Counter-Errorism in Diving: Applying Human Factors to Diving

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

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: guy.shockey@thehumandiver.com   Tags:  English, Debrief, Decision-Making, Guy Shockey, Leadership, Teamwork