SH190: You can't learn from adverse events if you are going to blame

In this episode, we explore the role of punishment in learning and accident investigations, challenging the idea that punishment fosters accountability or safety. Drawing from research by Heraghty, Dekker, and Rae, we discuss how punishment often stifles honesty, trust, and meaningful learning by creating a culture of fear. Using real-world examples, like a tragic drysuit diving accident and the grounding of a liveaboard vessel, we examine systemic issues that contribute to failures and how biases like hindsight and severity affect our responses. Instead of focusing on blame, we advocate for systemic, science-based approaches to foster psychological safety, support accountability, and promote learning to prevent future incidents.

Original blog: https://www.thehumandiver.com/blog/blame-or-learn

 

Links: Modifying an accident process and its justice system: https://www.sciencedirect.com/science/article/abs/pii/S092575352100093X?via%3Dihub

Punishment doesn’t change behaviours associated with errant behaviours: https://www.simplypsychology.org/operant-conditioning.html

Managing accidents using retributive justice mechanisms: https://www.sciencedirect.com/science/article/abs/pii/S0925753520300746?via%3Dihub

Linnea Mills case: https://divernet.com/scuba-news/12m-lawsuit-follows-suit-squeeze-death/

Mission Improbable: Using Fantasy Documents to Tame Disaster: https://www.jstor.org/stable/3791858?seq=1

The likelihood of drift: https://www.thehumandiver.com/blog/being-a-deviant-is-normal

Modifying an accident process and its justice system: https://www.sciencedirect.com/science/article/abs/pii/S092575352100093X?via%3Dihub

CIEHF Guide to Learning from Adverse Events: https://ergonomics.org.uk/resource/learning-from-adverse-events.html

Socorro Vortex grounding: https://www.deeperblue.com/socorro-vortex-liveaboard-runs-aground/

Report from the Danish MAritime Accident Investigation Board: https://dmaib.com/reports/2021/beaumaiden-grounding-on-18-october-2021/

Cognitive biases that limit learning: https://gue.com/blog/drift-is-normal-being-a-deviant-is-normal-heres-why/

Identifying error prone or error producing conditions: https://www.thehumandiver.com/blog/human-error-in-diving-is-it-really-that-simple

Stoney Cove “Safety Stop” case: https://divernet.com/scuba-diving/diving-instructor-cleared-in-safety-stop-death-case/

Sidney Dekker’s Restorative Just Culture Checklist: https://drive.google.com/file/d/1Vkg0o4Fc8XWsAul-mkXNqD5lwokQ0ntP/view?usp=sharing

 

Tags:  English, Gareth Lock, Incident Analysis, Incident Investigation, Incident Reporting, Just Culture, Leadership, Psychological Safety