Counter-Errorism in Diving: Applying Human Factors to Diving

In this episode, we explore the importance of checklists in diving, inspired by lessons from aviation and medicine. After a tragic 1935 plane crash, pilots introduced simple checklists to reduce human error—an approach now standard in high-risk industries. Checklists help compensate for our natural forgetfulness and distractions by providing quick prompts for essential tasks. For divers, effective checklists should be simple, fit for the environment, and backed by proper training. Teams benefit from shared checklists, improving safety through collaboration and consistency. Adopting checklists as a cultural norm, much like in surgery, can make diving safer and more efficient for everyone. Original blog: https://www.thehumandiver.com/blog/why-checklists-work   Links: Atul Gawande’s Reith Lecture: https://www.bbc.co.uk/programmes/articles/6F2X8TpsxrJpnsq82hggHW/dr-atul-gawande-2014-reith-lectures Reduction in mortality due to checklists: https://www.nejm.org/doi/full/10.1056/nejmsa0810119 How a checklist can be the difference between living and dying: https://www.thehumandiver.com/ifonly   Tags:  English, Checklists, Decision-Making, Mike Mason

Experience and practice are crucial for making better decisions, especially in uncertain situations, but they aren’t the same. Perfect practice builds expertise, while varied experiences across different environments enhance decision-making by expanding mental patterns. Decision-making relies on situational awareness, which involves sensing, understanding, and projecting future outcomes, all influenced by our training, memories, and expectations. Models like Gary Klein’s recognition-primed decision-making show how we use cues and past experiences to act efficiently, even under pressure. Feedback loops and a culture of learning are key to refining our actions. By diversifying your practice and learning, you can build the mental models needed to think and act like an expert. Original blog: https://www.thehumandiver.com/blog/the-importance-of-experience   Links: DEBRIEF model: https://www.thehumandiver.com/debrief   Tags:  English, Decision Making, Gareth Lock, Situation Awareness

In this episode, we explore how human perception and assumptions can lead to critical errors, using real-world examples like the tragic 1994 friendly fire incident where two US helicopters were mistaken for enemy aircraft. These events highlight the dangers of "believing is seeing" and how expectations can shape our decisions under pressure. We connect these lessons to diving, where incomplete information and mental shortcuts can result in serious incidents. Learn how to reduce errors by validating assumptions, improving communication, and fostering shared mental models, helping to enhance safety and teamwork in high-risk environments. Original blog: https://www.thehumandiver.com/blog/believing-is-seeing   Links: What You Look For Is What You Find paper: https://www.sciencedirect.com/science/article/abs/pii/S0925753509000137 Language can shape expectations: https://gue.com/blog/the-role-of-agency-when-discussing-diving-incidents-an-adverse-event-occurs-an-instructor-makes-a-mistake/   Tags:  English, Cave Diving, Decision-Making, Gareth Lock, Rebreather, Situation Awareness

In this episode, we discuss integrating Human Factors training into technical diving courses, inspired by a new program blending eLearning, hands-on skills, and real-world exploration. The program emphasized teamwork, leadership, and psychological safety, with the DEBRIEF model becoming a standout tool for improving feedback and team efficiency. Students embraced these concepts, leading to more effective learning and collaboration. Lessons learned included refining teaching methods, incorporating Human Factors into all course modules, and fostering a just culture. The result? Better divers, better teammates, and a better instructor. Tune in for insights on enhancing diver education through Human Factors. Original blog: https://www.thehumandiver.com/blog/HF_Into_Archaeology   Links: Underwater Archaeology Society of British Columbia: http://www.uasbc.com/ DEBRIEF model: https://www.thehumandiver.com/debrief The Essentials class: https://www.thehumandiver.com/HFiD-Essentials Guy Shockey: [email protected]   Tags:  English, Debrief, Decision-Making, Guy Shockey, Leadership, Teamwork

In this episode, we explore the complexities of situational awareness (SA) in diving and why it's often only recognized as missing after an event has occurred. SA involves interpreting sensory data and predicting future outcomes based on experience. Experienced divers may notice subtle signs of danger, like coral movements indicating currents or rust falling in a wreck, while novices lack the knowledge to anticipate or respond. Distractions, limited mental capacity, or unclear information can divert attention from critical issues. Rather than focusing on "loss of SA," we discuss how effective briefings, experience, and deliberate focus can help divers pay attention to what truly matters underwater. Original blog: https://www.thehumandiver.com/blog/cant_pay_MORE_attention   Tags:  English, Decision Making, Gareth Lock, Non-technical Skills, Situation Awareness

In this blog, a diver reflects on a simulated rescue scenario during a PADI Rescue Course, highlighting critical lessons about human factors in diving. The incident underscores the impact of high task focus, reduced situational awareness, and psychological stress, which led a student to run critically low on gas without asking for help. The writer explores contributing factors, including the challenges of operating in cold, low-visibility conditions, the pressures of performing under assessment, and the lack of a "just culture" where errors can be openly discussed and learned from. This real-life example emphasizes the importance of fostering psychological safety and vigilance in all roles during training dives. Original blog: https://www.thehumandiver.com/blog/rescuer-and-rescued   Tags:  English, Communications, Decision Making, Gareth Lock, Just Culture, Psychological Safety, Situation Awareness

Pre-dive checks are essential for diving safety, but they’re often rushed or overlooked, especially on busy dive boats. Factors like time pressure, peer pressure, distractions, and overconfidence can lead divers to skip thorough checks, relying instead on past outcomes. However, regardless of experience, using a familiar checklist with your buddy is key to ensuring equipment works and everyone knows how to assist in an emergency. While dive boats may not always allow for perfect checks, taking time beforehand—at the dive shop or during the journey—to understand your buddy’s gear can mitigate risks. Dive Masters play a vital role in setting the standard by demonstrating thorough checks. Ultimately, effective pre-dive checks improve safety, reduce errors, and prepare divers for unexpected situations. Original blog: https://www.thehumandiver.com/blog/checks-on-a-dive-boat   Tags:  English, Checklists, Decision Making, Mike Mason, Teamwork

In this episode, Gareth Lock explores the critical role of situation awareness and risk management in diving, emphasizing the importance of building accurate mental models to anticipate and manage potential hazards. He discusses how assumptions, experience, and training shape decision-making, and highlights the distinction between managing risks logically and addressing uncertainty through mental shortcuts and emotions. Gareth shares how The Human Diver promotes non-technical skills, psychological safety, and a Just Culture, fostering a learning approach to adverse events. With new programs and instructors worldwide, 2025 promises more opportunities to improve diving safety and teamwork. Original blog: https://www.thehumandiver.com/blog/making-sense-now   Links: DAN Southern Africa webinar: https://www.youtube.com/watch?v=TSeKQidAZZA&t=547s Upcoming Face to Face courses: https://www.thehumandiver.com/hfid-level-2#section-1637697699737   Tags:  English, Decision-Making, Gareth Lock, Situation Awareness

In this blog, Bart Den Ouden shares a personal experience highlighting the importance of psychological safety, vulnerability, and human factors in diving. While teaching a rebreather instructor course, Bart forgot a critical piece of equipment, turning the oversight into a teachable moment. He emphasizes that instructors, as humans, can make mistakes, and fostering open communication and trust among divers is essential for safety and learning. By reflecting on errors—intentional or accidental—divers can improve team dynamics, decision-making, and preparedness, creating safer environments for themselves and others. Original blog: https://www.thehumandiver.com/blog/checking_each_other   Tags:  English, Bart Den Ouden, CCR, Human Error, Leadership, Psychological Safety, Rebreather, Teamwork

The first-ever Human Factors in Diving Conference, held on September 24-25, 2021, brought together 27 speakers from around the world to explore the application of human factors, non-technical skills, Just Culture, and psychological safety in diving. Spanning nearly 25 hours of content over two days, the event showcased a global virtual conference model using the LexGo Live platform, with a focus on interactive and engaging experiences. Despite challenges with ticket sales, tight deadlines, and technical logistics, the conference provided invaluable insights and demonstrated the potential of human factors to enhance safety across recreational, military, commercial, and public safety diving. The event highlighted both the successes and lessons learned, paving the way for future efforts to bring this critical knowledge to the diving community. Original blog: https://www.thehumandiver.com/blog/acorn-to-conference   Links: Conference website: https://www.hf-in-diving-conference.com/ Youtube channel: https://www.youtube.com/@thehumandiver863 LexGo platform: https://www.lexgo.work/ Marketing advisors: https://www.linkedin.com/in/rosconkie/ and https://www.linkedin.com/in/mickeywilsonfirestarter/   Tags: English, Gareth Lock, Human Factors

Accidents in diving, and life, rarely stem from a single "root cause" but rather from a complex interplay of factors—technical skills, context, randomness, and non-technical skills like communication and decision-making. This episode explores how cognitive biases, such as the fundamental attribution error, often lead us to blame individuals rather than considering the broader system in which events unfold. Drawing parallels from diving, surgery, and other high-stakes environments, we discuss the importance of understanding the full context, embracing feedback, and focusing on interdependencies to improve safety and outcomes. Tune in to challenge your assumptions and expand your perspective on risk and decision-making. Original blog: https://www.thehumandiver.com/blog/the-root-cause-of-an-accident   Links: Fundamental attribution bias: https://gue.com/blog/the-role-of-agency-when-discussing-diving-incidents-an-adverse-event-occurs-an-instructor-makes-a-mistake/ The rise of human factors paper: https://europepmc.org/article/med/31183182#free-full-text   Tags:  English, Gareth Lock, Incident Investigation, Investigations

In this episode, Gareth Lock delves into the nature of human error, exploring concepts like slips, lapses, mistakes, and violations through the lens of safety research and diving experiences. Drawing on James Reason’s work, Gareth explains how understanding errors and violations—whether unintended or situational—can foster learning, reduce outcome bias, and improve safety systems. By openly discussing mistakes, instructors can lower authority gradients, increase psychological safety, and promote a Just Culture where errors are seen as opportunities for growth rather than blame. Tune in to learn how these principles apply to diving and beyond. Original blog: https://www.thehumandiver.com/blog/mistakes-errors-words-have-meaning   Tags: English, Decision Making, Gareth Lock, Human Error, Psychological Safety

In this episode, Gareth Lock explores the critical role of checklists in enhancing safety and reducing errors in high-risk environments like diving, surgery, and aviation. Drawing insights from Atul Gawande's The Checklist Manifesto, Gareth highlights how properly designed checklists can prevent lapses, improve communication, and establish a culture of accountability. Despite resistance from those who view checklists as unnecessary or a sign of weakness, evidence shows their ability to save lives by addressing "unknown unknowns" and mitigating human error. Gareth shares personal experiences and emphasizes the importance of embracing checklists to ensure safety, reliability, and performance in diving and beyond. Original blog: https://www.thehumandiver.com/blog/surgeons-and-checklists   Links: Downloads and Transcripts of Atul Gawande’s lectures: http://www.bbc.co.uk/programmes/b00729d9/episodes/player The problem with not using checklists: http://aerossurance.com/helicopters/habits-kill/ The Checklist manifesto: https://cognitasresearch.wordpress.com/2015/01/17/only-20-of-surgeons-would-like-to-use-a-checklist-in-their-operations/0px%20!important;%22%20/%3E NHS checklist: http://www.nrls.npsa.nhs.uk/resources/?entryid45=59860 DAN study: http://www.alertdiver.com/checklists Checklist design: http://ti.arc.nasa.gov/profile/adegani/procedure-design/ Chain of events of things going wrong (1): http://silentdiversion.blogspot.co.uk/2015/01/human-error-dont-blame-rebreather.html?spref=fb&m=1 (2): https://www.navytimes.com/news/your-navy/2018/06/05/navy-officer-35-dies-in-off-duty-diving-mishap/   Tags:  English, Checklists, Gareth Lock, Human Factors

In this episode, Bart Den Ouden reflects on the importance of mastering the basics before taking on advanced challenges, using ice diving as a vivid example. During a rare opportunity for ice diving in the Netherlands, Bart observed several instructors rushing into instructor-level ice diving certifications without adequate experience. Drawing parallels with the Dunning-Kruger effect and highlighting the risks of "unknown unknowns," he emphasizes the dangers of overconfidence and taking shortcuts in training. Bart challenges dive professionals to lead by example, prioritize safety, and ensure they truly earn their certifications, reminding us all to slow down and build skills step by step. Original blog: https://www.thehumandiver.com/blog/run-before-walk   Links: Micheal Thomas’ blog for TDI: https://www.tdisdi.com/tdi-diver-news/slow-down-young-fella-attitudes-in-technical-diving/ Dunning Kruger effect: https://vimeo.com/223029249   Tags:  English, Bart Den Ouden, Decision Making, Instruction, Leadership

In this episode, we explore the critical role of leadership and decision-making in diving safety, using a real-life story about a young instructor, “Jack,” who made a risky dive on a rebreather he wasn’t certified to use. Despite his confidence, Jack’s actions reflect dangerous cognitive biases like overconfidence, outcome bias, and normalization of deviance, shaped by a culture of cutting corners in his early training. Through this cautionary tale, we highlight the importance of setting the right example as dive leaders, understanding the consequences of our actions, and promoting a safety-first mindset. Tune in to learn why responsible leadership and listening to feedback are vital for creating a safer diving community. Original blog: https://www.thehumandiver.com/blog/lead-a-horse-to-water   Tags:  English, Bart Den Ouden, Decision Making, Situation Awareness

In this episode, we explore how listening to your inner voice can be a lifesaver, both in diving and everyday life. Bart Den Ouden shares his personal journey of uncovering severe heart issues despite passing regular diving medicals, emphasizing the importance of recognizing warning signs and overcoming cognitive biases like denial and confirmation bias. We also discuss a diver’s near-fatal experience with immersion pulmonary edema (IPO) and how quick action and a well-equipped facility saved their life. These stories highlight the critical role of self-awareness, preventative measures, and teamwork in planning to fail safely—whether under water or on land. Listen in to learn why trusting that “little voice” could be the key to staying alive. Original blog: https://www.thehumandiver.com/blog/plan-to-fail-safely-part-2-passing-the-test-doesn-t-say-it-all   Links: Angioplasty and Stent: https://www.nhs.uk/conditions/coronary-angioplasty/what-happens/ HSE Medical requirements: https://www.hse.gov.uk/diving/medical-requirements.htm IPO (IPE): http://www.ukdmc.org/medical-conditions/immersion-pulmonary-oedema/ BMJ article: https://heart.bmj.com/content/80/6/537 DAN article: https://www.diversalertnetwork.org/health/heart/cardiac-health   Tags:  English, Bart Den Ouden, Cognitive Biases, Decision Making, Medical

In this episode, we delve into risk management and decision-making in diving, exploring the difference between personal and professional responsibilities. Using a case of a divemaster tasked with guiding divers on a challenging wreck dive, we examine the complexities of managing hazards, understanding acceptable risks, and the impact of assumptions and biases. The conversation highlights the importance of preparation, critical thinking, and a proactive approach to safety, while acknowledging the challenges of balancing rules with real-world scenarios. Ultimately, we discuss how diving professionals can navigate these grey areas, fostering safer practices while maintaining the adventurous spirit of diving. Original blog: https://www.thehumandiver.com/blog/who-owns-the-risk-in-diving   Links: HSE Terms: https://www.hse.gov.uk/managing/theory/alarpglance.htm Normalisation of Deviance video: https://vimeo.com/174875861 Work as Imagined vs Work as Done: https://humanisticsystems.com/2016/12/05/the-varieties-of-human-work/   Tags:  English, Decision Making, Gareth Lock, Risk, Risk Management

In this episode, we explore the importance of preparing for failure in diving education, inspired by Hal Watts' quote: “The most dangerous thing about diving is divers themselves.” Using a real-life example from a scuba Instructor Examination, we highlight how training focused solely on passing exams can lead to complacency and poor decision-making in real-life scenarios. Diving instructors and trainers must teach students to plan for and respond to unexpected challenges safely. This involves reflecting on training methods, addressing blind spots, and fostering a mindset where failure becomes a learning opportunity, not a life-threatening event. Part 2 will delve deeper into personal strategies for planning to fail safely. Original blog: https://www.thehumandiver.com/blog/plan-to-fail-safely   Tags:  English, Dart Den Ouden, Instruction, Leadership

In this episode, we explore the dangers of "normalisation of deviance"—the gradual erosion of safety standards through repeated shortcuts—and its impact on rebreather diving and other high-risk activities. Drawing on lessons from aviation and diving, we discuss how human factors, cognitive biases, and systemic drift contribute to accidents, emphasizing that outcomes should not be the sole focus when analyzing incidents. Using models like the Swiss Cheese Model and concepts of systems thinking, we unpack how multiple, seemingly minor factors can align to create critical incidents. Learn how applying tools like checklists, audits, and effective debriefs can help mitigate these risks and maintain safety margins in diving and beyond. Original blog: https://www.thehumandiver.com/blog/one-mistake   Links: “If Only” documentary: https://www.thehumandiver.com/ifonly John Bantin’s Undercurrent article: https://www.undercurrent.org/blog/2020/06/01/the-tragic-and-un-necessary-death-of-brian-bugge/ Debrief model: https://www.thehumandiver.com/debrief Normalisation of Deviance: https://vimeo.com/174875861 Simple Swiss cheese model: https://vimeo.com/326723142 Big Hole animation: https://vimeo.com/326723122 Little Hole animation: https://vimeo.com/326723109 HSE report: https://www.hse.gov.uk/research/rrpdf/rr871.pdf   Tags:  English. CCR, Complacency, Decision Making, Gareth Lock, Human Factors, Rebreather

This episode dives into the critical role of human factors in safety, using a tragic aviation incident and its parallels in diving to illustrate how distractions, pressures, and systemic issues contribute to accidents. We explore how a Royal Air Force training film, "Distractions," highlighted the cumulative factors behind a hypothetical crash, emphasizing the need for shared responsibility in preventing errors. Similarly, the story of Brian Bugge's 2018 diving accident reveals the dangers of focusing solely on individual mistakes while overlooking the broader contributing factors. Accidents rarely result from a single error but emerge from a combination of conditions. By understanding these dynamics, we can better mitigate risks and improve safety in both aviation and diving. Original blog: https://www.thehumandiver.com/blog/outcomes-are-so-sexy   Links: “If Only” Documentary: https://www.thehumandiver.com/ifonly   Tags:  English, CCR, Checklists, Decision Making, Gareth Lock, If Only, Investigations, Rebreather

In this episode, a newly qualified Human Factors in Diving Instructor shares their journey of grappling with impostor syndrome and the challenges of teaching human factors to divers. Despite over a decade of diving instruction experience, they recount feeling inadequate compared to peers and doubting their knowledge, especially when students might view human factors as "common sense." Reflecting on the Dunning-Kruger effect, they explore how experts often underestimate their abilities because they understand the vastness of their field. Through conversations with peers and self-reflection, they learn to embrace the value they bring to the classroom and the importance of fostering curiosity in their students. Original blog: https://www.thehumandiver.com/blog/the-best-is-the-enemy-of-the-good   Tags:  English, Communications, Jenny Lord, Leadership, Teamwork

This episode dives into the critical importance of recognizing deviations from the norm in diving, a concept rooted in situational awareness. Inspired by the 1972 attack at Lod Airport, Bart den Ouden draws parallels between how assumptions can blind us and the role of training and experience in diving. By understanding what “normal” looks like, divers can detect and respond to unexpected changes. We explore mental models, decision-making under pressure, and the value of learning skills the right way to build a strong foundation. Tune in to learn why paying attention to the small details can make all the difference underwater! Original blog: https://www.thehumandiver.com/blog/predicitive-profiling   Links: Situational Awareness and Decision Making in Diving: https://gue.com/blog/situational-awareness-and-decision-making-in-diving/?fbclid=IwAR1Pq5eqIxWxcc0s1S2CoYefJgkWeXy_pUi8AsjQ8BoKSx-xKKXrLTPqleQ   Tags:  English, Bart Den Ouden, Decision Making

In this episode, we explore the pitfalls of blindly trusting technology through two cautionary tales—one about a GPS mishap in snowy Quebec and another about divers relying solely on their computers. Automation offers precision and convenience, but over-reliance can dull our awareness and problem-solving skills. We discuss how this applies to diving, where dive computers are invaluable but prone to errors if misconfigured or when they fail. Listeners will learn why it’s essential to combine technology with old-school skills, planning, and situational awareness to ensure safety. Embrace technology, but always have a backup plan!   Original blog: https://www.thehumandiver.com/blog/the-good-the-bad-the-ugly   Tags:  English, Decision Making, Helene Pellerin, Situational Awareness

In this episode, we explore how safety in diving is not just about avoiding accidents but about building systems that can fail safely. Drawing on a real-life incident shared by Phil Short, we examine how a small technical issue—debris in a rebreather valve—could have escalated into a life-threatening situation during a cave dive. We highlight the critical role of technical preparation, situational awareness, and non-technical skills like teamwork, leadership, and communication in managing and recovering from unexpected challenges. By sharing these stories, we aim to help divers understand how to plan for failures and enhance safety through learning, reflection, and a chronic unease about what could go wrong. Original blog: https://www.thehumandiver.com/blog/failing-safely-400m-back-in-a-cave   Links: How Safe is Your Diving blog: https://www.thehumandiver.com/blog/how-safe-is-your-diving   Tags:  English, CCR, Decision Making, Gareth Lock, Leadership, Non-Technical Skills, Teamwork

In this episode, we dive into the concept of psychological safety and its critical role in diving and team performance. Psychological safety, defined as a shared belief that it's safe to take interpersonal risks, enables people to ask questions, make mistakes, contribute ideas, and challenge the status quo without fear of judgment or reprisal. Drawing on insights from experts like Amy Edmondson and Dr. Timothy Clark, we explore its four stages: inclusion, learner safety, contributor safety, and challenger safety, with a focus on how each stage impacts divers, instructors, and teams. From life-or-death scenarios to fostering innovation, creating a culture of psychological safety can improve decision-making, teamwork, and training outcomes. Tune in to learn how to build this essential skill in your diving and beyond. Original blog: https://www.thehumandiver.com/blog/how-safe-is-your-diving   Links: If Only video: https://vimeo.com/382399090 Debrief guide: https://www.thehumandiver.com/debrief Psychological Safety and Learning Behaviour in Work Teams: http://web.mit.edu/curhan/www/docs/Articles/15341_Readings/Group_Performance/Edmondson%20Psychological%20safety.pdf High Performing Teams need Psychological Safety: https://liberationist.org/high-performing-teams-need-psychological-safety/ What Psychological Safety is not: https://qz.com/work/1470164/what-is-psychological-safety/   Tags:  English, Communication, Decision Making, Gareth Lock, Just Culture, Leadership, Teamwork

In this episode, we explore the double-edged nature of goal setting—how it drives achievement but can also lead to risky decisions when pressure and commitment override safety and judgment. Using examples from mountaineering and advanced diving, including a personal story about a challenging CCR trimix course, we delve into the concept of "destructive goal setting." The discussion highlights how external pressures and an unwillingness to abandon goals can cloud decision-making, and emphasizes the importance of open communication, team empowerment, and stepping back to reassess whether "the juice is worth the squeeze." Original blog: https://www.thehumandiver.com/blog/is-the-juice-worth-the-squeeze   Tags:  English, Cognitive Biases, Decision Making, Guy Shockey

In this episode, we explore the concept of counterfactual reasoning—our tendency to imagine how incidents could have been avoided by different actions—and why it falls short in improving safety. While this type of hindsight helps us feel better by creating a sense of order, it doesn’t address the real-world conditions or decisions that led to the incident. Instead of asking, "Why didn’t they do Y instead of X?" we should ask, "How did doing X make sense to them at the time?" By focusing on what actually happened and understanding the context, we can uncover valuable insights to improve safety and decision-making in diving. Original blog: https://www.thehumandiver.com/blog/counter-factuals   Tags:  English, Cognitive Biases, Decision Making, Gareth Lock, Incident Analysis

In this episode, we explore a personal account of a Gareth’s experience with decompression sickness (DCS) and the critical decision-making process that followed. The story dives into the internal monologue, biases, and stigmas surrounding DCS, highlighting how emotions and uncertainties influence risk-based decisions. We also examine industry practices, the importance of creating a psychologically safe culture for discussing incidents, and the need for better preparedness when things go wrong. This episode challenges listeners to reflect on their own decision-making and encourages a shift toward curiosity and learning in the diving community. Original blog: https://www.thehumandiver.com/blog/the-bend-is-uninteresting-the-related-decisions-are-much-more-so   Links: PACE model: https://gcaptain.com/graded-assertiveness-captain-i-have-a-concern/ Prospect Theory: https://www.jstor.org/stable/1914185 Blog about Normalisation of Deviance: https://www.thehumandiver.com/blog/being-a-deviant-is-normal Distancing through Differencing: https://www.researchgate.net/profile/David_Woods11/publication/292504703_Distancing_through_differencing_An_obstacle_to_organizational_learning_following_accidents/links/5742fb1808ae9ace8418b7ea/Distancing-through-differencing-An-obstacle-to-organizational-learning-following-accidents.pdf   Tags: English, Decision Making, Gareth Lock

In this episode, we explore Professor James Reason's Swiss Cheese Model, which helps explain how incidents occur when multiple safety barriers fail at different levels within a system. We discuss how organizational, supervisory, and individual errors can combine to create accidents, and how the holes in these barriers move and shift over time. Using dynamic models, we highlight that safety is an emergent property of a system, where small errors accumulate and can lead to larger, more significant failures. We also examine the role of human error, risk management, and attention to detail in preventing accidents and emphasize the complexity of real-world systems, where multiple factors often lead to a critical mass of failure before an incident happens. Original blog: https://www.thehumandiver.com/blog/when-the-holes-line-up   Links: Animated simple Swiss Cheese model: https://vimeo.com/326723142 Big Hole model: https://vimeo.com/326723122 Little Hole model: https://vimeo.com/326723109   Tags:  English, Gareth Lock, Human Factors, Incident Investigation

In this episode, we dive into the concept of "good enough" in diving and how it relates to decision-making, risk, and safety. We explore why terms like "safe" and "good" are subjective and often influenced by context, experience, and social pressures, rather than absolutes. Using real-life examples, we discuss how divers weigh trade-offs between efficiency and thoroughness, balancing time, money, and risk to make decisions in uncertain situations. By understanding the biases and constraints that shape our choices, we can better assess what "good enough" means in different scenarios and improve through shared stories and context-rich learning. Original blog: Spiderman drawing video: https://youtu.be/x9wn633vl_c Blog from Steve Shorrock: https://humanisticsystems.com/2016/12/05/the-varieties-of-human-work/ Efficiency-Thouroughness Trade Off: http://erikhollnagel.com/ideas/etto-principle/index.html Latent Pathogens from James Reason: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1117770/ Outcome bias: https://en.wikipedia.org/wiki/Outcome_bias   Tags: English, Gareth Lock

In this episode, we explore how decision-making under uncertainty plays a crucial role in scuba diving, drawing insights from Prospect Theory and real-life scenarios. We discuss how psychological factors, like loss aversion, influence divers to take risks they might otherwise avoid—whether it's diving with faulty gear after weeks of being unable to dive or dealing with pressures during high-profile expeditions. Highlighting examples from both individual dives and operational standards in dive centers, we examine the balance between minimizing loss and managing uncertainty. Finally, we emphasize the importance of teamwork, robust communication, and standardization to mitigate risks, ensuring safer and more informed diving decisions. Original blog: DOSPERT Study: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=1301089 Near death experience in Truk lagoon: https://www.scubaboard.com/community/threads/complacency-kills-its-not-just-an-empty-threat.567481/   Tags:  English, Decision Making, Gareth Lock, Human Factors, Risk

In this episode, we explore how risk is perceived and managed in diving, where emotions, biases, and mental shortcuts often outweigh logic and statistics. Diving fatalities are statistically rare, but those numbers don’t resonate emotionally—our decisions are more influenced by stories and personal experiences. Through real-life examples, we unpack biases like availability bias, outcome bias, and the “turkey illusion,” showing how these distort our understanding of risks. The discussion also highlights strategies for improving risk management, such as using checklists, planning and debriefing effectively, and sharing experiences to enhance collective learning. Join us to rethink how we approach uncertainty and decision-making in diving and beyond. Original blog: https://www.thehumandiver.com/blog/riskoffatality   Links: Fatalities COnference Procceedings: https://www.diversalertnetwork.org/files/Fatalities_Proceedings.pdf Numbers don;t have the same emotional relevance as stories: https://hbr.org/2003/06/storytelling-that-moves-people Risk of dying from a shark attack: https://www.floridamuseum.ufl.edu/shark-attacks/odds/compare-risk/death/ Behavioural economics: https://www.behavioraleconomics.com/resources/introduction-behavioral-economics/ Prospect theory: https://www.behavioraleconomics.com/resources/mini-encyclopedia-of-be/prospect-theory/ Video about normalisation of deviance: https://vimeo.com/174875861 4 T’s of risk management: https://www.facebook.com/groups/1612046102342961/permalink/2160646497482916/ How it makes sense for “stupid” decisions: https://www.facebook.com/gareth.lock.5/videos/10155465887236831/   Tags: English, Gareth Lock

How do you measure safety in diving? This episode dives into a real story of a dive team that adapted to an emerging safety risk when two divers, certified but inexperienced in drysuits and challenging conditions, showed signs of stress. Through situational awareness, communication, and teamwork, the team adjusted their plan, choosing a safer dive site where the less experienced divers could build confidence. The story highlights how safety isn’t about luck or strict rule-following but proactive decision-making and collaboration. We explore how divers can develop the skills to create safety and why “nothing happening” often means someone made it happen. Original blog: https://www.thehumandiver.com/blog/safety-is-nothingness   Tags:  English, Decision Making, Gareth Lock, Human Factors, Leadership, Safety, Teamwork

In this episode, we explore the decision-making challenges in diving, sharing a personal story of risky dives and lessons learned. A diver reflects on their early diving experiences, from breaking training depth limits to encountering equipment failures at 30m, and how a lack of knowledge and overconfidence contributed to risky choices. We discuss the importance of understanding context when evaluating incidents, avoiding hindsight bias, and learning from mistakes to improve safety. Diving involves inherent risks, but by fostering curiosity, sharing lessons, and acknowledging uncertainties, we can create a safer and more informed diving community. Original blog: https://www.thehumandiver.com/blog/responsible-but-not-informed   Tags:  English, Decision Making, Gareth Lock, Human Factors, Risk Management

In this episode, we dive into cognitive dissonance—the psychological discomfort of confronting facts that challenge our beliefs—and how it impacts decision-making and safety in diving. Drawing on insights from Black Box Thinking by Matthew Syed and examples from aviation, justice, and diving, we explore why even highly educated individuals can resist change to protect their reputation. From misconceptions about Nitrox and gas planning to biases in equipment and training preferences, we examine common examples in diving and discuss how human factors can improve safety. We also share practical steps to reduce cognitive dissonance, embrace learning from failure, and foster open-mindedness in the diving community. Original blog: https://www.thehumandiver.com/blog/cognitive-dissonance   Links: Ditching in the Hudson of Cactus 1549: https://en.wikipedia.org/wiki/US_Airways_Flight_1549 Story about cult foollowers expecting a UFO: https://www.minnpost.com/second-opinion/2011/04/when-facts-fail-ufo-cults-birthers-and-cognitive-dissonance “Unintended co-ejaculators”: https://ethicsunwrapped.utexas.edu/cognitive-dissonance-case-unindicted-co-ejaculator Examples of cognitive dissonance: https://en.wikipedia.org/wiki/Cognitive_dissonance   Tags:  English, Decision Making, Gareth Lock, Human Factors

In this episode, we explore the gap between knowledge and action, focusing on how even small, intentional changes can lead to significant improvements in safety and performance. Drawing from examples like the WHO Safe Surgical Checklist and lessons from diving, we highlight the importance of applying what we know—whether through simple tools like checklists and debriefs or by understanding decision-making and systemic issues. Alongside a personal story about working with a coach to turn knowledge into impactful action, we challenge listeners to reflect: what will you do to turn your insights into meaningful change? Original blog: https://www.thehumandiver.com/blog/anotherbrickinthewall   Links: CAP 737 http://publicapps.caa.co.uk/modalapplication.aspx?appid=11&mode=detail&id=6480 IOGP Doc 502 https://www.iogp.org/bookstore/product/guidelines-for-implementing-well-operations-crew-resource-management-training/ Non-technical skills for surgeons: https://www.rcsed.ac.uk/professional-support-development-resources/learning-resources/non-technical-skills-for-surgeons-notss The Castle: http://www.thisiscolossal.com/2018/02/the-castle-by-jorge-mendez-blake/ World Health Organisation Safe Surgical Checklist: https://www.nejm.org/doi/full/10.1056/NEJMsa0810119 Semmelweis: https://en.wikipedia.org/wiki/Ignaz_Semmelweis Distancing through differencing: https://www.researchgate.net/publication/292504703_Distancing_through_differencing_An_obstacle_to_organizational_learning_following_accidents   Tags:  English, Decision-Making, Gareth Lock, Human Factors, Non-Technical Skills

In this episode, we delve into the complexities of managing risk and uncertainty in diving, challenging the notion that accidents are "entirely predictable." Unlike measurable risks, diving involves countless variables that create uncertainty, often managed through mental shortcuts and biases. We discuss how hindsight bias, overconfidence, and peer pressure can cloud judgment, leading to poor decisions. Effective feedback, teamwork, and tools like checklists can reduce uncertainty, while debriefs and learning from others’ mistakes are crucial for improvement. Tune in to explore how divers can navigate uncertainty to enhance safety and performance in this high-stakes environment. Original blog: https://www.thehumandiver.com/blog/uncertainty-vs-predictable   Links: Risk vs Uncertainty: http://www.mindtherisk.com/literature/67-risk-savvy-by-gerd-gigerenzer Thinking, Fast and Slow: https://en.wikipedia.org/wiki/Thinking,_Fast_and_Slow Blog about the Dunning Kruger effect: https://www.thehumandiver.com/blog/incompetent-and-unaware-you-don-t-know-what-you-don-t-know Blog about biases: https://www.humaninthesystem.co.uk/blog/i-am-biased-you-are-biased-we-are-all-biased   Tags:  English, Decision Making, Gareth Lock, Risk

The diving industry faces challenges in maintaining high safety standards due to a lack of effective feedback mechanisms and a fear of reprisal for reporting substandard practices. Feedback is essential for improving performance and preventing dangerous "normalization of deviance," but it’s often viewed as blame rather than an opportunity for learning. Without proper acknowledgment or action from agencies, divers and instructors lose trust in the system, leading to fewer reports and greater risks. To protect the self-regulating nature of the industry, the community must embrace constructive feedback, report unsafe practices, and demand accountability from agencies to ensure safety and uphold standards. Original blog: https://www.thehumandiver.com/blog/standard-you-accept   Links: Blog about normalisation of deviance: https://www.thehumandiver.com/blog/being-a-deviant-is-normal Willful blindness: https://www.ted.com/talks/margaret_heffernan_the_dangers_of_willful_blindness ​Case study from healthcare in the US: https://news.aamc.org/patient-care/article/best-response-medical-errors-transparency/   Tags:  English, Gareth Lock, Just Culture, Reporting

When discussing diving incidents, it’s vital to shift away from blame and hindsight bias and instead foster a culture of open dialogue to understand why decisions made sense at the time. Often, divers are doing their best with the resources, training, and information available, but situational awareness and decision-making are shaped by incomplete data, personal experience, and environmental factors. Criticism without context or constructive feedback doesn’t improve safety or learning; instead, it deters people from sharing critical insights. By embracing a "just culture," the diving community can better explore the underlying factors behind incidents, address systemic issues, and create meaningful opportunities for growth and safety improvement. Original blog: https://www.thehumandiver.com/blog/cannot-improve-do-not-understand   Links: Report of the death of CCR diver: https://cognitasresearch.files.wordpress.com/2015/05/dillon-2015-findings-in-the-inquest-into-the-death-of-philip-gray.pdf   Tags: English, Gareth Lock, Just Culture ​​

Safety in diving is not a standalone priority but one of many factors, including time, money, resources, and productivity, that individuals and organizations must balance in a dynamic environment. Safety is best understood as reducing risk to an "acceptable level," but defining what is acceptable can be complex and context-dependent. Using principles like ALARP (As Low As Reasonably Practicable), risk is mitigated until further reduction becomes disproportionately expensive or impractical. Both training organizations and divers face trade-offs between safety and competing priorities, which can shift depending on circumstances. Divers must critically assess their own safety standards and weigh the effort, time, and money required to mitigate risks, understanding that "safety" is a shared responsibility within the larger system of diving. Ultimately, improving safety requires self-awareness, courage, and a commitment to learning from near-misses and incidents. Original blog: https://www.thehumandiver.com/blog/safetyisnot_the_priority   Links: ICAO Safety Management Manual: https://www.icao.int/safety/SafetyManagement/Documents/Doc.9859.3rd%20Edition.alltext.en.pdf Royal Sociecty Risk Assessment report: https://books.google.co.uk/books/about/Risk_Assessment.html?id=LRcmQwAACAAJ&redir_esc=y John Adams book ‘Risk’: http://www.john-adams.co.uk/wp-content/uploads/2017/01/RISK-BOOK.pdf Efficiency-Throughouness Trade Off: http://erikhollnagel.com/ideas/etto-principle/index.html] Work as Imagined/Work as Done: https://www.thehumandiver.com/blog/what-does-human-factors-in-diving-mean Cognitive biases: https://www.thehumandiver.com/blog/17-cognitive-biases   Tags:  English, Gareth Lock, Human Factors, Safety

Human factors in diving encompass everything from individual behavior to the interaction between divers, technology, and organizational systems. This podcast dives into the complexities of human factors, exploring how they influence safety, performance, and decision-making. Topics include cognitive biases, stress, and fatigue, as well as the gap between "Work as Imagined" and "Work as Done." We also discuss the importance of Crew Resource Management (CRM) and Non-Technical Skills (NTS) in improving team dynamics and situational awareness, even in solo diving. Additionally, we touch on the lack of formal human factors standards in diving and the need for better incident reporting systems. Finally, we highlight practical approaches to training, such as effective pre-dive briefs, debriefs, and feedback mechanisms, to help divers and instructors foster safer, more adaptive practices. Original blog: https://www.thehumandiver.com/blog/what-does-human-factors-in-diving-mean   Links: Steven Shorrocks blogs about the four parts of Human Factors:  ​​ Tags: English, Gareth Lock, Human Factors

This podcast explores the limitations of attributing diving accidents to "human error," a reductionist explanation that fails to address the complexities of real-world decision-making and system failures. By examining a case study involving oxygen toxicity during a rebreather dive, the episode delves into how biases, situational awareness, and flawed mental models contribute to adverse events. It highlights the importance of understanding the context behind decisions, recognizing that divers rarely intend to put themselves or others at risk. Drawing parallels with aviation and other industries, the podcast advocates for systemic changes, better training, and a culture of learning to enhance safety, rather than placing blame. Original blog: https://www.thehumandiver.com/blog/why-human-error-is-a-poor-term Links: Animated Swiss cheese model: https://vimeo.com/249087556 References:1.        Bierens, J. Handbook on drowning: Prevention, rescue, treatment. 50, (2006). 2.        Denoble, P. J. Medical Examination of Diving Fatalities Symposium: Investigation of Diving Fatalities for Medical Examiners and Diving. (2014). 3.        Denoble,  PJ, Caruso,  JL, de Dear,  GL, Pieper,  CF & Vann,  RD. Common causes of open-circuit recreational diving fatalities. Undersea Hyperb Med 35, 393–406 (2008). 4.        Parry, G. W. Human reliability analysis—context and control By Erik Hollnagel, Academic Press, 1993, ISBN 0-12-352658-2. Reliability Engineering & System Safety 99–101 (1996). doi:10.1016/0951-8320(96)00023-3 5.        Reason, J. T. Human Error. (Cambridge University Press, 1990). 6.        Phipps, D. L. et al. Identifying violation-provoking conditions in a healthcare setting. Ergonomics 51, 1625–1642 (2008). 7.        Dekker, S. The Field Guide to Understanding Human Error. 205–214 (2013). doi:10.1201/9781315239675-20 8.        Endsley,  MR. Toward a theory of situation awareness in dynamic systems. Human Factors: The Journal of the Human Factors and Ergonomics Society 37, 32–64 (1995). 9.        Klein,  GA. Streetlights and shadows: Searching for the keys to adaptive decision making. (2011). 10.      Amalberti,  R, Vincent,  C, Auroy,  Y & de Maurice, S. G. Violations and migrations in health care: a framework for understanding and management. Quality & safety in health care 15 Suppl 1, i66–71 (2006). 11.      Cook,  R & Rasmussen,  J. ‘Going solid’: a model of system dynamics and consequences for patient safety. Quality & safety in health care 14, 130–134 (2005). 12.      Woods,  DD & Cook,  RI. Mistaking Error. Patient Safety Handbook 1–14 (2003). Tags: English, Gareth Lock, Human Error

In this episode, we explore a diving incident that highlights the critical importance of understanding human factors in high-risk activities like technical diving. A diver survived an oxygen toxicity seizure thanks to her buddy's quick thinking, but the investigation revealed a web of human errors, from outdated equipment to flawed decision-making. We discuss the lessons learned, the role of human variability in performance, and how other industries like aviation and healthcare have transformed safety through Crew Resource Management (CRM). Diving’s focus on technical skills often overlooks the human element—decision-making, communication, and teamwork—that can make or break a dive. Tune in to learn how adopting these skills can enhance safety, performance, and the culture of diving. Original blog: https://www.thehumandiver.com/blog/stop-making-stupid-mistakes   Tags:  English, Gareth Lock, Human Factors

Effective communication is critical for safety and performance in diving, yet many divers struggle to speak up due to fear of judgment, peer pressure, or an adversarial culture. This silence can lead to mistakes, unreported incidents, and missed opportunities for improvement. Leaders at all levels play a vital role in fostering open dialogue by responding to mistakes constructively, avoiding blame, and creating trust. Self-awareness, humility, and a willingness to learn are key traits for maintaining open communication. By embracing these principles and shifting focus from blame to learning, divers and teams can enhance safety, build stronger relationships, and achieve high performance. Original blog: https://www.thehumandiver.com/blog/nine-ways   Links: Blog about peer pressure: https://www.thehumandiver.com/blog/why-is-it-so-hard-to-thumb-a-dive-or-end-something-that-you-have-committed-to Blog about leadership: https://www.thehumandiver.com/blog/leadershipindiving   Tags:  English, Communications, Gareth Lock, Leadership, Teamwork

Cognitive biases and mental shortcuts significantly impact decision-making, especially in high-risk environments like diving, where errors can have critical or fatal consequences. Factors such as narcosis, reduced visibility, and altered sound perception exacerbate these biases, distorting reality and affecting safety. Common biases include anchoring, overconfidence, and confirmation bias, each influencing risk perception and decision-making in unique ways. Awareness and mitigation of these biases are vital, achieved through strategies like education, training, crew resource management, and system changes to reduce reliance on human behavior alone. Understanding these factors is essential to improving safety and preventing incidents often attributed to "human error." Original blog: https://www.thehumandiver.com/blog/17-cognitive-biases   Links: Types of cognitive bias: https://www.thehumandiver.com/blog/i-am-biased-you-are-biased-we-are-all-biased Normalisation of deviance blog: https://www.thehumandiver.com/blog/being-a-deviant-is-normal Dunning-Kruger effect blog:  ​​https://www.thehumandiver.com/blog/incompetent-and-unaware-you-don-t-know-what-you-don-t-know   Tags: English, Gareth Lock ​​

This episode explores the complexities of human error in diving incidents, challenging the oversimplified blame often placed on individuals. Drawing on James Reason’s Swiss Cheese Model, we examine how both active failures (individual actions) and latent conditions (systemic weaknesses) contribute to accidents. We also discuss cognitive biases, such as hindsight and outcome bias, that hinder objective learning from incidents. By shifting focus from blame to systemic improvement, fostering accountability without shame, and continuously reforming processes, we can better manage errors and enhance safety. Tune in to rethink “human error” and embrace a systems approach to diving performance. Original blog: https://www.thehumandiver.com/blog/human-error-in-diving-is-it-really-that-simple   Links: Shappell and Weigmann’s HFACS model: https://www.skybrary.aero/index.php/Human_Factors_Analysis_and_Classification_System_(HFACS) Animated Swiss cheese model: https://vimeo.com/249087556 James Reason, Managing Maintainence Error: https://www.amazon.co.uk/gp/search/ref=sr_adv_b/?field-title=Managing%20Maintenance%20Error&search-alias=stripbooks&unfiltered=1   Tags:  English, Gareth Lock, Human Error, Human Factors

This episode dives into the importance of investing in skills and experience to prepare for unexpected challenges in diving and life. Using an analogy of red and white blood cells, we explore the balance between productivity and response readiness, emphasizing why both are essential. Drawing lessons from Captain Sullenberger’s emergency landing on the Hudson River, we highlight the value of deliberate practice, teamwork, and situational awareness. By learning from our own experiences and others’ stories, we can improve decision-making and be better equipped to handle ambiguity, uncertainty, and complexity. Are you ready to invest in your “bank of experience”? Original blog: https://www.thehumandiver.com/blog/blood-banks-diving   Tags:  English, Decision Making, Gareth Lock, Human Factors, Risk

This episode explores the critical role of leadership in diving, drawing on a challenging night dive on the Abu Nuhas reef and lessons from military aviation. The dive highlighted the importance of accountability, planning, and adapting leadership styles to the situation. Diving lacks formal leadership training, yet all divers—from instructors to dive center managers—play leadership roles. Drawing inspiration from a Marine Corps officer’s letter, we discuss core leadership values such as professional hunger, focus, attitude, moral courage, and dedication. These values, combined with structured debriefs and continuous learning, are essential for fostering safety, excellence, and teamwork in diving. Original blog: https://www.thehumandiver.com/blog/leadershipindiving   Links: Blog about deviation:  ​​”Leaders in learning mode develop stronger skills than their peers”: https://hbr.org/2017/08/good-leaders-are-good-learners   Tags:  English, Gareth Lock, Human Factors, Leadership, Teamwork

This episode dives into the lessons the diving community can learn from aviation safety practices, using the near-disaster of Air Canada Flight AC759 at San Francisco Airport as a starting point. In aviation, near-misses are thoroughly investigated to uncover systemic issues rather than just individual mistakes, fostering a culture of learning and improvement. By contrast, the diving industry often discourages open discussions about close calls due to fear of criticism or legal consequences, hindering collective growth. We explore how a shift toward non-judgmental analysis and systemic thinking could enhance safety in diving, encouraging shared learning from mistakes and near-misses to prevent future incidents. Original blog: https://www.thehumandiver.com/blog/aviation-diving-errors   Links: Mercury News report: http://www.mercurynews.com/2017/08/02/ntsb-finds-blind-spot-in-sfo-radar-following-air-canada-near-disaster/   Tags: English, Gareth Lock, Human Factors

In this episode, we explore how authority gradients—the imbalance of power or experience between individuals—can lead to critical mistakes in diving and other high-stakes environments. Drawing lessons from aviation, medicine, and real-world diving incidents, we discuss how the fear of questioning a more experienced person can prevent vital safety concerns from being raised. Whether it's a student diver hesitant to challenge their instructor or a junior crew member in aviation unable to assert their concerns, the consequences can be life-threatening. We highlight the importance of fostering open communication, psychological safety, and mutual accountability to prevent errors and improve safety across all levels of experience. Original blog: https://www.thehumandiver.com/blog/the-power-of-one   Links: Wrong site surgery: http://www.newstatesman.com/2014/05/how-mistakes-can-save-lives Pan Am/KLM accident: https://www.skybrary.aero/index.php/B742_/_B741,_Los_Rodeos_Tenerife,_1977_(RI_AGC_WX) Landing gear light problem: https://en.wikipedia.org/wiki/United_Airlines_Flight_173 Crew Resource Management: https://publicapps.caa.co.uk/docs/33/CAP720.PDF Non-Technical Skills: https://www.rcsed.ac.uk/professional-support-development-resources/learning-resources/non-technical-skills-for-surgeons-notss Human Factors skills in Diving: https://www.thehumandiver.com/   Tags: English, Gareth Lock