When we ask 'What conditions made this more likely?' perspectives (should) change

Instead of asking what they didn't do, or what rules got broken, or why did they did something that was obviously dangerous or extra risky, ask a different question.

What social, cultural, and professional conditions lead 5 divers to enter an underwater cave system in a remote location? What conditions lead military divers to undertake a recovery (where time isn't really of the essence) with limited equipment capabilities (single cylinder) for that depth?

I am not going to mention gases or equipment for the initial deaths because they haven't been confirmed, but the images/video show single cylinder divers involved in the recovery.

What conditions make this more likely? Government pressure to have to be seen doing something? 'Identity' of military divers - get stuff done. The death has been attributed to DCS. The reason why the Maldives traditionally (and at the government level) limits diving to 30m is because of the scarcity of recompression chambers. You can't eliminate the hazard of DCS, so reduce the exposure to the hazard by limiting depth and time. Having a 30m depth limit doesn't materially change the DCS hazard if you dive for an hour at 30m...

What conditions inside a government/military prevent people from asking for help? What national cultures prevent such behaviours too? What commercial pressures exist to show that diving is still safe in the Maldives (and wider)?

Context shapes behaviours.

Even when we look at apparently irrational behaviour, it made sense to THOSE INVOLVED at the time. Look at the Everest fatalities in 1998. When we look backwards, we can join the dots and identify the critical gaps. However, after the event we have an outcome. WE also have a different perspective going into such events, and a set of life experiences that shape our LOCAL rationality.

When we are in the system looking forward, we are making educated guesses about what the future will look like based on our direct and vicarious life experiences, most of the times things go right, and why that can lead us into a false sense of security the next time.

Don't use counterfactuals (could have, should have, would have, failed to).

Be careful of the language used: probably, likely, maybe, might have... These are all words around uncertainty, but they have different weighting factors.

Finally, as with the Brian Bugge, Linnea Mills and the Dylan Harrison cases, the conditions and behaviours that led to those events were present (and likely still present) but they haven't combined to create an emergent outcomes.

https://www.thehumandiver.com/post/what-is-leodsi-petteot

PETTEOT: The Seven Elements of the Diving System

LEODSI analyses diving through a structured model of the work system called PETTEOT. The acronym stands for Person(s), Environment, Tasks, Tools and Technology, External Influences, Organisation, and Time, pronounced 'pett-ee-ott'. These are the seven elements whose interactions shape every dive, whether it ends safely, badly, or somewhere in between:

Persons are critical to the model, because they contribute to both success and failure. Not them as individuals, but their skills, experience(s), physical and cognitive states, expectations, fatigue, confidence, and the ability to speak up when something doesn't feel right: all of these are in play on every dive. LEODSI deliberately uses "person(s)" to reflect that much of diving is team-based, or at least involves multiple people taking part in the activity. The interaction between divers, instructor and student, buddy pair, expedition team, is itself a system element.

Environment covers what divers actually experience in the water: current, visibility, temperature, depth, noise, and access. These are not neutral backdrops. A 3°C thermocline at 30 metres changes cognitive capacity. A surge that wasn't forecast changes workload. The environment interacts with everything else in the system.

Tasks describes the sequencing, complexity, and competing demands of what divers are trying to do. Photography and navigation are both legitimate goals, but they compete for attention. Deco management and buoyancy control are both critical tasks, but under stress, one may dominate the other. LEODSI asks how tasks were structured, what was competing, and whether the task design set people up to succeed or to struggle.

Tools and Technology covers the equipment divers depend on: how it's designed, configured, and how well it communicates with the diver. A dive computer alarm that is subtle and easy to miss in high workload conditions is not a neutral object. It's a system element that shapes whether a diver gets useful feedback at the moment they need it.

External Influences acknowledges that a dive doesn't happen in a vacuum. Weather, boat schedules, regulations, commercial or social pressures, and logistics all shape what decisions are available and how much slack the system has. When the boat leaves at noon regardless, the surface interval gets compressed. When limited site access creates pressure to complete a dive, divers and teams stretch their margins.

Organisation addresses the training systems, standards, cultural norms, incentives, and informal rules that shape behaviour before anyone enters the water. This is often where the conditions for an incident are created, long before the dive day. The instructor who has learned that debriefs are routinely cut short, the dive centre that normalises running behind schedule, the training programme that has never examined the gap between the standards it publishes and the way training actually gets delivered: these are all organisational realities that LEODSI takes seriously.

Time is the seventh and most recently formalised element, and it's one that traditional incident analysis consistently makes invisible. Time is not simply when things happened. It is an active system element that shapes performance, decision-making, and safety margins throughout a dive. LEODSI analyses time through three lenses: Work as Imagined (WAI), the planned timeline and what the standards and briefings assumed would happen; Work as Normal (WAN), what actually happens when things go "normally," including the routine workarounds and adjustments that experienced practitioners make; and Work as Actually Done (WADD), what happened on this specific dive, on this specific day.

The gap between these three perspectives is where much of the real learning lives. Consider an open water course scheduled to take place at an inland dive site. WAI assumes adequate visibility for a four-to-one instructor ratio, with enough bottom time per student to attempt each skill, receive feedback, and repeat it where needed. WAN knows that conditions at this site are variable, and experienced instructors quietly build in a buffer. On this day, visibility drops to no more than two metres. The ratio reduces to two students per instructor to maintain any meaningful supervision at all, which immediately halves the available water time per student across the group. The session runs to its scheduled end because the site closes at 5pm. Every skill gets completed. Ticks appear in every box. But the temporal compression created by the visibility change meant that feedback loops were shortened, repetition was reduced, and the debrief that should have addressed what students found difficult was squeezed into ten minutes on a cold quarryside picnic bench. WADD tells a different story to WAI: the course was delivered, but the conditions under which mastery is actually built were not present for much of it.