Gareth LockWhen 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.
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.
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.
Gareth LockDive 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.
The way we describe events shapes how we learn from them. "The diver ran out of gas" invites blame, while "the gas ran out" sparks deeper questions. In high-risk environments, precise, non-judgmental language fosters learning and safety. Shift your focus from fault to context—and improve outcomes!
A comprehensive report from the CREER safety and line committee into a fatality in February 2024. It is of note because it includes commentary about HF and the wider contextual factors.
Human factors, non-technical skills and learning from emergent outcomes for the divers who refuse the bad-apple story.
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