SH182: Joining Dots is Easy, Especially If You Know the Outcome

SH182: Joining Dots is Easy, Especially If You Know the Outcome

In this episode, we discuss the complexities of learning from mistakes and adverse events in diving and beyond. Using real-world examples, including a technical diving error and a high-profile medical case, we explore how systemic pressures, biases like hindsight and confirmation bias, and the gap between "work as imagined" and "work as done" influence decisions. We highlight the importance of Just Culture in fostering open discussions and meaningful learning, emphasizing that improving safety means addressing systemic issues, not just individual actions. Join us to rethink how we approach errors and build resilience in high-pressure environments.

Original blog: https://www.thehumandiver.com/blog/joining-dots-is-easy-if-you-know-the-outcome

Links: Last week’s blog: https://www.thehumandiver.com/blog/my-biggest-mistake

HFiD Facebook group: https://www.facebook.com/groups/184882365201810

Some cognitive biases: https://www.thehumandiver.com/blog/from_blaming_to_learning

RaDonda Vaught verdict: https://www.npr.org/sections/health-shots/2022/03/25/1088902487/former-nurse-found-guilty-in-accidental-injection-death-of-75-year-old-patient

Learning from RaDonda Vaught case: https://www.linkedin.com/pulse/reckless-homicide-vanderbilt-just-culture-analysis-david-marx/

The learning line (page 7, section 6): http://sunnyday.mit.edu/16.863/rasmussen-safetyscience.pdf

Learning organisation: https://gue.com/blog/improvement-requires-learning-learning-happens-at-the-organizational-level-too/

Tags: English, Decision Making, Gareth Lock, Hindsight Bias, Just Culture, Psychological Safety

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Episoder(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 Jul 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 Jul 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 Jul 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 Jul 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 Jun 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 Jun 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 Jun 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 Jun 15min

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