SH196: They broke the rules! So...?

SH196: They broke the rules! So...?

When diving accidents occur, the immediate response often blames rule-breaking, but reality is far more complex. Rules are designed to enhance safety, yet accidents can happen even when rules are followed—and sometimes rules are broken without incident. Diving operations occur within a web of technical, social, and cultural conditions, which can provoke deviations. This highlights the gap between “work as imagined” (rules and procedures) and “work as done” (real-world practice). Understanding why rules are broken requires looking at the system rather than focusing solely on individuals. A Just Culture, where context-rich stories can be shared without fear of punishment, helps address underlying issues and drives meaningful improvements in safety. Punishment alone rarely deters rule-breaking if systemic conditions remain unchanged.

Original blog: https://www.thehumandiver.com/blog/they-broke-the-rules

Links: Root Cause blog: https://www.thehumandiver.com/blog/the-root-cause-of-an-accident

Identifying violation-provoking conditions in a healthcare setting: https://pubmed.ncbi.nlm.nih.gov/18941971/

The Extent of Conditions: https://preaccidentpodcast.podbean.com/e/papod-399-the-extent-of-condition-episode/

Normalisation of Deviance from the Challenger launch decision: https://www.amazon.co.uk/Challenger-Launch-Decision-Technology-Deviance/dp/0226851761

Tags: English, Decision-Making, Gareth Lock, Just Culture, Normalisation of Deviance, Normalization of Deviance

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Jaksot(295)

SH295: Four Ways We Talk About 'Human Factors' in Diving

SH295: Four Ways We Talk About 'Human Factors' in Diving

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 phra...

11 Heinä 11min

SH294: Clickbait, trolls and comments. How dive incident posts can teach us — if we let them

SH294: Clickbait, trolls and comments. How dive incident posts can teach us — if we let them

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, ...

8 Heinä 13min

SH293: Why does nothing change? Why do the same failures keep happening?

SH293: Why does nothing change? Why do the same failures keep happening?

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 individua...

4 Heinä 22min

SH292: Learning or Blaming: The Choice the Diving Industry Needs to Make. Part 3 of 3.

SH292: Learning or Blaming: The Choice the Diving Industry Needs to Make. Part 3 of 3.

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 quie...

1 Heinä 14min

SH291: What the Data Told Us: Fear, Trust, and the Stories That Never Get Told. Part 2 of 3.

SH291: What the Data Told Us: Fear, Trust, and the Stories That Never Get Told. Part 2 of 3.

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 interv...

27 Kesä 13min

SH290: What Happens Underwater, Stays Underwater — And That's a Problem. Part 1 of 3

SH290: What Happens Underwater, Stays Underwater — And That's a Problem. Part 1 of 3

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 mist...

24 Kesä 12min

SH289: Chac Mool - Diving Deeper into a Triple Fatality with Human Factors

SH289: Chac Mool - Diving Deeper into a Triple Fatality with Human 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, in...

20 Kesä 24min

SH288: The 'Obvious Thing' Nobody Noticed

SH288: The 'Obvious Thing' Nobody Noticed

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, u...

17 Kesä 15min

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