SH289: Chac Mool - Diving Deeper into a Triple Fatality with Human Factors
About this episode
This episode analyzes a 2012 triple fatality in diving through a Human Factors lens, emphasizing the interplay of various contributing factors.
This episode examines a 2012 triple fatality at Cenote Chac Mool in Mexico using a Human Factors approach, showing how accidents are rarely caused by a single mistake but by a combination of small, interacting factors. A guide took two recreational divers beyond safe limits into an overhead cave environment without a continuous guideline, and all three ran out of gas and died. Instead of simply blaming the guide, the analysis explores how things made sense at the time, including authority gradients that stopped the divers from questioning decisions, fatigue from multiple dives, pressure to show something impressive, and increasing task load in a complex environment. Using the PETTEOT framework, the case highlights how people, environment, equipment, organisational culture, and time pressures combined to reduce safety margins until there was no capacity left to recover. The key lesson is that safety depends on understanding these system interactions, building psychological safety so people can speak up, and reinforcing clear rules and preparation to prevent small, “normal” deviations from turning into fatal outcomes. Original blog…
People in this episode
Host: Gareth Lock
Topics covered
- human factors
- diving safety
- accident analysis
- psychological safety
- overhead environments
Mentioned in this episode
Organizations: The Human Diver
Places: Cenote Chac Mool, Mexico
More episodes of Counter-Errorism in Diving: Applying Human Factors to Diving
- SH297: CRM, ISO 8804, and Scientific Diving: Opportunities and Existing Materials
- SH296: When 'I'm Fine' Isn't True: Speaking Up and Ending the Dive
- SH295: Four Ways We Talk About 'Human Factors' in Diving
- SH294: Clickbait, trolls and comments. How dive incident posts can teach us — if we let them
- SH293: Why does nothing change? Why do the same failures keep happening?
- SH292: Learning or Blaming: The Choice the Diving Industry Needs to Make. Part 3 of 3.
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