SH106: Language Matters: An HF Approach to Reviewing an ‘Accident Analysis’
Manage episode 441023877 series 3516753
In this podcast episode, we discuss a recent accident analysis published by RAID, which was framed as a hypothetical event but turned out to be based on a real-life diving incident without full consultation with those involved. The focus is on how we frame learning opportunities in diving and the importance of understanding the decisions made in the moment rather than placing blame after the fact. Effective accident analysis must explore the conditions and pressures present, fostering empathy and a learning culture within the diving community. A PDF review of this case is available in the show notes.
Original blog: https://www.thehumandiver.com/blog/language-matters-an-HF-approach-to-reviewing-an-accident-analysis
Links: PDF copy of the analysis text: https://bit.ly/THD_Incident_Analysis_Review
Learning from Unintended Outcomes training: https://www.thehumandiver.com/lfuo
Danish Maritime Investigation board report: https://dmaib.com/reports/2021/beaumaiden-grounding-on-18-october-2021
US Air Force report: https://www.afgsc.af.mil/News/Article-Display/Article/3850845/b-1b-accident-investigation-report-released/
Other reports and blogs: Roaring River Fatality
- Maltese Diving Fatality
- The role of ‘Agency’ in understanding adverse events.
- Unlocking the Secrets of Safer Diving: A Guide to Learning Reviews in Diving
- It’s obvious why it happened!! (In hindsight)
- Don’t just focus on the Errors – Look at the Conditions
Links: English, Gareth Lock, Incident Analysis, Incident Investigation, Incident Reporting, Just Culture
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