Counter-Errorism in Diving: Applying Human Factors to Diving

In this episode, we dive into cognitive dissonance—the psychological discomfort of confronting facts that challenge our beliefs—and how it impacts decision-making and safety in diving. Drawing on insights from Black Box Thinking by Matthew Syed and examples from aviation, justice, and diving, we explore why even highly educated individuals can resist change to protect their reputation. From misconceptions about Nitrox and gas planning to biases in equipment and training preferences, we examine common examples in diving and discuss how human factors can improve safety. We also share practical steps to reduce cognitive dissonance, embrace learning from failure, and foster open-mindedness in the diving community. Original blog: https://www.thehumandiver.com/blog/cognitive-dissonance   Links: Ditching in the Hudson of Cactus 1549: https://en.wikipedia.org/wiki/US_Airways_Flight_1549 Story about cult foollowers expecting a UFO: https://www.minnpost.com/second-opinion/2011/04/when-facts-fail-ufo-cults-birthers-and-cognitive-dissonance “Unintended co-ejaculators”: https://ethicsunwrapped.utexas.edu/cognitive-dissonance-case-unindicted-co-ejaculator Examples of cognitive dissonance: https://en.wikipedia.org/wiki/Cognitive_dissonance   Tags:  English, Decision Making, Gareth Lock, Human Factors

In this episode, we explore the gap between knowledge and action, focusing on how even small, intentional changes can lead to significant improvements in safety and performance. Drawing from examples like the WHO Safe Surgical Checklist and lessons from diving, we highlight the importance of applying what we know—whether through simple tools like checklists and debriefs or by understanding decision-making and systemic issues. Alongside a personal story about working with a coach to turn knowledge into impactful action, we challenge listeners to reflect: what will you do to turn your insights into meaningful change? Original blog: https://www.thehumandiver.com/blog/anotherbrickinthewall   Links: CAP 737 http://publicapps.caa.co.uk/modalapplication.aspx?appid=11&mode=detail&id=6480 IOGP Doc 502 https://www.iogp.org/bookstore/product/guidelines-for-implementing-well-operations-crew-resource-management-training/ Non-technical skills for surgeons: https://www.rcsed.ac.uk/professional-support-development-resources/learning-resources/non-technical-skills-for-surgeons-notss The Castle: http://www.thisiscolossal.com/2018/02/the-castle-by-jorge-mendez-blake/ World Health Organisation Safe Surgical Checklist: https://www.nejm.org/doi/full/10.1056/NEJMsa0810119 Semmelweis: https://en.wikipedia.org/wiki/Ignaz_Semmelweis Distancing through differencing: https://www.researchgate.net/publication/292504703_Distancing_through_differencing_An_obstacle_to_organizational_learning_following_accidents   Tags:  English, Decision-Making, Gareth Lock, Human Factors, Non-Technical Skills

In this episode, we delve into the complexities of managing risk and uncertainty in diving, challenging the notion that accidents are "entirely predictable." Unlike measurable risks, diving involves countless variables that create uncertainty, often managed through mental shortcuts and biases. We discuss how hindsight bias, overconfidence, and peer pressure can cloud judgment, leading to poor decisions. Effective feedback, teamwork, and tools like checklists can reduce uncertainty, while debriefs and learning from others’ mistakes are crucial for improvement. Tune in to explore how divers can navigate uncertainty to enhance safety and performance in this high-stakes environment. Original blog: https://www.thehumandiver.com/blog/uncertainty-vs-predictable   Links: Risk vs Uncertainty: http://www.mindtherisk.com/literature/67-risk-savvy-by-gerd-gigerenzer Thinking, Fast and Slow: https://en.wikipedia.org/wiki/Thinking,_Fast_and_Slow Blog about the Dunning Kruger effect: https://www.thehumandiver.com/blog/incompetent-and-unaware-you-don-t-know-what-you-don-t-know Blog about biases: https://www.humaninthesystem.co.uk/blog/i-am-biased-you-are-biased-we-are-all-biased   Tags:  English, Decision Making, Gareth Lock, Risk

The diving industry faces challenges in maintaining high safety standards due to a lack of effective feedback mechanisms and a fear of reprisal for reporting substandard practices. Feedback is essential for improving performance and preventing dangerous "normalization of deviance," but it’s often viewed as blame rather than an opportunity for learning. Without proper acknowledgment or action from agencies, divers and instructors lose trust in the system, leading to fewer reports and greater risks. To protect the self-regulating nature of the industry, the community must embrace constructive feedback, report unsafe practices, and demand accountability from agencies to ensure safety and uphold standards. Original blog: https://www.thehumandiver.com/blog/standard-you-accept   Links: Blog about normalisation of deviance: https://www.thehumandiver.com/blog/being-a-deviant-is-normal Willful blindness: https://www.ted.com/talks/margaret_heffernan_the_dangers_of_willful_blindness ​Case study from healthcare in the US: https://news.aamc.org/patient-care/article/best-response-medical-errors-transparency/   Tags:  English, Gareth Lock, Just Culture, Reporting

When discussing diving incidents, it’s vital to shift away from blame and hindsight bias and instead foster a culture of open dialogue to understand why decisions made sense at the time. Often, divers are doing their best with the resources, training, and information available, but situational awareness and decision-making are shaped by incomplete data, personal experience, and environmental factors. Criticism without context or constructive feedback doesn’t improve safety or learning; instead, it deters people from sharing critical insights. By embracing a "just culture," the diving community can better explore the underlying factors behind incidents, address systemic issues, and create meaningful opportunities for growth and safety improvement. Original blog: https://www.thehumandiver.com/blog/cannot-improve-do-not-understand   Links: Report of the death of CCR diver: https://cognitasresearch.files.wordpress.com/2015/05/dillon-2015-findings-in-the-inquest-into-the-death-of-philip-gray.pdf   Tags: English, Gareth Lock, Just Culture ​​

Safety in diving is not a standalone priority but one of many factors, including time, money, resources, and productivity, that individuals and organizations must balance in a dynamic environment. Safety is best understood as reducing risk to an "acceptable level," but defining what is acceptable can be complex and context-dependent. Using principles like ALARP (As Low As Reasonably Practicable), risk is mitigated until further reduction becomes disproportionately expensive or impractical. Both training organizations and divers face trade-offs between safety and competing priorities, which can shift depending on circumstances. Divers must critically assess their own safety standards and weigh the effort, time, and money required to mitigate risks, understanding that "safety" is a shared responsibility within the larger system of diving. Ultimately, improving safety requires self-awareness, courage, and a commitment to learning from near-misses and incidents. Original blog: https://www.thehumandiver.com/blog/safetyisnot_the_priority   Links: ICAO Safety Management Manual: https://www.icao.int/safety/SafetyManagement/Documents/Doc.9859.3rd%20Edition.alltext.en.pdf Royal Sociecty Risk Assessment report: https://books.google.co.uk/books/about/Risk_Assessment.html?id=LRcmQwAACAAJ&redir_esc=y John Adams book ‘Risk’: http://www.john-adams.co.uk/wp-content/uploads/2017/01/RISK-BOOK.pdf Efficiency-Throughouness Trade Off: http://erikhollnagel.com/ideas/etto-principle/index.html] Work as Imagined/Work as Done: https://www.thehumandiver.com/blog/what-does-human-factors-in-diving-mean Cognitive biases: https://www.thehumandiver.com/blog/17-cognitive-biases   Tags:  English, Gareth Lock, Human Factors, Safety

Human factors in diving encompass everything from individual behavior to the interaction between divers, technology, and organizational systems. This podcast dives into the complexities of human factors, exploring how they influence safety, performance, and decision-making. Topics include cognitive biases, stress, and fatigue, as well as the gap between "Work as Imagined" and "Work as Done." We also discuss the importance of Crew Resource Management (CRM) and Non-Technical Skills (NTS) in improving team dynamics and situational awareness, even in solo diving. Additionally, we touch on the lack of formal human factors standards in diving and the need for better incident reporting systems. Finally, we highlight practical approaches to training, such as effective pre-dive briefs, debriefs, and feedback mechanisms, to help divers and instructors foster safer, more adaptive practices. Original blog: https://www.thehumandiver.com/blog/what-does-human-factors-in-diving-mean   Links: Steven Shorrocks blogs about the four parts of Human Factors:  ​​ Tags: English, Gareth Lock, Human Factors

This podcast explores the limitations of attributing diving accidents to "human error," a reductionist explanation that fails to address the complexities of real-world decision-making and system failures. By examining a case study involving oxygen toxicity during a rebreather dive, the episode delves into how biases, situational awareness, and flawed mental models contribute to adverse events. It highlights the importance of understanding the context behind decisions, recognizing that divers rarely intend to put themselves or others at risk. Drawing parallels with aviation and other industries, the podcast advocates for systemic changes, better training, and a culture of learning to enhance safety, rather than placing blame. Original blog: https://www.thehumandiver.com/blog/why-human-error-is-a-poor-term Links: Animated Swiss cheese model: https://vimeo.com/249087556 References:1.        Bierens, J. Handbook on drowning: Prevention, rescue, treatment. 50, (2006). 2.        Denoble, P. J. Medical Examination of Diving Fatalities Symposium: Investigation of Diving Fatalities for Medical Examiners and Diving. (2014). 3.        Denoble,  PJ, Caruso,  JL, de Dear,  GL, Pieper,  CF & Vann,  RD. Common causes of open-circuit recreational diving fatalities. Undersea Hyperb Med 35, 393–406 (2008). 4.        Parry, G. W. Human reliability analysis—context and control By Erik Hollnagel, Academic Press, 1993, ISBN 0-12-352658-2. Reliability Engineering & System Safety 99–101 (1996). doi:10.1016/0951-8320(96)00023-3 5.        Reason, J. T. Human Error. (Cambridge University Press, 1990). 6.        Phipps, D. L. et al. Identifying violation-provoking conditions in a healthcare setting. Ergonomics 51, 1625–1642 (2008). 7.        Dekker, S. The Field Guide to Understanding Human Error. 205–214 (2013). doi:10.1201/9781315239675-20 8.        Endsley,  MR. Toward a theory of situation awareness in dynamic systems. Human Factors: The Journal of the Human Factors and Ergonomics Society 37, 32–64 (1995). 9.        Klein,  GA. Streetlights and shadows: Searching for the keys to adaptive decision making. (2011). 10.      Amalberti,  R, Vincent,  C, Auroy,  Y & de Maurice, S. G. Violations and migrations in health care: a framework for understanding and management. Quality & safety in health care 15 Suppl 1, i66–71 (2006). 11.      Cook,  R & Rasmussen,  J. ‘Going solid’: a model of system dynamics and consequences for patient safety. Quality & safety in health care 14, 130–134 (2005). 12.      Woods,  DD & Cook,  RI. Mistaking Error. Patient Safety Handbook 1–14 (2003). Tags: English, Gareth Lock, Human Error

In this episode, we explore a diving incident that highlights the critical importance of understanding human factors in high-risk activities like technical diving. A diver survived an oxygen toxicity seizure thanks to her buddy's quick thinking, but the investigation revealed a web of human errors, from outdated equipment to flawed decision-making. We discuss the lessons learned, the role of human variability in performance, and how other industries like aviation and healthcare have transformed safety through Crew Resource Management (CRM). Diving’s focus on technical skills often overlooks the human element—decision-making, communication, and teamwork—that can make or break a dive. Tune in to learn how adopting these skills can enhance safety, performance, and the culture of diving. Original blog: https://www.thehumandiver.com/blog/stop-making-stupid-mistakes   Tags:  English, Gareth Lock, Human Factors

Effective communication is critical for safety and performance in diving, yet many divers struggle to speak up due to fear of judgment, peer pressure, or an adversarial culture. This silence can lead to mistakes, unreported incidents, and missed opportunities for improvement. Leaders at all levels play a vital role in fostering open dialogue by responding to mistakes constructively, avoiding blame, and creating trust. Self-awareness, humility, and a willingness to learn are key traits for maintaining open communication. By embracing these principles and shifting focus from blame to learning, divers and teams can enhance safety, build stronger relationships, and achieve high performance. Original blog: https://www.thehumandiver.com/blog/nine-ways   Links: Blog about peer pressure: https://www.thehumandiver.com/blog/why-is-it-so-hard-to-thumb-a-dive-or-end-something-that-you-have-committed-to Blog about leadership: https://www.thehumandiver.com/blog/leadershipindiving   Tags:  English, Communications, Gareth Lock, Leadership, Teamwork