Counter-Errorism in Diving: Applying Human Factors to Diving

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-spaceReferences: 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/10.1111/1468-5973.12039EC. (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/1846144744Lock, 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_linkMills v Gull Dive Center PADI (2022). https://www.scribd.com/document/555406095/Mills-v-Gull-Dive-Center-PADI-2nd-Amended-ComplaintOrlady, H. W., & Orlady, L. M. (2017). Human factors in multi-crew flight operations (1st ed.). Routledge.Reason, J. (2016). Managing the risks of organizational accidents. Routledge. https://doi.org/10.4324/9781315543543Snowden, D. (2002). Complex acts of knowing: Paradox and descriptive self-awareness. Journal of Knowledge Management, 6(2), 100–111. https://doi.org/10.1108/13673270210424639Waring, 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.2004.08.055Tags: English| Learning, Incidents & Just Culture

This episode explores the fatal case of 18-year-old Linnea Mills to show how visible hazards can go unnoticed when an instructor lacks the mental capacity to recognise them. Linnea was overweighted, unable to inflate her drysuit, and using equipment that couldn’t provide enough lift—risks that seem obvious in hindsight but were missed due to a combination of inexperience, time pressure, unfamiliar gear, and commercial expectations. Using models like ECOM and COCOM, the episode explains how an instructor’s attention can be consumed by immediate tasks, leaving no capacity to monitor the bigger picture or reassess whether a dive should proceed. This isn’t about blaming an individual, but understanding how systems, workload, and limited experience can overwhelm decision-making. The key lesson is that effective instructors don’t just rely on skill, but on preparation—setting clear plans, checks, and limits before the dive—to protect their ability to recognise problems when it matters most.Original blog: https://www.thehumandiver.com/post/the-obvious-thing-nobody-noticedLinks: Part 1: https://www.thehumandiver.com/post/the-picture-went-darkThe Linnea Mills case: https://www.thehumandiver.com/post/linnea-mills-death-hf-systems-lensTags: English| Sense-making, Decision-making, & Psychology