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. 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
  2. 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
  3. SH271: When the Story Hurts Too Much to Change

    APR 18

    SH271: When the Story Hurts Too Much to Change

    This episode explores why diving accidents involving children create such strong reactions and deep divisions, and how our need for simple explanations often gets in the way of real learning. It explains how people quickly form strong opinions after tragedies, not because they don’t care about safety, but because events like this challenge their beliefs about control, training, and protection. To feel safe again, communities often rush to blame individuals, which brings emotional comfort but blocks deeper understanding. The episode shows how psychology, identity, and group thinking shape these reactions, and why early public stories become hard to question. The key message is that real safety comes from slowing down, asking harder questions, and looking at the wider system — the pressures, culture, and conditions that shape decisions — instead of just asking who is at fault. Original blog: https://www.thehumandiver.com/post/when-the-story-hurts-too-much Links: The moral dimension of an investigation: https://www.thehumandiver.com/post/what-is-the-purpose-of-an-investigation Cognitive dissonance: https://thedecisionlab.com/biases/cognitive-dissonance Blame providing moral comfort: https://www.thehumandiver.com/post/what-is-the-purpose-of-an-investigation Suppressing events: https://www.youtube.com/watch?v=DRXqeQvRFK0 The death of Linnea Mills: https://www.thehumandiver.com/post/linnea-mills-death-hf-systems-lens Tags: English| Learning, Incidents & Just Culture

    10 min
5
out of 5
11 Ratings

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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