Counter-Errorism in Diving: Applying Human Factors to Diving24 Jan

SH247: At a system level, we don't learn from diving fatalities, and here's why

This episode explains why the diving industry struggles to learn from fatalities and argues that the problem is not one bad decision or one person, but the whole system. Using the death of 18-year-old diver Linnea Mills as an example, it shows how normal people, doing what made sense at the time, can be caught by gaps in training, supervision, equipment, communication, and emergency planning. The focus is on moving beyond neat, blame-based “first stories” and instead telling messier “second stories” that explore context, pressure, trade-offs, and gradual drift away from safety margins. The episode looks at ideas like normalisation of deviance, weak feedback loops, authority gradients, and the gap between what rules say should happen and what really happens on dives. The key message is that safety improves when we change conditions, not just criticise people: by building psychological safety, matching supervision to the real task, checking equipment properly, planning for emergencies that fit the location, learning from near misses, and raising standards above the bare minimum. Learning from tragedy requires courage, honest stories, and system-level change, but it is possible—and it starts before the next dive.

Original blog: https://www.thehumandiver.com/blog/we-don-t-learn-from-diving-fatalities-and-here-s-why

Links: Webinar about Linnea Mills: https://www.youtube.com/watch?v=lu4tc8gtNio&t=3s

No learning focused investigation process in diving: https://www.thehumandiver.com/blog/learning-reviews-in-diving

Compliance can give an illusion of safety: https://www.youtube.com/watch?v=VNhmxz2_adc

What conditions made it harder to do the ‘right’ thing and easier to do the ‘wrong’ thing?

Creating the conditions and space for speaking up: https://www.thehumandiver.com/blog/top-tips-for-diving-instructors-leadership-creating-the-space-for-others-to-be-heard

Having difficult conversations as an instructor: https://www.thehumandiver.com/blog/top-tips-for-diving-instructors-communication-the-difficult-kind

TEDS open question acronym: https://www.thehumandiver.com/blog/communications-ask-better-questions

Psychological safety blogs: Blog 1. Blog 2. Blog 3. Blog 4. Blog 5.

Debrief model: https://www.thehumandiver.com/debrief

Diving Talks video: https://www.youtube.com/watch?v=VNhmxz2_adc

Child welfare changes: https://www.collaborative-safety.com/collaborative-safety-reading-packet

Tags: - english gareth lock safety safety culture system safety

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