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محتوای ارائه شده توسط Gareth Lock at The Human Diver. تمام محتوای پادکست شامل قسمت‌ها، گرافیک‌ها و توضیحات پادکست مستقیماً توسط Gareth Lock at The Human Diver یا شریک پلتفرم پادکست آن‌ها آپلود و ارائه می‌شوند. اگر فکر می‌کنید شخصی بدون اجازه شما از اثر دارای حق نسخه‌برداری شما استفاده می‌کند، می‌توانید روندی که در اینجا شرح داده شده است را دنبال کنید.https://fa.player.fm/legal
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SH141: We cannot improve if we don't learn. We can't learn if we don't understand.

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Manage episode 462427969 series 3516753
محتوای ارائه شده توسط Gareth Lock at The Human Diver. تمام محتوای پادکست شامل قسمت‌ها، گرافیک‌ها و توضیحات پادکست مستقیماً توسط Gareth Lock at The Human Diver یا شریک پلتفرم پادکست آن‌ها آپلود و ارائه می‌شوند. اگر فکر می‌کنید شخصی بدون اجازه شما از اثر دارای حق نسخه‌برداری شما استفاده می‌کند، می‌توانید روندی که در اینجا شرح داده شده است را دنبال کنید.https://fa.player.fm/legal

When discussing diving incidents, it’s vital to shift away from blame and hindsight bias and instead foster a culture of open dialogue to understand why decisions made sense at the time. Often, divers are doing their best with the resources, training, and information available, but situational awareness and decision-making are shaped by incomplete data, personal experience, and environmental factors. Criticism without context or constructive feedback doesn’t improve safety or learning; instead, it deters people from sharing critical insights. By embracing a "just culture," the diving community can better explore the underlying factors behind incidents, address systemic issues, and create meaningful opportunities for growth and safety improvement.

Original blog: https://www.thehumandiver.com/blog/cannot-improve-do-not-understand

Links: Report of the death of CCR diver: https://cognitasresearch.files.wordpress.com/2015/05/dillon-2015-findings-in-the-inquest-into-the-death-of-philip-gray.pdf

Tags: English, Gareth Lock, Just Culture

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185 قسمت

Artwork
iconاشتراک گذاری
 
Manage episode 462427969 series 3516753
محتوای ارائه شده توسط Gareth Lock at The Human Diver. تمام محتوای پادکست شامل قسمت‌ها، گرافیک‌ها و توضیحات پادکست مستقیماً توسط Gareth Lock at The Human Diver یا شریک پلتفرم پادکست آن‌ها آپلود و ارائه می‌شوند. اگر فکر می‌کنید شخصی بدون اجازه شما از اثر دارای حق نسخه‌برداری شما استفاده می‌کند، می‌توانید روندی که در اینجا شرح داده شده است را دنبال کنید.https://fa.player.fm/legal

When discussing diving incidents, it’s vital to shift away from blame and hindsight bias and instead foster a culture of open dialogue to understand why decisions made sense at the time. Often, divers are doing their best with the resources, training, and information available, but situational awareness and decision-making are shaped by incomplete data, personal experience, and environmental factors. Criticism without context or constructive feedback doesn’t improve safety or learning; instead, it deters people from sharing critical insights. By embracing a "just culture," the diving community can better explore the underlying factors behind incidents, address systemic issues, and create meaningful opportunities for growth and safety improvement.

Original blog: https://www.thehumandiver.com/blog/cannot-improve-do-not-understand

Links: Report of the death of CCR diver: https://cognitasresearch.files.wordpress.com/2015/05/dillon-2015-findings-in-the-inquest-into-the-death-of-philip-gray.pdf

Tags: English, Gareth Lock, Just Culture

​​

  continue reading

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This episode dives into a powerful, real-life story of a cave diving incident that highlights the importance of psychological safety, trust, and clear communication in high-stakes environments. The narrative explores how a seemingly small misunderstanding about gas pressure spiraled into a stressful situation, showcasing the impact of doubt and unspoken concerns within a team. Lessons learned include the value of speaking up, taking responsibility, and building a culture of questioning and trust. The story serves as a reminder that even experienced divers can learn from mistakes, reinforcing the idea that addressing doubts early can prevent cascading problems and improve team dynamics. Original blog: https://www.thehumandiver.com/blog/whenever-there-is-any-doubt-there-is-no-doubt Tags: English, Decision Making, Gareth Lock, Leadership Psychological Safety, Teamwork…
 
Why do we do things the way we do? This question is at the heart of a story about a family’s tradition of cutting the ends off meat before cooking—a habit traced back to a Great Grandmother’s small tray. The tale highlights how unexamined habits can persist long after their original purpose is gone. In diving, the same applies to the debate over teaching students on their knees versus neutrally buoyant. While the former method made sense in the past, equipment advancements and new techniques now show better results with neutral buoyancy. Change, though, is hard—habits, convenience, and social norms all play a role. But by questioning the status quo, we open doors to improvements, whether it’s in teaching techniques, post-dive debriefs, or even gas analysis. Change may require effort, but the rewards can make it worthwhile. So, ask yourself: why have we always done it that way? Original blog: https://www.thehumandiver.com/blog/why-change-is-hard-in-diving Tags: English, Decision Making, Jenny Lord, Leadership…
 
In this episode, we discuss the complexities of learning from mistakes and adverse events in diving and beyond. Using real-world examples, including a technical diving error and a high-profile medical case, we explore how systemic pressures, biases like hindsight and confirmation bias, and the gap between "work as imagined" and "work as done" influence decisions. We highlight the importance of Just Culture in fostering open discussions and meaningful learning, emphasizing that improving safety means addressing systemic issues, not just individual actions. Join us to rethink how we approach errors and build resilience in high-pressure environments. Original blog: https://www.thehumandiver.com/blog/joining-dots-is-easy-if-you-know-the-outcome Links: Last week’s blog: https://www.thehumandiver.com/blog/my-biggest-mistake HFiD Facebook group: https://www.facebook.com/groups/184882365201810 Some cognitive biases: https://www.thehumandiver.com/blog/from_blaming_to_learning RaDonda Vaught verdict: https://www.npr.org/sections/health-shots/2022/03/25/1088902487/former-nurse-found-guilty-in-accidental-injection-death-of-75-year-old-patient Learning from RaDonda Vaught case: https://www.linkedin.com/pulse/reckless-homicide-vanderbilt-just-culture-analysis-david-marx/ The learning line (page 7, section 6): http://sunnyday.mit.edu/16.863/rasmussen-safetyscience.pdf Learning organisation: https://gue.com/blog/improvement-requires-learning-learning-happens-at-the-organizational-level-too/ Tags: English, Decision Making, Gareth Lock, Hindsight Bias, Just Culture, Psychological Safety…
 
In this episode, we explore how context drives behavior and how mistakes can happen even to experienced professionals. Sharing a personal story about a diving oversight, we examine how time pressures, language barriers, and assumptions led to a dangerous error—and the lessons learned from it. Highlighting the importance of psychological safety and robust pre-dive checks, we discuss why understanding "how it made sense at the time" is key to improving safety and preventing future mistakes. Tune in to rethink how we approach errors and learn from unintended outcomes. Original blog: https://www.thehumandiver.com/blog/my-biggest-mistake Links: Gareth’s blog: https://www.thehumandiver.com/blog/from_blaming_to_learning Tags: English, Cognitive Biases, Communications, Decision Making, Jenny Lord, Just Culture, Psychological Safety…
 
Mistakes, slips, and lapses are a natural part of human performance, influenced by factors like training, time pressures, and equipment design. While rule-breaking may seem deliberate, it's often shaped by context, social pressures, and the perceived benefits of deviation. Biases like hindsight, outcome, and severity distort how we interpret incidents, leading to blame rather than understanding. Effective learning requires exploring why decisions made sense at the time and avoiding counterfactual judgments like "should have" or "could have." By shifting from blame to understanding and investigating systemic factors, we can improve safety and performance in diving and beyond. Original blog: https://www.thehumandiver.com/blog/from_blaming_to_learning Links: Research about anaesthetists: https://pubmed.ncbi.nlm.nih.gov/18941971/ Bad apples: https://gue.com/blog/do-bad-apples-actually-exist/ Attribution of agency: https://gue.com/blog/the-role-of-agency-when-discussing-diving-incidents-an-adverse-event-occurs-an-instructor-makes-a-mistake/ Further reading: To blame is human. To fix is to engineer. https://www.academia.edu/527985/People_or_Systems_To_blame_is_human_The_fix_is_to_engineer The Field Guide to Understanding Human Error . S. Dekker. Chartered Institute of Ergonomics and Human Factors: Learning from Adverse Events https://ergonomics.org.uk/resource/learning-from-adverse-events.html US Forest Service - Learning Review Guide. https://www.fs.usda.gov/rmrs/coordinated-response-protocol-learning-review "Blame is the Enemy of Safety" from Engineering a Safer World by Nancy Leveson. Tags: English, Gareth Lock, Incident Analysis, Incident Investigation, Incident Reporting, Just Culture…
 
In this episode, we explore how instructors can balance leadership with fostering psychological safety in diving education. Psychological safety, defined as a "rewarded vulnerability," is crucial for creating environments where mistakes, questions, and challenges to the status quo are welcomed without fear of ridicule or blame. By understanding and implementing the four stages of psychological safety—Inclusion, Learner, Contributor, and Challenger safety—diving leaders can create teams that thrive on collaboration, trust, and continuous learning. We discuss practical strategies, like sharing mistakes, setting ground rules, and encouraging constructive feedback, to nurture this safety and improve outcomes for both instructors and students. Original blog: https://www.thehumandiver.com/blog/challenger-safety-control Tags: English, Gareth Lock, Just Culture, Leadership, Psychological Safety…
 
In this episode, we explore the importance of checklists in diving, inspired by lessons from aviation and medicine. After a tragic 1935 plane crash, pilots introduced simple checklists to reduce human error—an approach now standard in high-risk industries. Checklists help compensate for our natural forgetfulness and distractions by providing quick prompts for essential tasks. For divers, effective checklists should be simple, fit for the environment, and backed by proper training. Teams benefit from shared checklists, improving safety through collaboration and consistency. Adopting checklists as a cultural norm, much like in surgery, can make diving safer and more efficient for everyone. Original blog: https://www.thehumandiver.com/blog/why-checklists-work Links: Atul Gawande’s Reith Lecture: https://www.bbc.co.uk/programmes/articles/6F2X8TpsxrJpnsq82hggHW/dr-atul-gawande-2014-reith-lectures Reduction in mortality due to checklists: https://www.nejm.org/doi/full/10.1056/nejmsa0810119 How a checklist can be the difference between living and dying: https://www.thehumandiver.com/ifonly Tags: English, Checklists, Decision-Making, Mike Mason…
 
Experience and practice are crucial for making better decisions, especially in uncertain situations, but they aren’t the same. Perfect practice builds expertise, while varied experiences across different environments enhance decision-making by expanding mental patterns. Decision-making relies on situational awareness, which involves sensing, understanding, and projecting future outcomes, all influenced by our training, memories, and expectations. Models like Gary Klein’s recognition-primed decision-making show how we use cues and past experiences to act efficiently, even under pressure. Feedback loops and a culture of learning are key to refining our actions. By diversifying your practice and learning, you can build the mental models needed to think and act like an expert. Original blog: https://www.thehumandiver.com/blog/the-importance-of-experience Links: DEBRIEF model: https://www.thehumandiver.com/debrief Tags: English, Decision Making, Gareth Lock, Situation Awareness…
 
In this episode, we explore how human perception and assumptions can lead to critical errors, using real-world examples like the tragic 1994 friendly fire incident where two US helicopters were mistaken for enemy aircraft. These events highlight the dangers of "believing is seeing" and how expectations can shape our decisions under pressure. We connect these lessons to diving, where incomplete information and mental shortcuts can result in serious incidents. Learn how to reduce errors by validating assumptions, improving communication, and fostering shared mental models, helping to enhance safety and teamwork in high-risk environments. Original blog: https://www.thehumandiver.com/blog/believing-is-seeing Links: What You Look For Is What You Find paper: https://www.sciencedirect.com/science/article/abs/pii/S0925753509000137 Language can shape expectations: https://gue.com/blog/the-role-of-agency-when-discussing-diving-incidents-an-adverse-event-occurs-an-instructor-makes-a-mistake/ Tags: English, Cave Diving, Decision-Making, Gareth Lock, Rebreather, Situation Awareness…
 
In this episode, we discuss integrating Human Factors training into technical diving courses, inspired by a new program blending eLearning, hands-on skills, and real-world exploration. The program emphasized teamwork, leadership, and psychological safety, with the DEBRIEF model becoming a standout tool for improving feedback and team efficiency. Students embraced these concepts, leading to more effective learning and collaboration. Lessons learned included refining teaching methods, incorporating Human Factors into all course modules, and fostering a just culture. The result? Better divers, better teammates, and a better instructor. Tune in for insights on enhancing diver education through Human Factors. Original blog: https://www.thehumandiver.com/blog/HF_Into_Archaeology Links: Underwater Archaeology Society of British Columbia: http://www.uasbc.com/ DEBRIEF model: https://www.thehumandiver.com/debrief The Essentials class: https://www.thehumandiver.com/HFiD-Essentials Guy Shockey: guy.shockey@thehumandiver.com Tags: English, Debrief, Decision-Making, Guy Shockey, Leadership, Teamwork…
 
In this episode, we explore the complexities of situational awareness (SA) in diving and why it's often only recognized as missing after an event has occurred. SA involves interpreting sensory data and predicting future outcomes based on experience. Experienced divers may notice subtle signs of danger, like coral movements indicating currents or rust falling in a wreck, while novices lack the knowledge to anticipate or respond. Distractions, limited mental capacity, or unclear information can divert attention from critical issues. Rather than focusing on "loss of SA," we discuss how effective briefings, experience, and deliberate focus can help divers pay attention to what truly matters underwater. Original blog: https://www.thehumandiver.com/blog/cant_pay_MORE_attention Tags: English, Decision Making, Gareth Lock, Non-technical Skills, Situation Awareness…
 
In this blog, a diver reflects on a simulated rescue scenario during a PADI Rescue Course, highlighting critical lessons about human factors in diving. The incident underscores the impact of high task focus, reduced situational awareness, and psychological stress, which led a student to run critically low on gas without asking for help. The writer explores contributing factors, including the challenges of operating in cold, low-visibility conditions, the pressures of performing under assessment, and the lack of a "just culture" where errors can be openly discussed and learned from. This real-life example emphasizes the importance of fostering psychological safety and vigilance in all roles during training dives. Original blog: https://www.thehumandiver.com/blog/rescuer-and-rescued Tags: English, Communications, Decision Making, Gareth Lock, Just Culture, Psychological Safety, Situation Awareness…
 
Pre-dive checks are essential for diving safety, but they’re often rushed or overlooked, especially on busy dive boats. Factors like time pressure, peer pressure, distractions, and overconfidence can lead divers to skip thorough checks, relying instead on past outcomes. However, regardless of experience, using a familiar checklist with your buddy is key to ensuring equipment works and everyone knows how to assist in an emergency. While dive boats may not always allow for perfect checks, taking time beforehand—at the dive shop or during the journey—to understand your buddy’s gear can mitigate risks. Dive Masters play a vital role in setting the standard by demonstrating thorough checks. Ultimately, effective pre-dive checks improve safety, reduce errors, and prepare divers for unexpected situations. Original blog: https://www.thehumandiver.com/blog/checks-on-a-dive-boat Tags: English, Checklists, Decision Making, Mike Mason, Teamwork…
 
In this episode, Gareth Lock explores the critical role of situation awareness and risk management in diving, emphasizing the importance of building accurate mental models to anticipate and manage potential hazards. He discusses how assumptions, experience, and training shape decision-making, and highlights the distinction between managing risks logically and addressing uncertainty through mental shortcuts and emotions. Gareth shares how The Human Diver promotes non-technical skills, psychological safety, and a Just Culture, fostering a learning approach to adverse events. With new programs and instructors worldwide, 2025 promises more opportunities to improve diving safety and teamwork. Original blog: https://www.thehumandiver.com/blog/making-sense-now Links: DAN Southern Africa webinar: https://www.youtube.com/watch?v=TSeKQidAZZA&t=547s Upcoming Face to Face courses: https://www.thehumandiver.com/hfid-level-2#section-1637697699737 Tags: English, Decision-Making, Gareth Lock, Situation Awareness…
 
In this blog, Bart Den Ouden shares a personal experience highlighting the importance of psychological safety, vulnerability, and human factors in diving. While teaching a rebreather instructor course, Bart forgot a critical piece of equipment, turning the oversight into a teachable moment. He emphasizes that instructors, as humans, can make mistakes, and fostering open communication and trust among divers is essential for safety and learning. By reflecting on errors—intentional or accidental—divers can improve team dynamics, decision-making, and preparedness, creating safer environments for themselves and others. Original blog: https://www.thehumandiver.com/blog/checking_each_other Tags: English, Bart Den Ouden, CCR, Human Error, Leadership, Psychological Safety, Rebreather, Teamwork…
 
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