Stay ConnectedHuman factors is a critical topic within the world of SCUBA diving, scientific diving, military diving, and commercial diving. This podcast is a mixture of interviews and ‘shorts’ which are audio versions of the weekly blog from The Human Diver.
Each month we will look to have at least one interview and one case study discussion where we look at an event in detail and how human factors and non-technical skills contributed (or prevented) it from happening in the manner it did.
Copyright: © 2023 (c) The Human Diver 2023
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, ignored concerns, and unreported near-misses, the text shows how blame cultures stop people speaking up and allow problems to grow. Instead, it argues for a learning-focused approach where divers, instructors, and organisations reflect on decision-making, encourage honest reporting, and examine the wider system. The key message is that accountability should not be about punishment, but about creating an environment where people can speak openly, learn from mistakes, and prevent future incidents.
Original blog: https://www.thehumandiver.com/post/youre-accountable-youre-responsible-youre-it
Links: Blog about the Scylla wreck incident: https://www.thehumandiver.com/post/scylla-wreck-penetration-leodsi
IJN SATA case study: https://wreckedinmyrevo.com/2023/11/16/close-call-on-the-ijn-sata-palau-120-fsw/
Blog about Linnea Mills: https://www.thehumandiver.com/post/linnea-mills-death-hf-systems-lens
PDF guide: https://drive.google.com/file/d/1Ugx0lQM5am2gQ9rJa4aCq39JBukGZyLK/view?usp=sharing
Ruth Parris: https://www.linkedin.com/in/ruth-parris-76a53635/
Ruth’s thesis: https://lup.lub.lu.se/student-papers/search/publication/9186204
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 deciding to take a risk. When a problem finally forces action, it can look sudden, but it is usually the result of many reasonable choices made over time. The key message is that this isn’t about individual failure, but about system design: isolation reduces challenge, delays response, and makes it easier for risk to build unnoticed. To manage this, the blog argues that remote operations need stronger structures—like clear governance, tracking, and shared visibility of equipment performance—so that small issues stay visible and are addressed before they become bigger problems.
Original blog: https://www.thehumandiver.com/post/isolation-amplifies-drift
Links: Governance mechanisms: https://remoteassetgovernance.com/framework
Tags: English| Operations & Procedures
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 combine with changing environments, increasing stress, and limited time to slowly reduce safety margins. By understanding how these factors interacted to produce the outcome, the aim is to help the diving community learn in a deeper way and improve the overall system so that safer decisions become easier and tragedies like this are less likely to happen.
Original blog: https://www.thehumandiver.com/post/scylla-wreck-penetration-leodsi
Links: Interview with Adam on the Deep Wreck Diver Youtube channel: https://www.youtube.com/watch?v=OMYKjZocins
Linnea Mills Case: https://www.thehumandiver.com/post/linnea-mills-death-hf-systems-lens
Death of a 12 year old in Texas during Open Water training: https://www.thehumandiver.com/post/learning-from-tragedy-dh
Learning from Emergent Outcomes: https://www.thehumandiver.com/lfeo
Dive Talk review of the interview: https://www.youtube.com/watch?v=WvCr3_pX4a4
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 the wider industry learn unless there is transparency about what actually went wrong. Instead of blaming a “bad operator,” the focus is on understanding how safety systems drift over time, why single points of failure are dangerous, and how stronger safety comes from multiple checks, open feedback from staff and customers, and a culture of continuous improvement that looks for problems before they turn into accidents.
Original blog: https://www.thehumandiver.com/post/this-could-happen-to-any-dive-operator
Links: Australian Maritime Safety Authority: https://www.amsa.gov.au/
How we measure safety in diving: https://www.thehumandiver.com/post/what-does-safe-mean
Systems in diving: https://www.thehumandiver.com/post/the-road-to-excellence-systems-and-structure-form-the-foundation-of-a-culture-of-improvement
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 safety, and it is what we are used to seeing in the media and official reports. Instead of asking what someone “should have done,” the more useful question is how their actions made sense at the time with the information and resources they had. By shifting from judgement to curiosity and looking at the wider system, divers and instructors can learn more from incidents and improve both their technical and non-technical skills to make future dives safer.
Original blog: https://www.thehumandiver.com/post/and-still-the-tower-is-standing
Links: “Blaming a bad apple is like wetting your pants”:https://indepthmag.com/do-bad-apples-actually-exist/
Blog about the death of Linnea Mills: https://www.thehumandiver.com/post/linnea-mills-death-hf-systems-lens
Blog about the death of a 12 year old child in Texas: https://www.thehumandiver.com/post/learning-from-tragedy-dh
Wait list for Learning from Emergent Outcomes course: https://www.thehumandiver.com/lfeo
Facebook group: https://www.facebook.com/groups/184882365201810/permalink/2729409417415746/
Tags: English| Safety & Risk Management
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 to understand why decisions made sense at the time, dive teams and the wider community can make better choices, create safer environments, and build a healthier culture for everyone.
Original blog: https://www.thehumandiver.com/post/be-curious-not-judgemental
Links: Original Facebook post and video: https://www.facebook.com/share/r/1DnwV8qM1r/
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. Real safety comes from having the courage to stop, slow down, and ask not “Can we do this dive?” but “Do we still have enough room for things to go wrong?”
Original blog: https://www.thehumandiver.com/post/you-are-entering-water-with-known-problems
Links: Work as Imagined vs Work as Done blog: https://www.thehumandiver.com/blog/Work-as-Imagined-vs-Work-as-Done
Tags: English| Safety & Risk Management
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 safety doesn’t come from paperwork alone, but from building real capacity — skills, time, support, learning systems, and honest culture — so people can make good decisions under pressure and prevent small compromises from slowly turning into serious danger.
Original blog: https://www.thehumandiver.com/post/no-silver-bullets-build-capacity
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 a system that allowed risky practices to become normal. The goal is not blame, but learning: understanding how everyday routines, shortcuts, and pressures can slowly increase danger, and how changing the system — not just individuals — is the only real way to prevent this from happening again.
Original blog: https://www.thehumandiver.com/post/learning-from-tragedy-dh
Links: Court filings: https://www.documentcloud.org/documents/26789283-dylanharrisonlawsuit/
Purpose of investigation blog: https://www.thehumandiver.com/post/what-is-the-purpose-of-an-investigation
Learning from Emergent Outcomes and LEODSI: https://www.thehumandiver.com/lfeo
Psychological safety: https://lup.lub.lu.se/student-papers/search/publication/9151225
Research around “stop work” orders: https://www.researchgate.net/publication/352017590_Deciding_to_stop_work_or_deciding_how_work_is_done
https://www.sciencedirect.com/science/article/abs/pii/S0925753517308871
RSTC guidance and Standards: https://www.youtube.com/watch?v=kNRrrosDJYs
Trade off between performance, cost and resources: https://youtu.be/vtgIwHrUWVQ?list=PLNXuyLsCTX6hHS3newpcROfJ_JiI27q3C&t=555
Regulated environments such as military aviation: https://www.mdpi.com/2313-576X/8/2/37
Barriers to learning from adverse events: https://lup.lub.lu.se/student-papers/search/publication/9151225
Social acceptance of drift: https://www.thehumandiver.com/post/normalisation-of-deviance-not-about-rule-breaking
Work as Imagined vs Work as Done: https://youtu.be/vtgIwHrUWVQ?list=PLNXuyLsCTX6hHS3newpcROfJ_JiI27q3C&t=962
Performance Influencing Factors: https://www.thehumandiver.com/post/top-tips-for-diving-instructors-performance-influencing-factors
The shoot down of two Black Hawks: https://www.mindtherisk.com/literature/150-friendly-fire-the-accidental-shootdown-of-u-s-black-hawks-over-northern-iraq-by-scott-a-snook
Rebreather Forum 4.0 talk: https://www.youtube.com/watch?v=nkdVHBDnCjc
Challenger and Columbia disasters: https://www.montana.edu/rmaher/engr125/CAIB-History%20as%20a%20cause.pdf
Loss of HMNZ Manawanui: https://nzdf.mil.nz/court-of-inquiry-hmnzs-manawanui
The death of LCpl Partridge: https://assets.publishing.service.gov.uk/media/5d305623ed915d2feeac4a0f/LCpl_Partridge_Service_Inquiry_Parts_1.1._to_1.6_REDACTED_ONLINE_VERSION.pdf
The death of ADR Yarwood: https://www.nzdf.mil.nz/assets/Uploads/DocumentLibrary/Redacted-Death-Able-Diver-COI-Rpt-for-publication.pdf
Safety Science for Outdoor and Experiential Learning book: https://www.amazon.com/Safety-Science-Outdoor-Experiential-Education-ebook/dp/B0G99BD12G/ref=sr_1_1
The death of Linnea Mills: https://www.thehumandiver.com/post/linnea-mills-death-hf-systems-lens
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 end. The main message is clear: the goal of asking “why” isn’t to find someone to blame, but to understand the system well enough to change future behaviour — so the next dive is safer, even under pressure and imperfect conditions.
Original blog: https://www.thehumandiver.com/post/when-do-we-stop-asking-why
Links: Learning from Emergent Outcomes and LEODSI: https://www.thehumandiver.com/lfeo
Some relevant blogs: https://www.thehumandiver.com/post/what-story-gets-told-what-words-are-used
https://www.thehumandiver.com/post/when-the-story-hurts-too-much
https://www.thehumandiver.com/post/what-is-the-purpose-of-an-investigation
References:
Kletz, T. A. (2006). Accident investigation: Keep asking “why?”. Journal of hazardous materials, 130(1-2), 69-75.
Reason, J. (2016). Managing the risks of organizational accidents. Routledge.
Reason, J. (1991). Too little and too late: A commentary on accident and incident reporting systems. In Near miss reporting as a safety tool (pp. 9-26). Butterworth-Heinemann.
Rasmussen, J. (1990). Human error and the problem of causality in analysis of accidents. Philosophical Transactions of the Royal Society of London. B, Biological Sciences, 327(1241), 449-462.
Rasmussen, J. (1988). Coping safely with complex systems. In AAAS Annual Meeting 1988.
Cedergren, A., & Petersen, K. (2011). Prerequisites for learning from accident investigations–a cross-country comparison of national accident investigation boards. Safety Science, 49(8-9), 1238-1245.
Lessons from Longford: the Esso Gas Plant Explosion. Andrew Hopkins. CCH Australia, Sydney. 2000
Lundberg, J., Rollenhagen, C., & Hollnagel, E. (2010). What you find is not always what you fix—How other aspects than causes of accidents decide recommendations for remedial actions. Accident Analysis & Prevention, 42(6), 2132-2139.
Manuele, F. A. (2016). Root-Causal Factors: Uncovering the Hows & Whys of Incidents. Professional Safety, 61(05), 48-55.
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