The Tower Was Already Full of Holes
by: Gareth LockPublished on: 03/03/2026When diving incidents occur, we blame the last person to touch the tower. But the holes were already there. Real learning comes from asking "how did it make sense?" not "who's to blame?" Systems thinking changes everything. Be better than yesterday.
'They Lost Situation Awareness'
When an adverse event occurs, we often hear the cause described as a 'loss of situation awareness.' This phrase by itself fails to yield the actual contributory factors that led to the event, limiting our ability to learn from the incident.
CCR Diver Goes Hypoxic on Surface – What Causal Reasoning Taught Me About Learning from Events
An experienced CCR diver nearly passed out due to low loop pO2 after missing a key pre-dive check. This blog uses Causal Reasoning to understand the situation, exploring human factors, system design, and performance-shaping conditions, rather than focusing on counterfactuals and the individual.
Diving Deep into Diving Safety: The death of Linnea Mills through a lens of HF and System Safety
by: Gareth LockPublished on: 09/03/2025Dive deeper into system safety and see how small mistakes can lead to big accidents. Drawing on real-life incidents—including the tragic Linnea Mills case—discover how we can strengthen teamwork, adopt just culture, and embrace best practices for safer, more resilient dives.
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