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Counter-Errorism in Diving: Applying Human Factors to Diving
Gareth Lock at The Human Diver
SH308: We Know, and We Say Nothing
SEP 16, 202617 MIN
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Description
This episode explores why experienced divers still die in situations that seem predictable, using the tragic 2026 Maldives cave accident as a starting point. It looks at how outcome bias, the normalisation of deviance, nitrogen narcosis, group dynamics, and silent drift can gradually erode safety margins without divers realising it. Rather than focusing on individual mistakes, the discussion explains how everyday decisions, accepted norms, and human psychology combine to create risk over time. It also examines what divers, teams, and the wider diving community can do to recognise these patterns, challenge unsafe habits, encourage open communication, and build a culture that learns from accidents instead of simply accepting them as bad luck.
Original blog: https://www.thehumandiver.com/post/we-know-and-we-say-nothing
Notes
Concept formalised by Baron, J. & Hershey, J. C., "Outcome bias in decision evaluation," Journal of Personality and Social Psychology 54 (1988), p. 569-579. PDF available: https://www.sas.upenn.edu/~baron/papers/outcomebias.pdf
Vaughan, D., The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA, University of Chicago Press, 1996. Publisher page: https://press.uchicago.edu/ucp/books/book/chicago/C/bo22781921.html
Lock, G., Under Pressure: Diving Deeper with Human Factors (2019); see also The Human Diver (https://www.thehumandiver.com) and the documentary If Only… (https://www.thehumandiver.com/ifonly).
First systematic experimental demonstration: Behnke, A. R., Thomson, R. M. & Motley, E. P., "The psychologic effects from breathing air at 4 atmospheres pressure," American Journal of Physiology 112(3), 1935, p. 554-558. DOI: https://doi.org/10.1152/ajplegacy.1935.112.3.554
For an overview, see Nitrogen Narcosis In Diving on StatPearls (NCBI/NIH): https://www.ncbi.nlm.nih.gov/books/NBK470304/; and Clark, J. E., Moving in extreme environments: inert gas narcosis and underwater activities, Extreme Physiology & Medicine 3 (2014), which establishes that narcosis directly contributes to up to 6% of diving deaths — free full text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4337274/
Hamilton, K., Laliberté, M. F. & Fowler, B., "Dissociation of the behavioral and subjective components of nitrogen narcosis and diver adaptation," Undersea & Hyperbaric Medicine 22(1), March 1995, p. 41-49 (PMID 7742709): https://pubmed.ncbi.nlm.nih.gov/7742709/
Bibliography
Decision biases, normalisation of deviance, human factors
Baron, J. & Hershey, J. C., "Outcome bias in decision evaluation," Journal of Personality and Social Psychology 54 (1988), p. 569-579. PDF: https://www.sas.upenn.edu/~baron/papers/outcomebias.pdf
Vaughan, D., The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA, University of Chicago Press, 1996. Publisher page: https://press.uchicago.edu/ucp/books/book/chicago/C/bo22781921.html
Lock, G., Under Pressure: Diving Deeper with Human Factors, 2019. The Human Diver: https://www.thehumandiver.com. Documentary If Only…: https://www.thehumandiver.com/ifonly
Physiology of narcosis
Behnke, A. R., Thomson, R. M. & Motley, E. P., "The psychologic effects from breathing air at 4 atmospheres pressure," American Journal of Physiology 112(3), 1935, p. 554-558. First systematic experimental demonstration of the narcotic effects of compressed air at depth. DOI: https://doi.org/10.1152/ajplegacy.1935.112.3.554
Kirkland, P. J., Mathew, D., Modi, P. & Cooper, J. S., Nitrogen Narcosis In Diving, StatPearls (NCBI/NIH), last updated 2023: https://www.ncbi.nlm.nih.gov/books/NBK470304/
Clark, J. E., "Moving in extreme environments: inert gas narcosis and underwater activities," Extreme Physiology & Medicine 3 (2014). Free full text via PMC: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4337274/
Hamilton, K., Laliberté, M. F. & Fowler, B., "Dissociation of the behavioral and subjective components of nitrogen narcosis and diver adaptation," Undersea & Hyperbaric Medicine 22(1), March 1995, p. 41-49. PMID 7742709: https://pubmed.ncbi.nlm.nih.gov/7742709/
Diving accident research
Divers Alert Network, Annual Diving Reports (long series, 1988 to 2021). Full collection consultable online: https://www.ncbi.nlm.nih.gov/books/NBK481542/
Exley, S., Basic Cave Diving: A Blueprint for Survival, National Speleological Society — Cave Diving Section, Branford (FL), 1979. Official NSS-CDS PDF: https://nsscds.org/wp-content/uploads/2018/05/Blueprint-for-Survival.pdf
Buzzacott, P., Zeigler, E., Denoble, P. & Vann, R., "American Cave Diving Fatalities 1969-2007," International Journal of Aquatic Research and Education 3(2), 2009, p. 162-177. Free full text: https://scholarworks.bgsu.edu/ijare/vol3/iss2/7/
Potts, L., Buzzacott, P. & Denoble, P. J., "Thirty years of American cave diving fatalities," Diving and Hyperbaric Medicine 46(3), September 2016, p. 150-154. PMID 27723015: https://pubmed.ncbi.nlm.nih.gov/27723015/
Tags: THD-English| THD-Learning, Incidents & Just Culture

