THD-English| THD-Learning, Incidents & Just Culture

    SH300: "We want accountability."

  5. Jul 25

    SH299: When we ask 'What conditions made this more likely?' perspectives (should) change

    This episode challenges the instinct to explain diving accidents by focusing only on individual mistakes or broken rules. Instead, it explores how social, cultural, organisational, and environmental conditions shape the decisions divers make, even when those decisions seem irrational in hindsight. Using recent diving incidents as examples, the discussion highlights how behaviour that appears risky often made sense to those involved at the time, influenced by pressures such as authority, identity, time, and the expectation to “get the job done.” The episode introduces the PETTEOT framework—Person(s), Environment, Tasks, Tools and Technology, External Influences, Organisation, and Time—as a way to better understand how different parts of the diving system interact to create both success and failure. By moving beyond blame and examining the wider system, divers, instructors, and leaders can uncover the hidden conditions that shape performance and learn where meaningful improvements can be made, helping the community become better than yesterday. Original blog: https://www.thehumandiver.com/post/what-conditions Links: Blog about LEODSI and PETTEOT: https://www.thehumandiver.com/post/what-is-leodsi-petteot Tags: THD-English| THD-Learning, Incidents & Just Culture

    SH299: When we ask 'What conditions made this more likely?' perspectives (should) change

  6. Jul 22

    SH298: Beyond the Floor: Why Meeting the Standard Isn't the Same as Being Safe

    This episode challenges the common belief that following diving standards automatically makes diving safe. It explores how industry standards, while important, can create an illusion of safety when compliance becomes the main goal rather than improving real-world performance. The discussion examines how many diving standards are written and assessed by the same organisations they are meant to guide, creating a closed system that can protect institutions legally while limiting opportunities for deeper learning and improvement. It also looks at why accident investigations often focus on individual mistakes rather than questioning whether the procedures, training, or standards themselves are fit for purpose. Drawing on research from aviation, healthcare, and other high-risk industries, the episode argues that safer diving requires more than rule-following—it needs independent oversight, greater transparency, and a willingness to learn from outside safety science. True progress comes not from assuming yesterday’s standards are enough, but from building systems that can recognise their own limits and continually improve. Original blog: https://www.thehumandiver.com/post/beyond-the-floor Links: Diving Talks: 'Compliance provides an illusion for safety in diving InDepth article: https://indepthmag.com/compliance-provides-an-illusion-of-safety-in-diving/ Suggested further readingAmalberti, R. (2001) The paradoxes of almost totally safe transportation systems. Safety Science, 37(2–3), pp. 109–126. https://www.sciencedirect.com/science/article/pii/S092575350000045X Carpenter, D. and Moss, D. (eds.), Preventing Regulatory Capture (Cambridge University Press, 2014). https://www.cambridge.org/core/books/preventing-regulatory-capture/ Dekker, S., The Safety Anarchist (Routledge, 2018) and Compliance Capitalism (Routledge, 2022). https://www.amazon.co.uk/Safety-Anarchist-innovation-bureaucracy-compliance-ebook/dp/B0FCCZCTG5 Dixon-Woods, M., Yeung, K., & Bosk, C. L. (2011). Why is UK medicine no longer a self-regulating profession? The role of scandals involving “bad apple” doctors. Social Science & Medicine, 73(10), 1452–1459. https://doi.org/10.1016/j.socscimed.2011.08.031 Hopkins, A., Failure to Learn: The BP Texas City Refinery Disaster (CCH Australia, 2008). https://www.amazon.co.uk/Failure-Learn-Texas-Refinery-Disaster/dp/1921322446 Lundberg, J., Rollenhagen, C., and Hollnagel, E., What-You-Look-For-Is-What-You-Find: The consequences of underlying accident models in eight accident investigation manuals, Safety Science 47(10), 2009. https://www-sciencedirect-com.ludwig.lub.lu.se/science/article/pii/S0925753509000137 Meyer, J. and Rowan, B., Institutionalized Organizations: Formal Structure as Myth and Ceremony, American Journal of Sociology 83(2), 1977. https://www.jstor.org/stable/pdf/2778293.pdf Rae, A., Provan, D., Weber, D., and Dekker, S., Safety Clutter: The Accumulation and Persistence of 'Safety' Work That Does Not Contribute to Operational Safety, Policy and Practice in Health and Safety 16(2), 2018. https://doi.10.1080/14773996.2018.1491147 Thompson, D., Moral Responsibility of Public Officials: The Problem of Many Hands, American Political Science Review 74(4), 1980. Tags: THD-English| THD-Operations & Procedures

    SH298: Beyond the Floor: Why Meeting the Standard Isn't the Same as Being Safe

  7. Jul 18

    SH297: CRM, ISO 8804, and Scientific Diving: Opportunities and Existing Materials

    This episode explores the growing recognition that safe and effective scientific diving depends on more than technical skill, equipment, and certification. Prompted by new research into applying Crew Resource Management (CRM) to scientific diver training, it examines why communication, leadership, teamwork, and decision-making are essential in complex underwater operations where divers must manage both life support and scientific tasks under pressure. Drawing on lessons from aviation, healthcare, and other high-risk industries, the discussion highlights key challenges such as cognitive overload, distributed situational awareness, and authority gradients that can prevent divers from speaking up or adapting effectively when conditions change. It also reviews the existing research, training tools, and practical frameworks already available to support this shift, while recognising that long-term improvement depends on treating diving safety as an ongoing process of learning rather than a box-ticking exercise. The message is clear: true safety is built through the conditions teams create, the culture they sustain, and how they respond when concerns are raised—always striving to be better than yesterday. Original blog: https://www.thehumandiver.com/post/CRM-and-Scientific-Diving Links: Original LinkedIn post: https://www.linkedin.com/posts/raymond-arce-528304355_cd37166-scientificdiving-divertraining-share-7460336156979888128-ASrc/?utm_source=social_share_send&utm_medium=member_desktop_web&rcm=ACoAAAELqPcBwf1_VKIPpplosn5XZ02d6xlOzRs 9th Annual European Conference on Scientific Diving: https://ecsd9azores.com/ Resilient Performance Model blog: https://www.thehumandiver.com/post/resilient-performance-model Outcomes are a Function of…..: https://youtu.be/nkdVHBDnCjc?t=2293 Looking at CRM relevant failures: https://www.thehumandiver.com/post/what-is-leodsi-petteot Guide to Diving Crew Resource Management: https://www.thehumandiver.com/commercial-occupational-diving Moving beyond the position that compliance means safety: https://indepthmag.com/compliance-provides-an-illusion-of-safety-in-diving/ ReferencesCaramanna, G., & Strickland, B. (2023). Risk Management for Diving Operations: How to enhance the safety and proficiency of diving teams. Self-published. ISBN: 979-8988399612. CSA Group (2026). CSA Z275.2: Occupational Health and Safety Code for Diving Operations. Toronto: CSA Group. Edmondson, A. (1999). Psychological safety and learning behavior in work teams. Administrative Science Quarterly, 44(2), 350–383. Endsley, M. R. (1995). Toward a theory of situation awareness in dynamic systems. Human Factors, 37(1), 32–64. Flin, R., & Maran, N. (2004). Identifying and training non-technical skills for teams in acute medicine. Quality and Safety in Health Care, 13(suppl 1), i80–i84. Flin, R., O'Connor, P., & Crichton, M. (2008). Safety at the Sharp End: A Guide to Non-Technical Skills. Farnham: Ashgate. Health and Safety Executive (2011). Research Report RR871: Assessment of Manual Operations and Emergency Procedures for Closed Circuit Rebreathers. London: HSE Books. International Association of Oil and Gas Producers (2018). Report 503: Introducing Behavioural Markers of Non-Technical Skills in Oil and Gas Operations. London: IOGP. Lock, G. (2019). Under Pressure: Diving Deeper with Human Factors. Milton Keynes: Human in the System Consulting. Lock, G. (2023). Human factors and rebreather diving. In: Pollock NW, ed. Rebreather Forum 4. Proceedings of the April 20-22, 2023 workshop. Valletta, Malta; 2024. p. 57–69. O'Brien, E., & Caramanna, G. (2017). Human factors in scientific diving: an experimental approach. In Proceedings of the AAUS Diving for Science Symposium 2017. Thunder Bay National Marine Sanctuary: American Academy of Underwater Sciences. Piispanen, W., Lundell, R., Tuominen, L., & Räisänen-Sokolowski, A. (2021). Assessment of alertness and cognitive performance of closed circuit rebreather divers with the Critical Flicker Fusion Frequency Test in Arctic diving conditions. Frontiers in Physiology, 12, 722915. Reader, T. W., & O'Connor, P. (2014). The Deepwater Horizon explosion: non-technical skills, safety culture, and system complexity. Journal of Risk Research, 17(3), 405–424. Reitz, M., Nilsson, V., Day, E. and Higgins, J. (2019). Speaking truth to power at work. Hult Research. Sinek, S. (2019). The Infinite Game. New York: Portfolio/Penguin. Stanton, N. A., Stewart, R., Harris, D., Houghton, R. J., Baber, C., McMaster, R., Salmon, P., Hoyle, G., Walker, G., Young, M. S., Linsell, M., Dymott, R., & Green, D. (2006). Distributed situation awareness in dynamic systems: theoretical development and application of an ergonomics methodology. Ergonomics, 49(12–13), 1288–1311. Sweller, J. (1988). Cognitive load during problem solving: effects on learning. Cognitive Science, 12(2), 257–285. Yule, S., Flin, R., Paterson-Brown, S., & Maran, N. (2006). Development of a rating system for surgeons' non-technical skills. Medical Education, 40(11), 1098–1104. Tags: THD-English| THD-CRM, Leadership & Teamwork

    SH297: CRM, ISO 8804, and Scientific Diving: Opportunities and Existing Materials

  8. Jul 15

    SH296: When 'I'm Fine' Isn't True: Speaking Up and Ending the Dive

    This episode explores a diving incident where nothing officially “went wrong,” yet a series of small decisions and social pressures nearly led to tragedy. A newer CCR diver and his wife joined more experienced divers on an unfamiliar shore dive, and although they surfaced safely, the dive revealed how easily people can ignore warning signs when they feel pressure to fit in, avoid disappointing others, or challenge more experienced teammates. Drawing on research into speaking up, psychological safety, and stop-work authority, the episode examines why divers often stay silent even when they feel uncomfortable, and why near-misses are rarely reported or discussed. It argues that the absence of accidents does not mean a system is safe, and that real safety depends less on rules and policies and more on leadership, team culture, and how people respond when someone calls a dive. The discussion highlights the importance of curiosity, open communication, and creating environments where stopping a dive is treated as good judgement rather than failure, helping divers and teams learn before luck runs out. Original blog: https://www.thehumandiver.com/post/when-im-fine-isnt-true Links: Resources page including the DEBrIEF guide and building psychological safety: https://www.thehumandiver.com/resources Tags: THD-English| THD-Learning, Incidents & Just Culture

    SH296: When 'I'm Fine' Isn't True: Speaking Up and Ending the Dive
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About

Human factors is a critical topic within the world of SCUBA diving, scientific diving, military diving, and commercial diving. This podcast is a mixture of interviews and 'shorts' which are audio versions of the weekly blog from The Human Diver. Each month we will look to have at least one interview and one case study discussion where we look at an event in detail and how human factors and non-technical skills contributed (or prevented) it from happening in the manner it did.

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