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. SH295: Four Ways We Talk About 'Human Factors' in Diving

    1d ago

    SH295: Four Ways We Talk About 'Human Factors' in Diving

    This episode explores what people really mean when they talk about “human factors” in diving—and why the term can sometimes create more confusion than clarity. It looks at four different ways the phrase is commonly used: blaming “the human factor” when something goes wrong, focusing on what is happening inside the diver such as stress or decision-making, examining the external conditions that shape performance like equipment, procedures, and team dynamics, and finally viewing diving as a complex socio-technical system where people, technology, organisations, and the environment all interact. While the first three approaches can offer useful insights, they often miss the bigger picture. Real learning and lasting safety improvements come from understanding how the whole system works together, not just identifying individual mistakes. By shifting from blame to systems thinking, instructors and divers can better understand why outcomes occur and make meaningful changes that help everyone become better than yesterday. Original blog: https://www.thehumandiver.com/post/four-ways-of-hf Tags: THD-English| THD-Education & Content Type

    12 min
  2. SH294: Clickbait, trolls and comments. How dive incident posts can teach us — if we let them

    4d ago

    SH294: Clickbait, trolls and comments. How dive incident posts can teach us — if we let them

    Discussions about diving incidents on social media often follow a predictable pattern: a short, simplified post describes what happened, and comments quickly focus on blaming the individual involved, creating a sense of clear-cut failure and easy lessons. This happens not because people have bad intentions, but because simple, linear stories and knowing the outcome push our brains toward hindsight judgement, making complex situations seem obvious after the fact. As a result, important factors like conditions, pressures, communication, and decision-making context are ignored, limiting real learning. Over time, this blame-focused culture encourages people to share less detail or avoid posting altogether, which removes the very information needed to understand incidents properly. To improve learning, the community needs to shift from asking “what went wrong” to “why it made sense at the time,” and respond to posts with curiosity rather than judgement, creating an environment where fuller, more useful stories can be shared and understood. Original blog: https://www.thehumandiver.com/post/clickbait-trolls-and-comments Tags: THD-English| THD-Learning, Incidents & Just Culture

    13 min
  3. SH293: Why does nothing change? Why do the same failures keep happening?

    Jul 4

    SH293: Why does nothing change? Why do the same failures keep happening?

    Over the past decade, diving fatalities have remained stubbornly consistent despite better equipment, more training, and growing participation, suggesting the problem isn’t just technical or individual error. Current safety approaches focus on equipment, skills, and counting deaths, but often ignore deeper issues like communication, teamwork, decision-making, and the wider system divers operate in. Research shows that most contributing factors in incidents come from these “upstream” conditions—such as training culture, social pressure, and organisational practices—rather than the diver’s final actions. A major gap is the lack of training and assessment in non-technical skills, which are critical for managing real-world situations under pressure. At the same time, diving lacks an effective system for learning from incidents, as divers are reluctant to report issues to organisations they believe won’t act on them. To improve safety, the industry needs a shared language around human performance, better systems for collecting and learning from data, and a culture that supports open, blame-free discussion—because without addressing these deeper factors, meaningful change is unlikely. Original blog: https://www.thehumandiver.com/post/why-does-nothing-change Links: Rebreather fatality documentation from RF4.0: https://indepthmag.com/rebreather-forum-4-proceedings-are-available-for-free-download/ DCS study from DAN: https://journals.viamedica.pl/international_maritime_health/article/view/108038 If Only… documentary: https://www.thehumandiver.com/ifonly Linnea Mills case: https://www.thehumandiver.com/post/linnea-mills-death-hf-systems-lens Divers Alert Network reporting: https://dan.org/research-reports/research-studies/diving-incident-reporting-system/ BSAC reporting: https://www.bsac.com/home/ DOSA reporting: https://duikongevallen.nl/ LEODSI and PETTEOT: https://www.thehumandiver.com/post/what-is-leodsi-petteot Blogs about learning from incidents: https://www.thehumandiver.com/blog/category/learning-JC-incidents Tags: THD-English| THD-Learning, Incidents & Just Culture

    22 min
  4. SH292: Learning or Blaming: The Choice the Diving Industry Needs to Make. Part 3 of 3.

    Jul 1

    SH292: Learning or Blaming: The Choice the Diving Industry Needs to Make. Part 3 of 3.

    This final blog explores what the research means and how the diving community can realistically improve learning and safety. It argues that the problem is not broken individuals but a system that quietly encourages blame and silence, making it hard for divers to share honest stories about mistakes and near-misses. Fear—of legal action, criticism, or damage to reputation—plays a big role, even when that fear is not based on real outcomes. The result is weak feedback loops, where lessons from real experiences never reach the people who design training or shape the culture. The blog suggests shifting focus from the idea of a formal “just culture” to a more practical “culture of justness,” where fairness, understanding, and learning are encouraged at a local level by respected leaders. It also highlights how sharing more context reduces blame and improves learning, but notes that most divers are never taught how to do this. While there is no single fix, the way forward includes clearer language, better-designed reporting systems, role modelling by instructors and experienced divers, and introducing honest discussions about incidents into training. Ultimately, meaningful change will come from gradually shifting behaviours and norms, so that sharing real experiences becomes normal, supported, and valued across the diving community. Original blog: https://www.thehumandiver.com/post/msc-part-3-the-outcomes Links: Part 1: https://www.thehumandiver.com/post/msc-part-1-the-problem-space Part 2: https://www.thehumandiver.com/post/msc-part-2-the-data-and-results The full thesis, Storytelling to Learn: What Happens Underwater, Stays Underwater, was submitted in partial fulfilment of the requirements for the MSc in Human Factors and System Safety at Lund University, 2024. Gareth Lock is the founder of The Human Diver References:Dekker, S. (2009). Just culture: Who gets to draw the line? Cognition, Technology & Work, 11(3), 177–185. https://doi.org/10.1007/s10111-008-0110-7 EC. (2014). Regulation (EU) No 376/2014 of the European Parliament and of the Council of 3 April 2014. European Commission. Exley, S. (1986). Basic cave diving: A blueprint for survival. National Speleological Society – Cave Diving Section. https://nsscds.org/wp-content/uploads/2018/05/Blueprint-for-Survival.pdf Heffernan, M. (2011). Wilful blindness: Why we ignore the obvious. Simon and Schuster. Hoffman, B. G. (2012). American icon: Alan Mulally and the fight to save Ford Motor Company. Crown. Rasmussen, J. (1997). Risk management in a dynamic society: A modelling problem. Safety Science, 27(2–3), 183–213. Tags: THD-English| THD-Learning, Incidents & Just Culture

    15 min
  5. SH291: What the Data Told Us: Fear, Trust, and the Stories That Never Get Told. Part 2 of 3.

    Jun 27

    SH291: What the Data Told Us: Fear, Trust, and the Stories That Never Get Told. Part 2 of 3.

    This blog explains how a mixed-methods study explored why divers struggle to share honest, learning-focused stories about incidents. Using a large international survey, focus groups, and expert interviews, the research found that storytelling is strongly shaped by organisational culture, fear, and trust. Many divers—especially instructors—fear legal consequences, criticism, or damage to their reputation, which stops them from speaking openly, particularly in public settings. At the same time, there is confusion about key ideas like what counts as an “incident,” what “risk” really means, and what a “just culture” looks like, with very few divers linking incidents to learning. The study also showed that when stories include more context, people are less likely to judge and more likely to learn, but most divers are not taught how to do this. Overall, the findings suggest the diving community knows that sharing near-misses and building a just culture would improve safety, but lacks the trust, understanding, and organisational support needed to make that happen. Original blog: https://www.thehumandiver.com/post/msc-part-2-the-data-and-results Links and references: British Diving Safety Groiup: https://bdsg.org.uk/ Chan, W. T.-K., & Li, W.-C. (2023). Development of effective human factors interventions for aviation safety management. Frontiers in Public Health, 11, 1144921. https://doi.org/10.3389/fpubh.2023.1144921 EC. (2014). Regulation (EU) No 376/2014 of the European Parliament and of the Council of 3 April 2014. European Commission. Reason, J. (2016). Managing the risks of organizational accidents. Routledge. https://doi.org/10.4324/9781315543543 Tags: THD-English| THD-Learning, Incidents & Just Culture

    13 min
  6. SH290: What Happens Underwater, Stays Underwater — And That's a Problem. Part 1 of 3

    Jun 24

    SH290: What Happens Underwater, Stays Underwater — And That's a Problem. Part 1 of 3

    This episode introduces the problem behind learning in diving safety, using the 2020 death of Linnea Mills to highlight how incidents are often caused by deeper system issues, not just individual mistakes. While near-misses and accidents happen regularly in diving, most are never shared or analysed, meaning valuable lessons are lost. Unlike industries such as aviation or healthcare, diving lacks strong reporting systems, regulation, and reliable data, so decisions are often based on uncertainty rather than evidence. Existing reports tend to focus on immediate causes like equipment failure or diver error, but miss the wider social, organisational, and environmental factors that shape outcomes. The episode argues that meaningful learning comes from “context-rich” stories that explain not just what happened, but why it made sense at the time. Drawing on safety research from other industries, it highlights the need for a stronger reporting culture, psychological safety, and system-level thinking to improve learning and prevent future incidents. Original blog: https://www.thehumandiver.com/post/msc-part-1-the-problem-space References: Dekker, S. (2017). Just culture: Restoring trust and accountability in your organization (3rd ed.). CRC Press, Taylor & Francis Group. Drupsteen, L., & Guldenmund, F. (2014). What is learning: A review of the safety literature to define learning from incidents, accidents and disasters. Journal of Contingencies and Crisis Management, 22(2), 81–96. https://doi.org/10.1111/1468-5973.12039 EC. (2014). Regulation (EU) No 376/2014 of the European Parliament and of the Council of 3 April 2014. European Commission. Gigerenzer, G. (2014). Risk savvy. Viking. https://www.amazon.co.uk/Risk-Savvy-Make-Good-Decisions/dp/1846144744 Lock, G. (2011). The application of the Human Factors Analysis and Classification System (HFACS) to improve diving safety. https://drive.google.com/file/d/1Iz3qRRyo2NjdiBGbPcRhj14NoCTuuM4/view?usp=share_link Mills v Gull Dive Center PADI (2022). https://www.scribd.com/document/555406095/Mills-v-Gull-Dive-Center-PADI-2nd-Amended-Complaint Orlady, H. W., & Orlady, L. M. (2017). Human factors in multi-crew flight operations (1st ed.). Routledge. Reason, J. (2016). Managing the risks of organizational accidents. Routledge. https://doi.org/10.4324/9781315543543 Snowden, D. (2002). Complex acts of knowing: Paradox and descriptive self-awareness. Journal of Knowledge Management, 6(2), 100–111. https://doi.org/10.1108/13673270210424639 Waring, J. J. (2005). Beyond blame: Cultural barriers to medical incident reporting. Social Science & Medicine, 60(9), 1927–1935. https://doi.org/10.1016/j.socscimed.2004.08.055 Tags: English| Learning, Incidents & Just Culture

    13 min
  7. SH289: Chac Mool - Diving Deeper into a Triple Fatality with Human Factors

    Jun 20

    SH289: Chac Mool - Diving Deeper into a Triple Fatality with Human Factors

    This episode examines a 2012 triple fatality at Cenote Chac Mool in Mexico using a Human Factors approach, showing how accidents are rarely caused by a single mistake but by a combination of small, interacting factors. A guide took two recreational divers beyond safe limits into an overhead cave environment without a continuous guideline, and all three ran out of gas and died. Instead of simply blaming the guide, the analysis explores how things made sense at the time, including authority gradients that stopped the divers from questioning decisions, fatigue from multiple dives, pressure to show something impressive, and increasing task load in a complex environment. Using the PETTEOT framework, the case highlights how people, environment, equipment, organisational culture, and time pressures combined to reduce safety margins until there was no capacity left to recover. The key lesson is that safety depends on understanding these system interactions, building psychological safety so people can speak up, and reinforcing clear rules and preparation to prevent small, “normal” deviations from turning into fatal outcomes. Original blog: https://www.thehumandiver.com/post/chac-mool-triple-diving-fatality Links: Full CREER manual: https://creer-mx.com/wp-content/uploads/2024/03/Manual-for-Cenote-Dive-Guides-vs010324.pdf The Thumb rule: https://www.thehumandiver.com/post/top-tips-for-diving-instructors-psychological-safety-and-the-thumb-rule Learning from Emergent Outcomes course waiting list: https://www.thehumandiver.com/lfeo Tags: English| Learning, Incidents & Just Culture

    24 min
  8. SH288: The 'Obvious Thing' Nobody Noticed

    Jun 17

    SH288: The 'Obvious Thing' Nobody Noticed

    This episode explores the fatal case of 18-year-old Linnea Mills to show how visible hazards can go unnoticed when an instructor lacks the mental capacity to recognise them. Linnea was overweighted, unable to inflate her drysuit, and using equipment that couldn’t provide enough lift—risks that seem obvious in hindsight but were missed due to a combination of inexperience, time pressure, unfamiliar gear, and commercial expectations. Using models like ECOM and COCOM, the episode explains how an instructor’s attention can be consumed by immediate tasks, leaving no capacity to monitor the bigger picture or reassess whether a dive should proceed. This isn’t about blaming an individual, but understanding how systems, workload, and limited experience can overwhelm decision-making. The key lesson is that effective instructors don’t just rely on skill, but on preparation—setting clear plans, checks, and limits before the dive—to protect their ability to recognise problems when it matters most. Original blog: https://www.thehumandiver.com/post/the-obvious-thing-nobody-noticed Links: Part 1: https://www.thehumandiver.com/post/the-picture-went-dark The Linnea Mills case: https://www.thehumandiver.com/post/linnea-mills-death-hf-systems-lens Tags: English| Sense-making, Decision-making, & Psychology

    15 min
See All (295)

5
out of 5
13 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.

Information

You Might Also Like