Counter-Errorism in Diving: Applying Human Factors to Diving

In this episode, we explore how systems, not just individuals, shape safety outcomes in aviation, diving, and daily life. We discuss historical lessons, such as redesigning cockpit controls in WWII B-17 bombers to prevent pilot errors, and modern examples like changes to ATM processes to reduce card loss. Diving safety is also examined, highlighting the recurring nature of incidents and the limitations of focusing solely on human error without addressing systemic issues. Drawing on insights from safety science and Professor James Reason's work, we emphasize the importance of creating conditions that support human performance rather than blaming individuals for predictable mistakes. Tune in to learn how understanding and improving systems can lead to safer, more effective outcomes. Original blog: https://www.thehumandiver.com/blog/fix-the-diver   Links: ‘Bad Apples’ blog: https://gue.com/blog/do-bad-apples-actually-exist/ Study from Denoble et al: https://www.researchgate.net/publication/23955484_Common_causes_of_open-circuit_recreational_diving_fatalities BSAC annual diving incident report: https://www.bsac.com/safety/diving-incidents/annual-diving-incident-report/ Forcing functions to reduce catastrophic failures: https://psnet.ahrq.gov/primer/human-factors-engineering Types of error: https://www.thehumandiver.com/blog/mistakes-errors-words-have-meaning Perception of risk paper: https://www.researchgate.net/publication/271767726_Perception_of_Risk   Tags:  English, Decision-Making, Gareth Lock, Non-Technical Skills

Status Quo Bias is the tendency to stick with familiar choices, even when better options exist, and it impacts decisions in many areas, including diving. From Coca-Cola's "New Coke" failure to nitrox's initial resistance in the diving world, this bias highlights our preference for the familiar and reluctance to embrace change. It shows up in dive site routes we repeat, equipment setups we hesitate to adjust, and training paths we follow without exploring alternatives. Being aware of this bias can help us question our habits, seek new perspectives, and make more informed decisions in diving and beyond. Original blog: https://www.thehumandiver.com/blog/status-quo   Links: Maintaining the Status Quo: https://www.academia.edu/8285384/The_Psychology_of_Preferences? …If there is choice overload: https://econweb.umd.edu/~masatlioglu/DKM.pdf …if there are costs to consider: https://philarchive.org/archive/NEBSQB   Tags:  English, Cognitive Biases, Decision-Making, Leadership, Mike Mason

This episode dives into the complexities of risk, decision-making, and resilience, blending personal experience with critical lessons for divers and beyond. Host Gareth Lock recounts his journey from peak physical fitness to surviving a near-fatal cardiac event, emphasizing the importance of recognizing weak signals, confronting cognitive biases, and understanding that safety isn’t just about training or equipment but also mindset and preparedness. Gareth challenges us to think critically about risk, share vulnerabilities, and prioritize health and safety—not just for ourselves, but for those around us. This episode is a powerful reminder that resilience and change start with awareness and action. Original blog: https://www.thehumandiver.com/blog/risks-decisions-lessons   Links: Fitness for Rescues video: https://www.youtube.com/watch?v=dOiHkpvp2NU Willful blindness: https://www.ted.com/talks/margaret_heffernan_the_dangers_of_willful_blindness?language=en UK-DMC Post COVID score: https://www.ukdmc.org/wp-content/uploads/2022/02/UKDMC_COVID-19_diver_scorecard_Rev_1_20220209.pdf   Tags:   English, Cognitive Biases, Decision-Making, Gareth Lock

This episode explores the Efficiency Thoroughness Trade-Off (ETTO), a concept by Erik Hollnagel that explains how we balance being thorough and efficient in everyday tasks, including diving. Using relatable examples like incomplete checks and forgotten tasks, we discuss how time pressures and biases often lead us to prioritize productivity over safety—usually with successful outcomes, but occasionally with costly mistakes. We examine how ETTO influences individual and organizational decisions, highlighting strategies like checklists and clear communication to counteract its risks. By understanding these trade-offs, we can learn from past incidents and create safer, more effective systems in diving and beyond. Original blog: https://www.thehumandiver.com/blog/ETTO   Links: If Only documentary: https://www.thehumandiver.com/ifonly Behavioural economics: https://www.thehumandiver.com/blog/the-bend-is-uninteresting-the-related-decisions-are-much-more-so ETTO paper: https://erikhollnagel.com/onewebmedia/ETTO.pdf System 1 to System 2 thinking: https://www.youtube.com/watch?v=Cfd8z3l3TYk   Tags:  English, Decision Making, Gareth Lock, Incident Analysis, Non-technical Skills

Explore a gripping cave diving incident that underscores the vital role of psychological safety and clear communication. A small misunderstanding about gas pressure leads to escalating tension, revealing how doubt can disrupt team dynamics. The discussion emphasizes the importance of speaking up and fostering a culture of trust. Learn how addressing concerns early can prevent bigger issues and improve collaboration among divers, proving that even seasoned professionals can benefit from reflecting on past experiences.

Why do we do things the way we do? This question is at the heart of a story about a family’s tradition of cutting the ends off meat before cooking—a habit traced back to a Great Grandmother’s small tray. The tale highlights how unexamined habits can persist long after their original purpose is gone. In diving, the same applies to the debate over teaching students on their knees versus neutrally buoyant. While the former method made sense in the past, equipment advancements and new techniques now show better results with neutral buoyancy. Change, though, is hard—habits, convenience, and social norms all play a role. But by questioning the status quo, we open doors to improvements, whether it’s in teaching techniques, post-dive debriefs, or even gas analysis. Change may require effort, but the rewards can make it worthwhile. So, ask yourself: why have we always done it that way? Original blog: https://www.thehumandiver.com/blog/why-change-is-hard-in-diving   Tags:  English, Decision Making, Jenny Lord, Leadership

In this episode, we discuss the complexities of learning from mistakes and adverse events in diving and beyond. Using real-world examples, including a technical diving error and a high-profile medical case, we explore how systemic pressures, biases like hindsight and confirmation bias, and the gap between "work as imagined" and "work as done" influence decisions. We highlight the importance of Just Culture in fostering open discussions and meaningful learning, emphasizing that improving safety means addressing systemic issues, not just individual actions. Join us to rethink how we approach errors and build resilience in high-pressure environments. Original blog: https://www.thehumandiver.com/blog/joining-dots-is-easy-if-you-know-the-outcome   Links: Last week’s blog: https://www.thehumandiver.com/blog/my-biggest-mistake HFiD Facebook group: https://www.facebook.com/groups/184882365201810 Some cognitive biases: https://www.thehumandiver.com/blog/from_blaming_to_learning RaDonda Vaught verdict: https://www.npr.org/sections/health-shots/2022/03/25/1088902487/former-nurse-found-guilty-in-accidental-injection-death-of-75-year-old-patient Learning from RaDonda Vaught case: https://www.linkedin.com/pulse/reckless-homicide-vanderbilt-just-culture-analysis-david-marx/ The learning line (page 7, section 6): http://sunnyday.mit.edu/16.863/rasmussen-safetyscience.pdf Learning organisation: https://gue.com/blog/improvement-requires-learning-learning-happens-at-the-organizational-level-too/   Tags:  English, Decision Making, Gareth Lock, Hindsight Bias, Just Culture, Psychological Safety

In this episode, we explore how context drives behavior and how mistakes can happen even to experienced professionals. Sharing a personal story about a diving oversight, we examine how time pressures, language barriers, and assumptions led to a dangerous error—and the lessons learned from it. Highlighting the importance of psychological safety and robust pre-dive checks, we discuss why understanding "how it made sense at the time" is key to improving safety and preventing future mistakes. Tune in to rethink how we approach errors and learn from unintended outcomes. Original blog: https://www.thehumandiver.com/blog/my-biggest-mistake   Links: Gareth’s blog: https://www.thehumandiver.com/blog/from_blaming_to_learning   Tags:  English, Cognitive Biases, Communications, Decision Making, Jenny Lord, Just Culture, Psychological Safety

Mistakes, slips, and lapses are a natural part of human performance, influenced by factors like training, time pressures, and equipment design. While rule-breaking may seem deliberate, it's often shaped by context, social pressures, and the perceived benefits of deviation. Biases like hindsight, outcome, and severity distort how we interpret incidents, leading to blame rather than understanding. Effective learning requires exploring why decisions made sense at the time and avoiding counterfactual judgments like "should have" or "could have." By shifting from blame to understanding and investigating systemic factors, we can improve safety and performance in diving and beyond. Original blog: https://www.thehumandiver.com/blog/from_blaming_to_learning   Links: Research about anaesthetists: https://pubmed.ncbi.nlm.nih.gov/18941971/ Bad apples: https://gue.com/blog/do-bad-apples-actually-exist/ Attribution of agency: https://gue.com/blog/the-role-of-agency-when-discussing-diving-incidents-an-adverse-event-occurs-an-instructor-makes-a-mistake/ Further reading: To blame is human. To fix is to engineer. https://www.academia.edu/527985/People_or_Systems_To_blame_is_human_The_fix_is_to_engineer  The Field Guide to Understanding Human Error. S. Dekker.   Chartered Institute of Ergonomics and Human Factors: Learning from Adverse Events https://ergonomics.org.uk/resource/learning-from-adverse-events.html  US Forest Service - Learning Review Guide. https://www.fs.usda.gov/rmrs/coordinated-response-protocol-learning-review  "Blame is the Enemy of Safety" from Engineering a Safer World by Nancy Leveson. Tags:  English, Gareth Lock, Incident Analysis, Incident Investigation, Incident Reporting, Just Culture

In this episode, we explore how instructors can balance leadership with fostering psychological safety in diving education. Psychological safety, defined as a "rewarded vulnerability," is crucial for creating environments where mistakes, questions, and challenges to the status quo are welcomed without fear of ridicule or blame. By understanding and implementing the four stages of psychological safety—Inclusion, Learner, Contributor, and Challenger safety—diving leaders can create teams that thrive on collaboration, trust, and continuous learning. We discuss practical strategies, like sharing mistakes, setting ground rules, and encouraging constructive feedback, to nurture this safety and improve outcomes for both instructors and students. Original blog: https://www.thehumandiver.com/blog/challenger-safety-control   Tags:  English, Gareth Lock, Just Culture, Leadership, Psychological Safety