Counter-Errorism in Diving: Applying Human Factors to Diving

Gareth Lock at The Human Diver
  • 5.0 (11)
  • EDUCATION
  • UPDATED SEMIWEEKLY

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. SH279: The Tower Was Already Full of Holes

    3D AGO

    SH279: The Tower Was Already Full of Holes

    This episode looks at how diving incidents are often explained by blaming the last person involved, much like blaming the person who pulls the final brick from an already unstable Jenga tower. While that person may be the last to act, many other factors—such as environment, equipment, training, social pressure, and organisational practices—may already have weakened the system. Through several real diving examples, the episode shows how accidents usually develop from a combination of conditions rather than a single mistake. It also explains why people are quick to blame individuals: it is easier, it protects our sense of safety, and it is what we are used to seeing in the media and official reports. Instead of asking what someone “should have done,” the more useful question is how their actions made sense at the time with the information and resources they had. By shifting from judgement to curiosity and looking at the wider system, divers and instructors can learn more from incidents and improve both their technical and non-technical skills to make future dives safer. Original blog: https://www.thehumandiver.com/post/and-still-the-tower-is-standing Links: “Blaming a bad apple is like wetting your pants”:https://indepthmag.com/do-bad-apples-actually-exist/ Blog about the death of Linnea Mills: https://www.thehumandiver.com/post/linnea-mills-death-hf-systems-lens Blog about the death of a 12 year old child in Texas: https://www.thehumandiver.com/post/learning-from-tragedy-dh Wait list for Learning from Emergent Outcomes course: https://www.thehumandiver.com/lfeo Facebook group: https://www.facebook.com/groups/184882365201810/permalink/2729409417415746/ Tags: English| Safety & Risk Management

    9 min
  2. SH278: Be Curious, Not Judgemental

    6D AGO

    SH278: Be Curious, Not Judgemental

    This episode looks at how quick judgement, especially online, can block learning and make diving less safe. Using a real example of an adaptive scuba training video that received harsh criticism, it explains how people often react without understanding the full context. The episode introduces two key ideas from Human Factors: psychological safety, where people feel safe to ask questions and speak up, and just culture, where the focus is on learning instead of blame. The main message is simple: when people judge, learning stops, but when people stay curious, learning begins. By slowing down, asking questions, and trying to understand why decisions made sense at the time, dive teams and the wider community can make better choices, create safer environments, and build a healthier culture for everyone. Original blog: https://www.thehumandiver.com/post/be-curious-not-judgemental Links: Original Facebook post and video: https://www.facebook.com/share/r/1DnwV8qM1r/ Tags: English| Learning, Incidents & Just Culture

    7 min
  3. SH277: You are entering water with known problems, and don't kid yourself that it's any different.

    MAY 9

    SH277: You are entering water with known problems, and don't kid yourself that it's any different.

    This episode explores why people often go diving even when something feels “off,” and how risk usually starts before anyone gets in the water. It explains that danger doesn’t come from one big mistake, but from small pressures like stress, tiredness, rushing, poor communication, and cutting corners that slowly build up and start to feel normal. Over time, these small compromises become habits, and people stop seeing them as problems at all. The key message is that safety isn’t just about following procedures underwater — it’s about noticing when your safety margin is already shrinking on the surface. Real safety comes from having the courage to stop, slow down, and ask not “Can we do this dive?” but “Do we still have enough room for things to go wrong?” Original blog: https://www.thehumandiver.com/post/you-are-entering-water-with-known-problems Links: Work as Imagined vs Work as Done blog: https://www.thehumandiver.com/blog/Work-as-Imagined-vs-Work-as-Done Tags: English| Safety & Risk Management

    12 min
  4. SH276: If there are no silver bullets, build capacity to fail safely

    MAY 6

    SH276: If there are no silver bullets, build capacity to fail safely

    This episode explores what real safety improvement in diving could look like if we stop copying other industries and start designing for the reality of diving itself. It explains that diving is commercial, lightly regulated, and full of everyday trade-offs between safety, money, time, and training, which means risk can’t be removed — only managed. Instead of relying only on rules and checklists, the focus should be on building “margin” into the system: better training time, safer conditions, lower ratios, rested instructors, better decision-making, and a culture where stopping a dive is normal, not failure. The key message is that safety doesn’t come from paperwork alone, but from building real capacity — skills, time, support, learning systems, and honest culture — so people can make good decisions under pressure and prevent small compromises from slowly turning into serious danger. Original blog: https://www.thehumandiver.com/post/no-silver-bullets-build-capacity Tags: English| Learning, Incidents & Just Culture

    15 min
  5. SH275: The death of a child in diver training. There are no ‘silver bullet’ solutions

    MAY 2

    SH275: The death of a child in diver training. There are no ‘silver bullet’ solutions

    This episode looks at the tragic death of 12-year-old D.H. during a scuba training dive and explains it not as one person’s mistake, but as a failure of the whole system around her. Using court documents and a safety science approach, the analysis shows how many “normal” things came together — rushed training, poor visibility, tired staff, missing safety equipment, weak rules, money pressure, and lack of oversight — to create a situation where there was no real safety margin left. The key message is that this was not a random accident or a single bad decision, but the result of a system that allowed risky practices to become normal. The goal is not blame, but learning: understanding how everyday routines, shortcuts, and pressures can slowly increase danger, and how changing the system — not just individuals — is the only real way to prevent this from happening again. Original blog: https://www.thehumandiver.com/post/learning-from-tragedy-dh Links: Court filings: https://www.documentcloud.org/documents/26789283-dylanharrisonlawsuit/ Purpose of investigation blog: https://www.thehumandiver.com/post/what-is-the-purpose-of-an-investigation Learning from Emergent Outcomes and LEODSI: https://www.thehumandiver.com/lfeo Psychological safety: https://lup.lub.lu.se/student-papers/search/publication/9151225 Research around “stop work” orders: https://www.researchgate.net/publication/352017590_Deciding_to_stop_work_or_deciding_how_work_is_done https://www.sciencedirect.com/science/article/abs/pii/S0925753517308871 RSTC guidance and Standards: https://www.youtube.com/watch?v=kNRrrosDJYs Trade off between performance, cost and resources: https://youtu.be/vtgIwHrUWVQ?list=PLNXuyLsCTX6hHS3newpcROfJ_JiI27q3C&t=555 Regulated environments such as military aviation: https://www.mdpi.com/2313-576X/8/2/37 Barriers to learning from adverse events: https://lup.lub.lu.se/student-papers/search/publication/9151225 Social acceptance of drift: https://www.thehumandiver.com/post/normalisation-of-deviance-not-about-rule-breaking Work as Imagined vs Work as Done: https://youtu.be/vtgIwHrUWVQ?list=PLNXuyLsCTX6hHS3newpcROfJ_JiI27q3C&t=962 Performance Influencing Factors: https://www.thehumandiver.com/post/top-tips-for-diving-instructors-performance-influencing-factors The shoot down of two Black Hawks: https://www.mindtherisk.com/literature/150-friendly-fire-the-accidental-shootdown-of-u-s-black-hawks-over-northern-iraq-by-scott-a-snook Rebreather Forum 4.0 talk: https://www.youtube.com/watch?v=nkdVHBDnCjc Challenger and Columbia disasters: https://www.montana.edu/rmaher/engr125/CAIB-History%20as%20a%20cause.pdf Loss of HMNZ Manawanui: https://nzdf.mil.nz/court-of-inquiry-hmnzs-manawanui The death of LCpl Partridge: https://assets.publishing.service.gov.uk/media/5d305623ed915d2feeac4a0f/LCpl_Partridge_Service_Inquiry_Parts_1.1._to_1.6_REDACTED_ONLINE_VERSION.pdf The death of ADR Yarwood: https://www.nzdf.mil.nz/assets/Uploads/DocumentLibrary/Redacted-Death-Able-Diver-COI-Rpt-for-publication.pdf Safety Science for Outdoor and Experiential Learning book: https://www.amazon.com/Safety-Science-Outdoor-Experiential-Education-ebook/dp/B0G99BD12G/ref=sr_1_1 The death of Linnea Mills: https://www.thehumandiver.com/post/linnea-mills-death-hf-systems-lens Tags: English| Learning, Incidents & Just Culture

    31 min
  6. SH274: When Do We Stop Asking “Why?”

    APR 29

    SH274: When Do We Stop Asking “Why?”

    This episode explores why asking “why did this happen?” after a diving accident is important — but not enough on its own. It explains that investigations often stop too early, not because everything is understood, but because people reach a point that feels comfortable, simple, or easy to fix. Many reports focus on equipment failures or individual mistakes, while deeper causes like pressure, workload, training culture, time limits, and business realities are left out. The episode shows that real learning comes from looking at how normal routines, shortcuts, and everyday decisions shape what people do, not just what went wrong at the end. The main message is clear: the goal of asking “why” isn’t to find someone to blame, but to understand the system well enough to change future behaviour — so the next dive is safer, even under pressure and imperfect conditions. Original blog: https://www.thehumandiver.com/post/when-do-we-stop-asking-why Links: Learning from Emergent Outcomes and LEODSI: https://www.thehumandiver.com/lfeo Some relevant blogs: https://www.thehumandiver.com/post/what-story-gets-told-what-words-are-used https://www.thehumandiver.com/post/when-the-story-hurts-too-much https://www.thehumandiver.com/post/what-is-the-purpose-of-an-investigation References: Kletz, T. A. (2006). Accident investigation: Keep asking “why?”. Journal of hazardous materials, 130(1-2), 69-75. Reason, J. (2016). Managing the risks of organizational accidents. Routledge. Reason, J. (1991). Too little and too late: A commentary on accident and incident reporting systems. In Near miss reporting as a safety tool (pp. 9-26). Butterworth-Heinemann. Rasmussen, J. (1990). Human error and the problem of causality in analysis of accidents. Philosophical Transactions of the Royal Society of London. B, Biological Sciences, 327(1241), 449-462. Rasmussen, J. (1988). Coping safely with complex systems. In AAAS Annual Meeting 1988. Cedergren, A., & Petersen, K. (2011). Prerequisites for learning from accident investigations–a cross-country comparison of national accident investigation boards. Safety Science, 49(8-9), 1238-1245. Lessons from Longford: the Esso Gas Plant Explosion. Andrew Hopkins. CCH Australia, Sydney. 2000 Lundberg, J., Rollenhagen, C., & Hollnagel, E. (2010). What you find is not always what you fix—How other aspects than causes of accidents decide recommendations for remedial actions. Accident Analysis & Prevention, 42(6), 2132-2139. Manuele, F. A. (2016). Root-Causal Factors: Uncovering the Hows & Whys of Incidents. Professional Safety, 61(05), 48-55. Tags: English| Learning, Incidents & Just Culture

    14 min
  7. SH273: What story gets told? What words are used? Who gets to the tell the multiple stories?

    APR 25

    SH273: What story gets told? What words are used? Who gets to the tell the multiple stories?

    This episode looks at two very different ways of telling the same tragic story — the death of a 12-year-old girl during a scuba training dive in Texas — and why the way we tell these stories matters for real safety. The first version focuses on blame, emotion, and individual failure, which feels powerful but pushes people toward anger instead of learning. The second version looks at how the whole system shaped what happened, including training pressure, poor visibility, equipment choices, fatigue, class structure, and missing safety checks. Instead of asking “who failed,” it asks how normal practices, routines, and decisions slowly combined to create dangerous conditions. The key message is simple: real prevention doesn’t come from blaming people, it comes from understanding how systems work in everyday conditions — and changing those systems so tragedies like this are far less likely to happen again. Original blog: https://www.thehumandiver.com/post/what-story-gets-told-what-words-are-used Links: Why hurting prevents change What is the purpose of an investigation Sharing stories: https://youtu.be/DRXqeQvRFK0 Linnea Mills case: https://youtu.be/lu4tc8gtNio Tags: English| Learning, Incidents & Just Culture

    10 min
  8. SH272: Seeing what is ‘unseen’: applying human factors to citizen science

    APR 22

    SH272: Seeing what is ‘unseen’: applying human factors to citizen science

    This episode explores how divers often overlook the richness of underwater environments they think they already know, and how greater awareness can transform both safety and understanding. Using real examples from rivers, lakes, and glacial landscapes, it shows how underwater spaces are shaped by nature, history, and human activity, even when they look simple on the surface. The episode explains how human factors help divers make better decisions, communicate clearly, and work more effectively as teams, while citizen science gives divers a way to contribute real knowledge to research and conservation. The core message is that when divers learn to look more carefully, every dive becomes more meaningful — improving safety, protecting underwater heritage, and turning ordinary dives into opportunities to learn, discover, and contribute. Original blog: https://www.thehumandiver.com/post/seeing-what-is-unseen-scientific-diving Tags: Sense-making, Decision-making, & Psychology

    9 min
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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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