About this episode

This episode analyzes the systemic failures leading to the tragic death of a child during scuba training.

This episode looks at the tragic death of 12-year-old D.H. during a scuba training dive and explains it not as one person’s mistake, but as a failure of the whole system around her. Using court documents and a safety science approach, the analysis shows how many “normal” things came together — rushed training, poor visibility, tired staff, missing safety equipment, weak rules, money pressure, and lack of oversight — to create a situation where there was no real safety margin left. The key message is that this was not a random accident or a single bad decision, but the result of a system that allowed risky practices to become normal. The goal is not blame, but learning: understanding how everyday routines, shortcuts, and pressures can slowly increase danger, and how changing the system — not just individuals — is the only real way to prevent this from happening again. Original blog: https://www.thehumandiver.com/post/learning-from-tragedy-dh Links: Court filings: https://www.documentcloud.org/documents/26789283-dylanharrisonlawsuit/ Purpose of investigation blog: https://www.thehumandiver.com/post/what-is-the-purpose-of-an-investigation Learning from Emergent Outcomes and LEODSI…

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