SH196: They broke the rules! So...?

When diving accidents occur, the immediate response often blames rule-breaking, but reality is far more complex. Rules are designed to enhance safety, yet accidents can happen even when rules are followed—and sometimes rules are broken without incident. Diving operations occur within a web of technical, social, and cultural conditions, which can provoke deviations. This highlights the gap between “work as imagined” (rules and procedures) and “work as done” (real-world practice). Understanding why rules are broken requires looking at the system rather than focusing solely on individuals. A Just Culture, where context-rich stories can be shared without fear of punishment, helps address underlying issues and drives meaningful improvements in safety. Punishment alone rarely deters rule-breaking if systemic conditions remain unchanged.

Original blog: https://www.thehumandiver.com/blog/they-broke-the-rules

 

Links: Root Cause blog: https://www.thehumandiver.com/blog/the-root-cause-of-an-accident

Identifying violation-provoking conditions in a healthcare setting: https://pubmed.ncbi.nlm.nih.gov/18941971/

The Extent of Conditions: https://preaccidentpodcast.podbean.com/e/papod-399-the-extent-of-condition-episode/

Normalisation of Deviance from the Challenger launch decision: https://www.amazon.co.uk/Challenger-Launch-Decision-Technology-Deviance/dp/0226851761

 

Tags:  English, Decision-Making, Gareth Lock, Just Culture, Normalisation of Deviance, Normalization of Deviance