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 mistakes. While near-misses and accidents happen regularly in diving, most are never shared or analysed, meaning valuable lessons are lost. Unlike industries such as aviation or healthcare, diving lacks strong reporting systems, regulation, and reliable data, so decisions are often based on uncertainty rather than evidence. Existing reports tend to focus on immediate causes like equipment failure or diver error, but miss the wider social, organisational, and environmental factors that shape outcomes. The episode argues that meaningful learning comes from “context-rich” stories that explain not just what happened, but why it made sense at the time. Drawing on safety research from other industries, it highlights the need for a stronger reporting culture, psychological safety, and system-level thinking to improve learning and prevent future incidents.

Original blog: https://www.thehumandiver.com/post/msc-part-1-the-problem-space

References: Dekker, S. (2017). Just culture: Restoring trust and accountability in your organization (3rd ed.). CRC Press, Taylor & Francis Group.

Drupsteen, L., & Guldenmund, F. (2014). What is learning: A review of the safety literature to define learning from incidents, accidents and disasters. Journal of Contingencies and Crisis Management, 22(2), 81–96. https://doi.org/10.1111/1468-5973.12039

EC. (2014). Regulation (EU) No 376/2014 of the European Parliament and of the Council of 3 April 2014. European Commission.

Gigerenzer, G. (2014). Risk savvy. Viking. https://www.amazon.co.uk/Risk-Savvy-Make-Good-Decisions/dp/1846144744

Lock, G. (2011). The application of the Human Factors Analysis and Classification System (HFACS) to improve diving safety. https://drive.google.com/file/d/1Iz3qRRyo2NjdiBGbPcRhj14NoCTuuM4/view?usp=share_link

Mills v Gull Dive Center PADI (2022). https://www.scribd.com/document/555406095/Mills-v-Gull-Dive-Center-PADI-2nd-Amended-Complaint

Orlady, H. W., & Orlady, L. M. (2017). Human factors in multi-crew flight operations (1st ed.). Routledge.

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Snowden, D. (2002). Complex acts of knowing: Paradox and descriptive self-awareness. Journal of Knowledge Management, 6(2), 100–111. https://doi.org/10.1108/13673270210424639

Waring, J. J. (2005). Beyond blame: Cultural barriers to medical incident reporting. Social Science & Medicine, 60(9), 1927–1935. https://doi.org/10.1016/j.socscimed.2004.08.055

Tags: English| Learning, Incidents & Just Culture