Counter-Errorism in Diving: Applying Human Factors to Diving

In this podcast episode, we explore the challenge of bringing about change, emphasizing the importance of recognizing value in stories. Three compelling examples are discussed: a near-fatal diving incident due to an oxygen mix-up, a media company's critical review of a faulty rebreather incident, and a rural Indian village adopting latrines after witnessing the consequences of unhygienic practices. The central theme revolves around the need for reflection to identify similarities and conditions leading to outcomes, rather than focusing solely on differences. The episode poses questions about trust in established practices, the depth of evidence required for change, and the factors hindering it. The diving industry's reliance on compliance and resistance to a Just Culture are highlighted, emphasizing the necessity of investing in continuous learning and applying human factors for lasting improvement. The podcast encourages listeners to move beyond identifying lessons to implementing meaningful changes for genuine learning. Original blog: https://www.thehumandiver.com/blog/learning-from-stories-isn-t-easy-here-s-why   Links: Look at the conditions, not the outcomes: https://www.thehumandiver.com/blog/don-t-just-focus-on-the-errors Article by Dan Heath on LinkedIn about trying to bring latrines to rural Indian villages: https://www.linkedin.com/pulse/you-can-change-anyones-mindif-help-them-trip-over-truth-dan-heath/ The status quo is good enough blog: https://www.thehumandiver.com/blog/status-quo Compliance provides an illusion of safety blog: https://gue.com/blog/compliance-provides-an-illusion-of-safety-in-diving/ Compliance provides an illusion of safety video: https://www.youtube.com/watch?v=VNhmxz2_adc Were you lucky or were you good blog: https://www.thehumandiver.com/blog/were-you-lucky-or-were-you-good-2   Tags: English, Debrief, Decision Making, Gareth Lock, Learning, LFUO

Dive into the world of diving safety with insights from Gareth's blog on counterfactuals in this podcast episode. Jenny tackles common but unhelpful statements following accidents, such as "They should have paid more attention" and "They lacked situation awareness." The episode explores practical strategies for divers, focusing on increasing capacity and directing attention effectively. She emphasizes the importance of making diving processes automatic and shares tips on self-assessment for skill readiness. The episode also covers the nuances of prioritizing attention to elements like mindset, buoyancy, and gas supply, offering a comprehensive guide for safer and more enjoyable diving experiences. The summary highlights the significance of practice, experience, and slowing down to build expertise in underwater environments. Original blog: https://www.thehumandiver.com/blog/unleashing-your-sixth-sense   Links: Gareths blog about counterfactuals: https://www.thehumandiver.com/blog/counterfactuals   Tags:  English, Jenny Lord, Situation Awareness, Situational Awareness

In this podcast episode, Jenny shares a humorous yet insightful experience from assessing an instructor course, highlighting the common issue of miscommunication. The example involves a diver misinterpreting hand signals during a training exercise, leading to an unexpected outcome. She explores the challenge of ensuring clear communication, emphasizing the responsibility of the communicator to provide sufficient information. The episode introduces the concept of closed loop communications as a way to check assumptions and ensure understanding, especially in underwater scenarios where verbal communication is limited. Cultural behavior and the importance of avoiding condescension in communication are also discussed. Jenny acknowledges the inevitability of miscommunication due to our natural inclination to be efficient and make assumptions, concluding with a humorous reference to the challenges of explaining every detail, especially for those with young children. The show notes include a link to a video that further explains the efficiency aspect of communication. Original blog: https://www.thehumandiver.com/blog/lost-in-translation   Links: Video about explaining every step of a process: https://www.youtube.com/watch?v=cDA3_5982h8   Tags:  English, Communication, Jenny Lord

In this podcast episode, we explore a diving incident where two divers entered a wreck without laying a line, resulting in a challenging situation inside a room. We reflect on common responses that often follow such incidents, emphasizing the limitations of retrospective counterfactuals, where people tend to say what the divers "should have," "could have," or "would have" done differently. The episode discusses biases and the importance of understanding the local rationality of those involved, urging listeners to consider the perspectives of the divers at the time. Gareth provides insights into various factors affecting decisions, such as training availability, financial constraints, and the emotional significance of past experiences. The episode concludes by highlighting the prevalence of counterfactuals in discussions about incidents and encourages listeners to approach learning from adverse events with an open mind, understanding the complexity and challenges involved in change. Original blog: https://www.thehumandiver.com/blog/counterfactuals   Links: The power of hindsight blog: https://www.thehumandiver.com/blog/joining-dots-is-easy-if-you-know-the-outcome Hindsight bias blog: https://www.thehumandiver.com/blog/its-obvious-why-it-happened We can’t pay more attention blog: https://www.thehumandiver.com/blog/cant_pay_MORE_attention Balasore train crash news report 1: https://indianexpress.com/article/india/odisha-accident-wrong-labelling-of-location-box-wires-led-to-mix-up-crs-report-8699655/ Balasore train crash news report 2: https://thewire.in/law/cbi-arrests-three-railway-employees-for-balasore-train-tragedy   Tags: English, Cognitive Biases, Counterfactuals, Decision Making, Hindsight Bias, Incident Analysis, Just Culture

In this podcast episode, we explore the profound wisdom encapsulated in various quotes about learning from mistakes. Quotations from figures like Oscar Wilde, Samuel Levenson, and Mary Tyler Moore emphasize the importance of embracing errors as opportunities for growth. The discussion delves into the challenge of learning from near-misses and the cognitive biases, such as the outcome bias, that hinder our ability to reflect on decision-making. Using the context of diving safety, Gareth highlights the significance of focusing on contributory factors rather than just outcomes when analyzing incidents. The episode emphasizes that true learning involves change and recounts a personal experience in a diving safety review, highlighting the crucial difference between lessons identified and lessons learned. The importance of reflection in activities like diving is stressed, and a four-question post-activity debrief model is shared. The episode concludes by distinguishing between types of errors – mistakes, slips, and lapses – and underscores the need for understanding the context surrounding these events for effective learning. The concept of psychological safety and Just Culture is introduced, highlighting the necessity of creating an environment where learning from mistakes is encouraged. The summary encourages listeners to recognize that merely focusing on outcomes without understanding the context may hinder the learning process, emphasizing that true learning involves embracing change. Original blog: https://www.thehumandiver.com/blog/you-need-more-than-mistakes-to-learn   Links: The difficulty in learning from near misses: https://www.thehumandiver.com/blog/were-you-lucky-or-were-you-good-2 The difference between mistakes, slips, and lapses: https://www.thehumandiver.com/blog/mistakes-errors-words-have-meaning Looking at conditions, not just outcomes: https://www.thehumandiver.com/blog/don-t-just-focus-on-the-errors Stages of psychological safety blogs: https://www.thehumandiver.com/blog/team-building-psych-safety-1 https://www.thehumandiver.com/blog/team-building-psych-safety-2 https://www.thehumandiver.com/blog/team-building-psych-safety-3 https://www.thehumandiver.com/blog/team-building-psych-safety-4 Just Culture video: https://vimeo.com/410128892?share=copy   Tags:  English, Debrief, Decision Making, Gareth Lock, Psychological Safety, Teamwork

In this podcast episode, Gareth reflects on the challenges of learning from near-misses, particularly in the context of recent tragic events involving the loss of the Titan submersible. The episode explores the biases that hinder our ability to analyze and learn from incidents, emphasizing the complexities of socio-technical systems and the difficulties in replicating conditions for learning. Drawing parallels with diving, Gareth discusses the dynamic nature of risks, the fallacy of binary safety assessments, and the importance of recognizing uncertainties. The episode delves into cognitive biases, heuristics, and psychological factors influencing decision-making, shedding light on the sunk cost fallacy, prospect theory, and the local rationality principle. It advocates for a culture of learning, critical debriefs, and the application of human factors principles in diving. Ultimately, the episode encourages listeners to approach incidents with curiosity, suspend judgment, and seek to understand the local rationality of those involved. The tragic loss of the Titan submersible serves as a poignant reminder of the imperative to learn and improve safety in complex systems. The episode concludes by honoring the lives lost in the incident. Original blog: https://www.thehumandiver.com/blog/its-obvious-why-it-happened   Links: How Near-Misses Influence Decision Making Under Risk: A Missed Opportunity for Learning: https://pubsonline.informs.org/doi/10.1287/mnsc.1080.0869 If we want to learn, notice the conditions, not the outcomes: https://www.thehumandiver.com/blog/don-t-just-focus-on-the-errors AccipMap: https://linkinghub.elsevier.com/retrieve/pii/S000368701730100X DMAIB report: https://dmaib.com/reports/2021/beaumaiden-grounding-on-18-october-2021/ Implications for hindsight bias: https://www.semanticscholar.org/paper/Perspectives-on-Human-Error%3A-Hindsight-Biases-and-Woods/d913cdeae4e2782881a52e635e06c208b0796aed If the adverse event occurs in an uncertain or unusual environment, then we are more likely to judge it more harshly: http://journals.sagepub.com/doi/10.1177/0146167292181012 Five principles behind High-Reliability Organisations (HRO): https://www.high-reliability.org/faqs?_gl=1*j0ylqo*_ga*NDkyNjExMzA3LjE2ODc2Nzc2NTI.*_ga_TM3DC1EMKK*MTY4NzY3NzY1MS4xLjEuMTY4NzY3OTI2OC4wLjAuMA.. Prospecive hindsight/Pre-mortems: https://www.thehumandiver.com/blog/how-to-help-correct-the-biases-which-lead-to-poor-decision-making Red Team Thinking: https://www.redteamthinking.com/ Guy’s blog, Is the Juice Worth the Squeeze?: https://www.thehumandiver.com/blog/is-the-juice-worth-the-squeeze Doc Deep’s final dive: https://gue.com/blog/i-trained-doc-deep/ Single and Double Loop learning: https://hbr.org/1977/09/double-loop-learning-in-organizations Columbia Accident Investigaion Board: https://govinfo.library.unt.edu/caib/news/report/pdf/vol1/chapters/chapter8.pdf New ways to learn from the Challenger disaster: https://dx.doi.org/10.1109/aero.2015.7118898 Drop your Tools: http://www.jstor.org/stable/2393722 Availability, Representativeness & Adjustment and Anchoring: https://www2.psych.ubc.ca/~schaller/Psyc590Readings/TverskyKahneman1974.pdf Trieste record breaking dive: https://www.usni.org/magazines/proceedings/2020/january/first-deepest-dive Resources from RF4 presentation: https://bit.ly/rf4-resources Psychological safety, Tom Geraghty’s site: https://psychsafety.co.uk/ Normal Accidents: https://en.wikipedia.org/wiki/Normal_Accidents Tags:  English, Decision Making, Gareth Lock, Human Factors, Incident Investigation

In this podcast episode, Gareth delves into the concept of near-misses in diving, exploring the two categories: those that "could happen" and those that "almost happened." The distinction lies in background risks versus perceived risks influenced by cognitive biases. The episode draws parallels with real-world examples, such as the normalization of risks in the space shuttle Columbia tragedy. Three dive scenarios are presented, examining the outcomes and whether the participants were lucky or skilled. The discussion emphasizes the impact of successful near-misses on risk perception, leading to potential complacency. The episode concludes with insights into mitigating these issues, promoting counterfactual thinking, and stressing the importance of effective debriefs to enhance learning from near-misses. The audience is encouraged to reflect on successful outcomes and consider whether they were lucky or good in order to improve diving practices. Original blog: https://www.thehumandiver.com/blog/were-you-lucky-or-were-you-good-2   Links: Normalisation of Deviance blog: https://www.thehumandiver.com/blog/normalisation-of-deviance-not-about-rule-breaking Debrief model: https://www.thehumandiver.com/debrief How Near-Misses Influence Decision Making Under Risk: A Missed Opportunity for Learning. Dillon & Tinsley, 2008: https://pubsonline.informs.org/doi/10.1287/mnsc.1080.0869   Tags:  English, Decision Making, Gareth Lock, Normalisation of Deviance, Risk Management

In this podcast episode, Gareth recounts the experience of an experienced cave diver during what was intended to be a routine sidemount dive. Despite their expertise and previous successful dives, this particular excursion took an unexpected turn, prompting reflection on why certain factors may not be apparent in the moment but become evident in hindsight. The episode explores the physiological and cognitive aspects affecting diver performance, touching on concepts like working memory, task load, and background cognitive loading. Analogies such as juggling and buckets of water are used to illustrate the limitations of cognitive capacity. The impact of being submerged on cognitive performance is discussed, emphasizing the need for awareness and adaptation during underwater activities. The episode concludes with insights into the narcotic effects of gases, particularly nitrogen and carbon dioxide, and examines the specific context that contributed to the diver's challenges. The importance of resilience in the face of errors is highlighted, encouraging listeners to understand the local rationality of those involved in adverse events and emphasizing the value of learning from near misses. Original blog:  https://www.thehumandiver.com/blog/please-sir-my-brain-is-full   Links: Carl Spencer’s last dive: https://www.sidetracked.com/the-siren-song-of-the-britannic/ Dalecki et Al, 2012: https://link.springer.com/article/10.1007/s00221-012-2999-6 Oxygen narcosis research: https://pubmed.ncbi.nlm.nih.gov/35859332/   Tags: English, Cognitive Biases, Decision Making, Gareth Lock, Incident Analysis

In this podcast episode, Gareth shares insights gained from conversations with survivors of the recent Carlton Queen liveaboard incident off the coast of Egypt. The survivors recounted harrowing experiences during the ship's sinking and discussed conditions that seemed "odd" in hindsight. The episode delves into the challenge of recognizing latent factors contributing to accidents before they occur and emphasizes the importance of understanding what 'normal' looks like in various situations. Drawing on the survivors' perspectives, Gareth explores the powerful effects of hindsight bias, providing practical tips for reducing its impact when analyzing events and learning from them. The episode concludes with a call for active reflection and the use of tools like DEBrIEF to uncover error-producing conditions and improve safety. Original blog: https://www.thehumandiver.com/blog/would-you-do-the-same-thing   Links: Looking for patterns: https://www.thehumandiver.com/blog/joining-dots-is-easy-if-you-know-the-outcome Error producing conditions: https://www.thehumandiver.com/blog/don-t-just-focus-on-the-errors Debrief guide: https://www.thehumandiver.com/debrief   Tags: English, Decision Making, Gareth Lock, Hindsight Bias

In this podcast episode, Gareth reflects on the power of assumptions in everyday life, using examples ranging from a humorous cycling sign to more serious incidents in diving. The discussion explores how assumptions, while essential for navigating the complexity of daily activities, can sometimes lead to oversights and mistakes. Drawing parallels with diving scenarios, the episode emphasizes the critical need to validate certain assumptions, especially those related to safety in the underwater environment. Gareth shares insights into the recent incident involving the Carlton Queen liveaboard, highlighting the individual and systemic failures that contributed to the event. The episode concludes by advocating for a shift from a punitive approach to a restorative one in learning from mistakes and fostering a culture of safety in diving. Original blog: https://www.thehumandiver.com/blog/assumptions-a-paradox   Links: Cognitive bias infographic: https://medium.com/thinking-is-hard/4-conundrums-of-intelligence-2ab78d90740f Buster Benson’s original blog about cognitive bias: https://betterhumans.pub/cognitive-bias-cheat-sheet-55a472476b18 Debrief model: https://www.thehumandiver.com/debrief   Tags:  English, Cognitive Biases, decision Making, Gareth Lock, Just Culture