Counter-Errorism in Diving: Applying Human Factors to Diving

In this episode, we explore the concept of a Just Culture in diving, where learning from mistakes and sharing incidents openly helps improve safety without fear of unfair criticism or blame. Inspired by Human Factors and Ergonomics, which emerged in WWII to address human error in fast-evolving systems, Just Culture highlights that mistakes often result from systemic issues, not individual faults. In diving, many errors go unreported due to fear of judgment, especially on social media, which prevents the community from learning valuable lessons. Just Culture fosters a fair, open environment where divers can learn from errors and incidents, understanding the difference between human error, risky behavior, and recklessness, helping all divers make safer decisions.

Original blog: https://www.thehumandiver.com/blog/we-all-make-errors-let-s-not-judge-those-involved-without-understanding-the-how-it-made-sense

Links: Blog about local rationality: https://www.thehumandiver.com/blog/local-rationality-why-an-old-lady-vandalised-art-and-how-to-improve-diving-safety

Tags: English, Gareth Lock

In this episode, we discuss how openly sharing failures can lead to safer, more effective diving practices and team connections. Inspired by a diving forum thread called “I Learned About Diving From That,” we explore how sharing mistakes helps others learn without fear of criticism, creating a “Just Culture.” Embracing failure is vital for growth: it strengthens team bonds, encourages personal learning, fosters tolerance, and prepares us for future challenges. By acknowledging our mistakes, we create a safe space for feedback, helping us improve and making every dive a chance to learn and grow. Failure is normal; learning from it is essential.

Original blog: https://www.thehumandiver.com/blog/why-is-it-so-hard-to-talk-about-failure

Links: The Dive Forum: http://www.thediveforum.co.uk/

Tags:  English, Diving, Failure, Gareth Lock, Human Factors, Leadership, Scuba Diving

In this episode, we explore how understanding "local rationality"—the idea that people make decisions that make sense to them in the moment—can improve diving safety and team performance. Using the story of a 91-year-old woman who "completed" a crossword art piece in a museum, believing it was interactive, we see how context shapes our actions. This concept is critical in diving, where incidents are often judged in hindsight, ignoring the pressures, norms, and limited information divers faced. By approaching errors with curiosity rather than blame, we can better understand and prevent future mishaps in diving and beyond.

Original blog: https://www.thehumandiver.com/blog/local-rationality-why-an-old-lady-vandalised-art-and-how-to-improve-diving-safety

Links: BBC report about “vandalism”: http://www.bbc.com/news/world-europe-36796581

Mod 1 CCR bailout: https://www.divingincidents.org/reports/136

Diving with out of date cells: https://cognitasresearch.wordpress.com/2015/05/04/ccr-incident-feb-2013-double-cell-failure-human-factors-inquest-report/

Tags:  English, Communication, Decision Making, Gareth Lock, Human Error, Human Factors

In this episode, we delve into "normalization of deviance"—how divers, like workers in many fields, can gradually drift from safe practices due to pressures to be more efficient or productive. Often starting with small rule-bending or shortcuts, this drift can increase over time, as divers operate closer to safety limits without realizing the risk. Drawing on examples from high-reliability organizations, we'll discuss strategies for recognizing and counteracting this drift, from clear baseline definitions to fostering environments where divers feel comfortable speaking up about concerns. Finally, we explore the value of critical debriefs to ensure safe practices remain a priority.

Original blog: https://www.thehumandiver.com/blog/being-a-deviant-is-normal

Links: Steve Lewis’ blog: https://decodoppler.wordpress.com/2015/03/04/normalization-of-deviance/

Andy Davis’ blog: http://scubatechphilippines.com/scuba_blog/guy-garman-world-depth-record-fatal-dive/#The_Issue_of_Normalization_of_Deviance

Amalberti’s papers: http://www.sciencedirect.com/science/article/pii/S092575350000045X

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2464877/

Cook’s paper: http://qualitysafety.bmj.com/content/14/2/130.short

Blog about complacency: https://www.thehumandiver.com/blog/complacency-the-silent-killer-but-it-s-not-that-simple

Efficiency thoroughness trade off: http://erikhollnagel.com/ideas/etto-principle/index.html

Tags:  English, Gareth Lock, Human Factors, Non-Technical Skills, Normalisation of Deviance, Normalization of Deviance

In this episode, we explore complacency in technical diving, using the tragic case of Wes Skiles' 2010 rebreather accident as a springboard. Often labeled as the "silent killer," complacency can emerge when divers become overly reliant on their equipment and fail to actively monitor it, especially automated systems like rebreathers. Diving systems, much like any automated setup, require continuous attention and critical monitoring to avoid a gradual drift from safe operating practices—a concept known as the "normalization of deviance." We discuss the importance of training, shared learning from others' experiences, and maintaining a mindset of proactive failure anticipation, following insights from human factors research.

Original blog: https://www.thehumandiver.com/blog/complacency-the-silent-killer-but-it-s-not-that-simple

Links: Report about Wes Skiles: http://postoncourts.blog.palmbeachpost.com/2016/05/20/pbc-jury-deciding-whether-to-award-widow-of-famed-diver-wes-skiles-25-million/

HFACS: https://www.nifc.gov/fireInfo/fireInfo_documents/humanfactors_classAnly.pdf

Parasuraman et al 2010: http://www.ncbi.nlm.nih.gov/pubmed/21077562

Normalisation of deviance blog: https://www.thehumandiver.com/blog/incompetent-and-unaware-you-don-t-know-what-you-don-t-know

Endsley’s Situation Awareness model: http://hfs.sagepub.com/content/37/1/32.short?rss=1&ssource=mfc

Bahner et al: http://www.sciencedirect.com/science/article/pii/S1071581908000724

HUDs research: http://www.ncbi.nlm.nih.gov/pubmed/21077562

Pilot missing parked aircraft: http://www.aviation.illinois.edu/avimain/papers/research/pub_pdfs/techreports/05-23.pdf

Tags: English, Gareth Lock

In this episode, we dive into the Dunning-Kruger effect and how it impacts diver safety. The presentation from TekDiveUSA 2016 emphasizes that humans often overestimate their own knowledge, creating gaps in situational awareness that can lead to dangerous decisions. By understanding cognitive biases, such as outcome and hindsight bias, divers can begin to recognize how easy it is to misjudge risks. Just as in aviation, implementing safety protocols like checklists and open communication within dive teams can improve decision-making. The Human Diver training offers essential human factors skills, enabling divers to better manage complex situations and avoid the complacency that comes from overconfidence.

Original blog: https://www.thehumandiver.com/blog/incompetent-and-unaware-you-don-t-know-what-you-don-t-know

Links: Wingsuit video: https://www.dropbox.com/s/9cs51gbyujce3i6/Wingsuit-small.mp4?dl=1

Digger video: https://www.dropbox.com/s/lmoj32hq6ajgd7h/Digger-Captioned.mp4?dl=1

Selective attention video: https://www.youtube.com/watch?v=IGQmdoK_ZfY&feature=youtu.be

Sidney Dekker’s videos on Just Culture: https://youtu.be/PVWjgqDANWA

Reading list: https://www.thehumandiver.com/pages/reading-list

Tags:  English, Diving, Gareth Lock, Human Factors, Safety

In this episode, we discuss how complacency and cutting corners can lead to serious diving accidents. We explore how the same mental shortcuts that help us operate efficiently can also cause us to miss critical changes in our environment, leading to dangerous situations. Using examples from aviation and diving, we highlight the importance of situational awareness, monitoring equipment, and questioning decisions—no matter how experienced you are. We also emphasize the need for open communication, where divers feel comfortable addressing concerns without fear of judgment. The Human Diver training helps develop these essential skills to improve safety and performance in diving.

Original blog: https://www.thehumandiver.com/blog/it-s-the-little-things-that-catch-you-out

Links: C130 accident summary: http://aerossurance.com/safety-management/c130j-control-restriction-crash/

Tags:  English, CCR, Diving, Gareth Lock, Human Factors, Safety, Scuba Diving

In this episode, we explore why Human Factors are crucial in diving, even if you haven’t experienced an accident. Drawing from high-risk industries like NASA and aviation, we highlight how human errors often lead to major incidents, even when no technical failures are present. We discuss real-life diving examples where poor communication, peer pressure, or lack of planning led to dangerous situations. By "sweating the small stuff" and embracing constructive feedback, divers can improve teamwork, decision-making, and safety. We also introduce the Human Factors Skills in Diving courses, which teach these vital skills, showing their importance both in diving and other high-performance environments.

Original blog: https://www.thehumandiver.com/blog/what-relevance-does-human-factors-have-to-recreational-and-technical-diving

Links: NASA and the Challenger and Columbia disasters 

An Executive Jet crew who forgot to remove the gust lock

Pilot who didn’t drain the water from his fuel tanks http://www.kathrynsreport.com/2012/07/experimental-plane-crash-at-sandy-creek.html

Student who bailed out of his CCR https://www.divingincidents.org/reports/136

Instructor diving with out of date cells https://cognitasresearch.wordpress.com/2015/05/04/ccr-incident-feb-2013-double-cell-failure-human-factors-inquest-report/

Recently qualified AOW diver https://issuu.com/divermedicandaquaticsafety/docs/divermedicmagazine_issue6

Even experts make mistakes http://www.telegraph.co.uk/news/uknews/1397693/Wrong-kidney-surgeon-ignored-me-says-student.html

Tags:  English, Diving, Gareth Lock, Human Factors, Performance, Safety

In this episode, we explore the concept of "pre-mortem" or prospective hindsight, a technique that helps teams identify potential reasons for failure before a project begins. Research shows that this approach increases the ability to foresee outcomes by 30%. By imagining a scenario where a project has already failed, team members can share their insights and concerns without the fear of being seen as negative, helping to prevent issues before they occur. This method is highly effective in decision-making and risk management, particularly in high-stakes environments like diving or complex team projects.

Original blog: https://www.thehumandiver.com/blog/how-to-help-correct-the-biases-which-lead-to-poor-decision-making

Links: Sunk cost fallacy: http://youarenotsosmart.com/2011/03/25/the-sunk-cost-fallacy/

Authority gradient: https://www.thehumandiver.com/blog/authority-gradient-why-people-don-t-or-can-t-speak-up

Video from Daniel Kahneman about the “pre-mortem”: https://vimeo.com/67596631

Hindsight bias: https://en.wikipedia.org/wiki/Hindsight_bias

Outcome bias: https://en.wikipedia.org/wiki/Outcome_bias

Tags: English, Gareth Lock

In this episode, we discuss the challenges teams face when speaking up, especially in the presence of authority figures. A German research study found that in 72% of cases, team members chose to remain silent even when verbal intervention was necessary, and only 40% of those who did speak up were assertive. Reasons for silence included deference to authority, lack of confidence, and failure to recognize the situation’s urgency. This highlights the need for effective Non-Technical Skills training, which helps individuals practice assertiveness without confrontation, improving safety and communication in high-stakes environments.

Original blog: https://www.thehumandiver.com/blog/authority-gradient-why-people-don-t-or-can-t-speak-up

Links: Tenerife crash 1977: https://en.wikipedia.org/wiki/Tenerife_airport_disaster

Surgeon who removed wrong kidney: http://www.telegraph.co.uk/news/uknews/1398408/Surgeons-who-removed-the-wrong-kidney-are-cleared.html

German research paper: https://www.researchgate.net/publication/231210745_Do_residents_and_nurses_communicate_safety_relevant_concerns_Simulation_study_on_the_influence_of_the_authority_gradient

Improving Anesthetists’ ability to speak up: http://www.ncbi.nlm.nih.gov/pubmed/26703413

Tags: English, Gareth Lock, Healthcare