SH25: Human Factors Analysis of a Maltese Diving Fatality

In this podcast episode, we delve into the tragic details surrounding a fatal diving accident between friends, investigating a series of factors leading to the unfortunate outcome. The incident took place outside formal dive center procedures, raising questions about the supply of compressed air by unlicensed operators and the lax recertification requirements for divers. Numerous issues emerged, such as buoyancy problems, rapid ascents, and the management of finite gas supplies. The proceedings scrutinize team protocols, gas tracking, and a lack of rescue attempts, shedding light on the complexities of mixed diving methods and decision-making under stress. The podcast highlights the intersection of errors, environmental influences, and diver fatigue, questioning the inevitability of the final outcome and implications for the criminalization of buddy system failures in the diving community.

Original blog: https://www.thehumandiver.com/blog/human-factors-analysis-of-a-maltese-diving-fatality

Links:

Danish Maritime Accident Investigation Board on the grounding of the Beau Maiden: https://dmaib.com/reports/2021/beaumaiden-grounding-on-18-october-2021/

References and source materials:

Summary of the judgement: https://www.divinginfo.mt/?p=1751

Judgement details (in Maltese) https://ecourts.gov.mt/onlineservices/Judgements/Details?JudgementId=0&CaseJudgementId=135422

Facebook page of the Professional Dive Schools Association of Malta: https://www.facebook.com/PDSAMalta

Scuba Tech Philippines- Andy Davies: http://scubatechphilippines.com/scuba_blog/accident-analysis-gauci-2020/

Clapham Rail Crash report: https://www.jesip.org.uk/uploads/media/incident_reports_and_inquiries/Clapham%20Rail%20Crash.pdf

Never Events: https://humanisticsystems.com/2016/02/27/neverzero-thinking/

Case studies from the outdoor activities sector in Australia: https://uploadsproject.org/

Criminalising human error: https://humanfactors101.com/2022/05/08/is-human-error-a-crime/

Being aware of hindsight bias doesn’t mean we won’t fall foul of it: https://www.researchgate.net/publication/10631443_Hindsight_is_not_equal_to_foresight_The_effect_of_outcome_knowledge_on_judgment_under_uncertainty

The “Reasonable Man”: https://en.wikipedia.org/wiki/Reasonable_person

Rodando Vought case: https://humanfactors101.com/2022/05/08/is-human-error-a-crime/

Liability of a buddy: https://www.undercurrent.org/UCnow/dive_magazine/2002/LiabilityBuddy200203.html

BSAC Safe Diving Guide: https://www.bsac.com/safety/bsacs-safe-diving-guide/

BSAC Duty of Care and Welfare page: https://www.bsac.com/advice-and-support/club-support/duty-of-care-and-welfare/duty-of-care-and-welfare--club-checklist/

British Mountaineering Council Risk, Responsibility, Duty of Care and Liability Club Guidelines: https://www.thebmc.co.uk/Download.aspx?id=385

Work as Imagined vs Work as Done: https://www.youtube.com/watch?v=vtgIwHrUWVQ&list=PLNXuyLsCTX6hHS3newpcROfJ_JiI27q3C&index=24

Professional Diving Schools Association statement: https://www.facebook.com/PDSAMalta

Maltese Diving Regulations: https://legislation.mt/eli/sl/409.13/eng/pdf

Everest tragedy: https://www.amazon.co.uk/Destructive-Goal-Pursuit-Everest-Disaster/dp/023000332X

Loss of Situation Awareness blog: https://gue.com/blog/the-cause-of-the-accident-loss-of-situational-awareness/

The shooting down of US Blackhawks in Iraq: https://www.mindtherisk.com/literature/150-friendly-fire-the-accidental-shootdown-of-u-s-black-hawks-over-northern-iraq-by-scott-a-snook

Tags:

- English, Gareth Lock, Incident Analysis, Just Culture, Psychological Safety