SH284: LEODSI and PETTEOT: A Systems Approach for Understanding How Diving Really Works

When something goes wrong in diving, people often ask “who made the mistake?”, but that question usually oversimplifies what really happened and stops us from learning. The Learning from Emergent Outcomes framework (LEODSI) takes a different approach by looking at diving as a system, where outcomes are shaped by many interacting factors rather than one person’s actions. It examines seven key elements—people, environment, tasks, equipment, external pressures, organisation, and time—to understand how decisions made sense in the moment and how conditions combined to produce the result. Instead of blaming individuals, LEODSI focuses on why events unfolded the way they did, recognising that both successes and failures come from the same system. By using this approach in everyday debriefs, not just after incidents, divers and teams can learn more effectively, improve safety, and make meaningful changes that reduce risk in the future.https://www.thehumandiver.com/post/what-is-leodsi-petteotLinks: Learning from Emergent Outcomes course: https://www.thehumandiver.com/lfeoTags: Learning, Incidents & Just Culture