SH216: Diving Deep into Diving Safety: The death of Linnea Mills through a lens of HF and System Safety

SH216: Diving Deep into Diving Safety: The death of Linnea Mills through a lens of HF and System Safety

Diving is often seen as a safe and relaxing sport, but true safety goes beyond avoiding accidents—it requires building resilience and learning from mistakes. In this episode, we explore how incidents often stem from systemic pressures and "practical drift," not just individual errors. Through real-world examples from diving and other high-risk industries, we highlight the importance of open debriefs, a just culture, and robust training to prepare divers for real-world challenges. By embracing transparency and focusing on system-level improvements, we can create a safer, more adaptive diving community that prioritizes learning and continuous improvement.

Original blog: https://www.thehumandiver.com/blog/linnea-mills-death-hf-systems-lens

Links: “Bad Apples”: https://www.thehumandiver.com/blog/from_blaming_to_learning

Just a Routine Operation video: https://www.youtube.com/watch?v=JzlvgtPIof4

Court submission for Linnea Mills death: https://www.scribd.com/document/555406095/Mills-v-Gull-Dive-Center-PADI-2nd-Amended-Complaint

History as a cause: https://www.montana.edu/rmaher/engr125/CAIB-History%20as%20a%20cause.pdf

Restorative Just Culture checklist: https://safetydifferently.com/restorative-just-culture-checklist/

Laura Walton’s Fit to Dive: https://www.fittodive.org/

Diving incidents often remain hidden: https://www.youtube.com/watch?v=DRXqeQvRFK0

Sidney Dekker’s tunnel: https://www.thehumandiver.com/blog/its-obvious-why-it-happened

Research about sharing stories in diving: https://www.youtube.com/watch?v=DRXqeQvRFK0

Blogs on THD about psychological safety: https://www.thehumandiver.com/blog?tag=psychological+safety

Blogs on THD about why context matters: https://www.thehumandiver.com/blog/search?q=context+matters

Asking questions about local rationality: https://www.thehumandiver.com/blog/learning-reviews-in-diving

Tags: English, Gareth Lock, Healthcare, Incident Analysis, Just Culture, Normalisation of Deviance, Psychological Safety

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Episoder(294)

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

SH287: When the Picture Goes Dark

SH287: When the Picture Goes Dark

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 sh...

13 Jun 16min

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