Counter-Errorism in Diving: Applying Human Factors to Diving

This episode explores why experienced divers still die in situations that seem predictable, using the tragic 2026 Maldives cave accident as a starting point. It looks at how outcome bias, the normalisation of deviance, nitrogen narcosis, group dynamics, and silent drift can gradually erode safety margins without divers realising it. Rather than focusing on individual mistakes, the discussion explains how everyday decisions, accepted norms, and human psychology combine to create risk over time. It also examines what divers, teams, and the wider diving community can do to recognise these patterns, challenge unsafe habits, encourage open communication, and build a culture...

This episode explores how a restorative just culture can help the diving community respond to incidents in a way that promotes learning rather than blame. Instead of focusing only on who broke the rules, it looks at who was harmed, what they need, and how trust can be rebuilt while addressing the wider conditions that contributed to the event. The discussion covers the impact on everyone involved, the role of accountability, compassion, and forgiveness, and why repairing systems is more effective than simply punishing individuals. It also introduces Professor Sidney Dekker's Restorative Just Culture Checklist as a practical tool...

This episode explores the difference between a retributive approach to diving incidents, which focuses on blame and punishment, and a restorative just culture, which focuses on learning, repair, and preventing future harm. It explains how incidents affect not only those directly involved but also instructors, organisations, and the wider diving community, and argues that real accountability means understanding what happened, supporting everyone affected, rebuilding trust, and fixing the conditions that allowed the event to occur. The discussion also introduces Professor Sidney Dekker's Restorative Just Culture Checklist as a practical tool for helping individuals and organisations move from blame to...

This episode explores an important distinction that is often missed when discussing diving incidents: the difference between a cause, a reason, and an excuse. A cause explains what contributed to an event, a reason explains why a person's actions made sense to them at the time, and an excuse uses those reasons to avoid accountability. Understanding these differences helps us learn from accidents without simply assigning blame or letting people off the hook. The discussion shows why complex incidents usually have many interacting causes, why understanding local decision-making is essential for improving safety, and how separating learning from punishment...

This episode explores why accident investigations often stop long before they uncover the full picture. Drawing on research from safety science, it argues that the “cause” of an incident is not simply discovered—it is shaped by who is investigating, what they are able to change, and what explanations their community accepts. In diving, investigations often focus on the actions of individual divers or instructors because these are the easiest problems to address, while deeper issues such as organisational culture, commercial pressures, and industry practices are left unexplored. The episode examines how different people can interpret the same event in ver...

This episode explores why diving accidents are so often explained by individual mistakes instead of the wider conditions that made those mistakes possible. Using the case of a fatal medication error in healthcare alongside the recent Maldives cave diving tragedy, it examines how hindsight, blame, and our natural tendency to focus on people rather than systems can prevent meaningful learning. The discussion highlights how unsafe practices can become normal when they repeatedly appear to work, and why serious accidents often reveal long-standing weaknesses that existed long before the final event. Rather than asking "Who is at fault?", the episode...

This episode explores why rule-breaking in diving is often more complicated than simply “breaking the rules.” It looks at the difference between shortcuts that organisations quietly depend on to keep operating and personal shortcuts taken for convenience or ego. Through real-world examples, the discussion explains how hindsight can unfairly turn system-wide problems into individual blame after an incident occurs. The episode also examines why teams often stay silent when they notice problems, how social pressure affects decision-making, and why genuine learning requires understanding the reality of how diving actually works rather than relying on simple explanations. Ultimately, it challenges dive...

This episode examines the deaths of five Italian divers in the Maldives and a Maldivian military diver who later died during the recovery operation, using the tragedy to explore how Just Culture approaches accidents in high-risk environments. Rather than rushing to blame individuals, the discussion walks through the Eight-Question Review framework, which looks first at the wider system: authority, procedures, training, resources, organisational culture, operational norms, and the pressures influencing decisions. The episode highlights how experienced scientific divers can still face hidden competence gaps when moving into technical cave environments, how commercial and research pressures can shape risk-taking, and...

This episode reflects on the tragic deaths of five Italian divers in the Maldives and a Maldivian military diver who died while trying to recover them, using the event to explore what real accountability should look like after a diving accident. Rather than rushing to blame or making assumptions based on limited information, the discussion challenges the diving community to resist quick judgement and focus instead on understanding the conditions, decisions, and systems that may have shaped the outcome. It examines the difference between backward-looking accountability, which seeks someone to blame, and forward-looking accountability, which asks better questions about...

This episode challenges the instinct to explain diving accidents by focusing only on individual mistakes or broken rules. Instead, it explores how social, cultural, organisational, and environmental conditions shape the decisions divers make, even when those decisions seem irrational in hindsight. Using recent diving incidents as examples, the discussion highlights how behaviour that appears risky often made sense to those involved at the time, influenced by pressures such as authority, identity, time, and the expectation to “get the job done.” The episode introduces the PETTEOT framework—Person(s), Environment, Tasks, Tools and Technology, External Influences, Organisation, and Time—as a way to...

This episode challenges the common belief that following diving standards automatically makes diving safe. It explores how industry standards, while important, can create an illusion of safety when compliance becomes the main goal rather than improving real-world performance. The discussion examines how many diving standards are written and assessed by the same organisations they are meant to guide, creating a closed system that can protect institutions legally while limiting opportunities for deeper learning and improvement. It also looks at why accident investigations often focus on individual mistakes rather than questioning whether the procedures, training, or standards themselves are fit...

This episode explores the growing recognition that safe and effective scientific diving depends on more than technical skill, equipment, and certification. Prompted by new research into applying Crew Resource Management (CRM) to scientific diver training, it examines why communication, leadership, teamwork, and decision-making are essential in complex underwater operations where divers must manage both life support and scientific tasks under pressure. Drawing on lessons from aviation, healthcare, and other high-risk industries, the discussion highlights key challenges such as cognitive overload, distributed situational awareness, and authority gradients that can prevent divers from speaking up or adapting effectively when conditions change...

This episode explores a diving incident where nothing officially “went wrong,” yet a series of small decisions and social pressures nearly led to tragedy. A newer CCR diver and his wife joined more experienced divers on an unfamiliar shore dive, and although they surfaced safely, the dive revealed how easily people can ignore warning signs when they feel pressure to fit in, avoid disappointing others, or challenge more experienced teammates. Drawing on research into speaking up, psychological safety, and stop-work authority, the episode examines why divers often stay silent even when they feel uncomfortable, and why near-misses are rarely repo...

This episode explores what people really mean when they talk about “human factors” in diving—and why the term can sometimes create more confusion than clarity. It looks at four different ways the phrase is commonly used: blaming “the human factor” when something goes wrong, focusing on what is happening inside the diver such as stress or decision-making, examining the external conditions that shape performance like equipment, procedures, and team dynamics, and finally viewing diving as a complex socio-technical system where people, technology, organisations, and the environment all interact. While the first three approaches can offer useful insights, they often miss...

Discussions about diving incidents on social media often follow a predictable pattern: a short, simplified post describes what happened, and comments quickly focus on blaming the individual involved, creating a sense of clear-cut failure and easy lessons. This happens not because people have bad intentions, but because simple, linear stories and knowing the outcome push our brains toward hindsight judgement, making complex situations seem obvious after the fact. As a result, important factors like conditions, pressures, communication, and decision-making context are ignored, limiting real learning. Over time, this blame-focused culture encourages people to share less detail or avoid posting...

Over the past decade, diving fatalities have remained stubbornly consistent despite better equipment, more training, and growing participation, suggesting the problem isn’t just technical or individual error. Current safety approaches focus on equipment, skills, and counting deaths, but often ignore deeper issues like communication, teamwork, decision-making, and the wider system divers operate in. Research shows that most contributing factors in incidents come from these “upstream” conditions—such as training culture, social pressure, and organisational practices—rather than the diver’s final actions. A major gap is the lack of training and assessment in non-technical skills, which are critical for managing...

This final blog explores what the research means and how the diving community can realistically improve learning and safety. It argues that the problem is not broken individuals but a system that quietly encourages blame and silence, making it hard for divers to share honest stories about mistakes and near-misses. Fear—of legal action, criticism, or damage to reputation—plays a big role, even when that fear is not based on real outcomes. The result is weak feedback loops, where lessons from real experiences never reach the people who design training or shape the culture. The blog suggests shifting focu...

This blog explains how a mixed-methods study explored why divers struggle to share honest, learning-focused stories about incidents. Using a large international survey, focus groups, and expert interviews, the research found that storytelling is strongly shaped by organisational culture, fear, and trust. Many divers—especially instructors—fear legal consequences, criticism, or damage to their reputation, which stops them from speaking openly, particularly in public settings. At the same time, there is confusion about key ideas like what counts as an “incident,” what “risk” really means, and what a “just culture” looks like, with very few divers linking incidents to learning. The st...

This episode introduces the problem behind learning in diving safety, using the 2020 death of Linnea Mills to highlight how incidents are often caused by deeper system issues, not just individual mistakes. While near-misses and accidents happen regularly in diving, most are never shared or analysed, meaning valuable lessons are lost. Unlike industries such as aviation or healthcare, diving lacks strong reporting systems, regulation, and reliable data, so decisions are often based on uncertainty rather than evidence. Existing reports tend to focus on immediate causes like equipment failure or diver error, but miss the wider social, organisational, and environmental factors...

This episode examines a 2012 triple fatality at Cenote Chac Mool in Mexico using a Human Factors approach, showing how accidents are rarely caused by a single mistake but by a combination of small, interacting factors. A guide took two recreational divers beyond safe limits into an overhead cave environment without a continuous guideline, and all three ran out of gas and died. Instead of simply blaming the guide, the analysis explores how things made sense at the time, including authority gradients that stopped the divers from questioning decisions, fatigue from multiple dives, pressure to show something impressive, and increasing...

This episode explores the fatal case of 18-year-old Linnea Mills to show how visible hazards can go unnoticed when an instructor lacks the mental capacity to recognise them. Linnea was overweighted, unable to inflate her drysuit, and using equipment that couldn’t provide enough lift—risks that seem obvious in hindsight but were missed due to a combination of inexperience, time pressure, unfamiliar gear, and commercial expectations. Using models like ECOM and COCOM, the episode explains how an instructor’s attention can be consumed by immediate tasks, leaving no capacity to monitor the bigger picture or reassess whether a dive s...

This episode explores why divers don’t truly “lose” situation awareness, but instead run out of the mental capacity needed to maintain it. Through the story of James on a challenging wreck dive, it shows how increasing demands—like current, task focus, and effort—can quietly narrow attention until the bigger picture is lost, even when skills and training are sound. Using two human factors models, COCOM and ECOM, the discussion explains how control shifts from broad, strategic thinking to narrow, reactive behavior as workload rises, and how different layers of awareness—from basic task execution to overall planning—can break down...

Divers make many decisions quickly, often without realising it, by using heuristics—mental shortcuts that help us act fast when time and information are limited. These shortcuts are essential and often effective, especially with experience, but they can also lead to predictable errors called biases when used in the wrong situation. Common examples include relying too much on recent experience, sticking to an original plan despite changing conditions, or only noticing information that supports what we already believe. In diving, where conditions vary and feedback is often limited, these biases can quietly increase risk. The key is not to av...

Diving operations rarely fail because people lack skill; they fail when skilled individuals are not supported by the systems around them. The Resilient Performance Model from The Human Diver explains that performance comes from the interaction of three areas: technical skills, non-technical skills like communication and decision-making, and the wider context such as culture, workload, and resources. When one of these areas is weak or missing, problems appear—such as highly skilled divers working in silence, well-coordinated teams lacking critical skills, or strong systems where people feel unable to challenge decisions. True resilience happens when all three are aligned, al...

When something goes wrong in diving, people often ask “who made the mistake?”, but that question usually oversimplifies what really happened and stops us from learning. The Learning from Emergent Outcomes framework (LEODSI) takes a different approach by looking at diving as a system, where outcomes are shaped by many interacting factors rather than one person’s actions. It examines seven key elements—people, environment, tasks, equipment, external pressures, organisation, and time—to understand how decisions made sense in the moment and how conditions combined to produce the result. Instead of blaming individuals, LEODSI focuses on why events unfolded the way th...

This piece explores how diving incidents are often misunderstood by focusing too quickly on blame rather than learning. It explains the important difference between responsibility (who was involved) and accountability (who answers for the outcome), showing that incidents are usually caused by a chain of decisions, pressures, and system factors—not just one person’s mistake. By comparing “blame questions” (who is at fault?) with “learning questions” (why did it make sense at the time?), it highlights how real improvement comes from understanding the conditions that led to an error. Through examples like missed safety checks, risky habits becoming normal, igno...

This blog by Michael John Snow explores how small equipment issues on a remote expedition vessel can gradually become accepted as “normal,” not because of poor decisions, but because of how isolated systems work. In these environments, teams are skilled and focused on keeping operations running, especially when guests, tight schedules, and limited support make stopping costly. With fewer external checks and less immediate feedback, minor irregularities are often monitored rather than acted on, and over time they fade into the background. This process, known as normalization of deviation, slowly shifts what is seen as acceptable without anyone clearly deci...

This episode looks at the 2021 wreck diving tragedy on HMS Scylla, where three experienced divers entered the wreck and only one survived. It first examines the kind of reaction often seen on social media, where the incident is explained as a series of obvious mistakes made by individuals. It then explores the same event using a human factors and systems approach called LEODSI, which looks at how people, environment, equipment, tasks, organisational culture, and time interact to shape decisions and outcomes. Instead of asking “who failed?”, this perspective asks how normal behaviour, built on experience, trust, and familiar conditions, can...

This episode explores the serious incident in which two divers were accidentally left behind by a dive boat near Rottnest Island while diving with Perth Diving Academy. Rather than treating it as the failure of one operator, the discussion looks at how a simple error—such as a headcount mistake—can reveal deeper weaknesses in safety systems that may exist across the dive charter industry. It explains how many operations rely on habits, assumptions, and informal checks that usually work, but can fail when conditions change. The episode also looks at the limits of fines and punishment, which rarely help...

This episode looks at how diving incidents are often explained by blaming the last person involved, much like blaming the person who pulls the final brick from an already unstable Jenga tower. While that person may be the last to act, many other factors—such as environment, equipment, training, social pressure, and organisational practices—may already have weakened the system. Through several real diving examples, the episode shows how accidents usually develop from a combination of conditions rather than a single mistake. It also explains why people are quick to blame individuals: it is easier, it protects our sense of s...

This episode looks at how quick judgement, especially online, can block learning and make diving less safe. Using a real example of an adaptive scuba training video that received harsh criticism, it explains how people often react without understanding the full context. The episode introduces two key ideas from Human Factors: psychological safety, where people feel safe to ask questions and speak up, and just culture, where the focus is on learning instead of blame. The main message is simple: when people judge, learning stops, but when people stay curious, learning begins. By slowing down, asking questions, and trying...

This episode explores why people often go diving even when something feels “off,” and how risk usually starts before anyone gets in the water. It explains that danger doesn’t come from one big mistake, but from small pressures like stress, tiredness, rushing, poor communication, and cutting corners that slowly build up and start to feel normal. Over time, these small compromises become habits, and people stop seeing them as problems at all. The key message is that safety isn’t just about following procedures underwater — it’s about noticing when your safety margin is already shrinking on the surface. Rea...

This episode explores what real safety improvement in diving could look like if we stop copying other industries and start designing for the reality of diving itself. It explains that diving is commercial, lightly regulated, and full of everyday trade-offs between safety, money, time, and training, which means risk can’t be removed — only managed. Instead of relying only on rules and checklists, the focus should be on building “margin” into the system: better training time, safer conditions, lower ratios, rested instructors, better decision-making, and a culture where stopping a dive is normal, not failure. The key message is that saf...

This episode looks at the tragic death of 12-year-old D.H. during a scuba training dive and explains it not as one person’s mistake, but as a failure of the whole system around her. Using court documents and a safety science approach, the analysis shows how many “normal” things came together — rushed training, poor visibility, tired staff, missing safety equipment, weak rules, money pressure, and lack of oversight — to create a situation where there was no real safety margin left. The key message is that this was not a random accident or a single bad decision, but the result of...

This episode explores why asking “why did this happen?” after a diving accident is important — but not enough on its own. It explains that investigations often stop too early, not because everything is understood, but because people reach a point that feels comfortable, simple, or easy to fix. Many reports focus on equipment failures or individual mistakes, while deeper causes like pressure, workload, training culture, time limits, and business realities are left out. The episode shows that real learning comes from looking at how normal routines, shortcuts, and everyday decisions shape what people do, not just what went wrong at the...

This episode looks at two very different ways of telling the same tragic story — the death of a 12-year-old girl during a scuba training dive in Texas — and why the way we tell these stories matters for real safety. The first version focuses on blame, emotion, and individual failure, which feels powerful but pushes people toward anger instead of learning. The second version looks at how the whole system shaped what happened, including training pressure, poor visibility, equipment choices, fatigue, class structure, and missing safety checks. Instead of asking “who failed,” it asks how normal practices, routines, and decisions slowly c...

This episode explores how divers often overlook the richness of underwater environments they think they already know, and how greater awareness can transform both safety and understanding. Using real examples from rivers, lakes, and glacial landscapes, it shows how underwater spaces are shaped by nature, history, and human activity, even when they look simple on the surface. The episode explains how human factors help divers make better decisions, communicate clearly, and work more effectively as teams, while citizen science gives divers a way to contribute real knowledge to research and conservation. The core message is that when divers learn...

This episode explores why diving accidents involving children create such strong reactions and deep divisions, and how our need for simple explanations often gets in the way of real learning. It explains how people quickly form strong opinions after tragedies, not because they don’t care about safety, but because events like this challenge their beliefs about control, training, and protection. To feel safe again, communities often rush to blame individuals, which brings emotional comfort but blocks deeper understanding. The episode shows how psychology, identity, and group thinking shape these reactions, and why early public stories become hard to qu...

This episode explores how accidents in diving and other high-risk jobs are often blamed on individuals, even when the real causes are deeper problems in the system, such as pressure, poor communication, lack of support, broken procedures, and unsafe cultures. Using real examples from rescue diving, healthcare, aviation, and emergency services, it shows how “blame cultures” create fear, silence, and hidden mistakes, which makes future accidents more likely. In contrast, “learning cultures” focus on understanding how systems shape behaviour, encourage people to speak up, and treat mistakes as chances to learn rather than punish. The message is clear and practica...

This episode looks at how diving accidents are often explained in simple ways that blame individuals, instead of exploring the deeper systems and pressures that shape what really happens. It explains that investigations are not just about facts, but about meaning, comfort, and fear after someone has died, which often leads to stories that focus on “human error” instead of learning. Using real examples, it shows how simple explanations may feel reassuring, but they don’t make diving safer. Real prevention comes from understanding how people, training, culture, pressure, equipment, and organisations interact in complex ways. The key message is tha...