SH304: Why Investigations Stop Where They Stop

This episode explores why accident investigations often stop long before they uncover the full picture. Drawing on research from safety science, it argues that the “cause” of an incident is not simply discovered—it is shaped by who is investigating, what they are able to change, and what explanations their community accepts. In diving, investigations often focus on the actions of individual divers or instructors because these are the easiest problems to address, while deeper issues such as organisational culture, commercial pressures, and industry practices are left unexplored. The episode examines how different people can interpret the same event in very different ways, why every investigation helps shape the community’s understanding of safety, and why asking “Why did the investigation stop here?” can lead to far richer learning than simply accepting the reported cause.Original blog: https://www.thehumandiver.com/post/why-investigations-stop-where-they-stopLinks: The most complete data on diving fatalities from 2008: https://pubmed.ncbi.nlm.nih.gov/19175195/Blog exploring the purposes of running an investigation: https://www.thehumandiver.com/post/what-is-the-purpose-of-an-investigationLFEO program: https://www.thehumandiver.com/lfeoHFiD conference: https://www.hf-in-diving-conference.com/What you look for is what you find: https://doi-org.ludwig.lub.lu.se/10.1016/j.ssci.2009.01.004What you find is what you fix: https://doi-org.ludwig.lub.lu.se/10.1016/j.aap.2010.07.003Blog about agency/organisation standards: https://www.thehumandiver.com/post/beyond-the-floorSpeaking truth to power: https://www.thehumandiver.com/post/when-im-fine-isnt-trueStructural conditions that produce decisions: https://www.thehumandiver.com/post/the-structure-is-normal-the-scale-is-notOther references:Blazsin, H. & Guldenmund, F. (2015). The social construction of safety: Comparing three realities. Safety Science, 71, 16–27.Lundberg, J., Rollenhagen, C. & Hollnagel, E. (2009). What-You-Look-For-Is-What-You-Find — The consequences of underlying accident models in eight accident investigation manuals. Safety Science, 47(10), 1297–1311.Lundberg, J., Rollenhagen, C. & Hollnagel, E. (2010). What you find is not always what you fix — How other aspects than causes of accidents decide recommendations for remedial actions. Accident Analysis and Prevention, 42, 2132–2139.Rasmussen, J. (1990). Human error and the problem of causality in analysis of accidents. Philosophical Transactions of the Royal Society of London B, 327, 449–462.Rochlin, G. I. (1999). Safe operation as a social construct. Ergonomics, 42(11), 1549–1560.Shreeves, K., Buzzacott, P., Hornsby, A., & Caney, M. (2018). Violations of safe diving practices among 122 diver fatalities. Int. Marit. Health, 69(2), 94–98. https://doi.org/10.5603/imh.2018.0014van der Schaaf, T. W., Lucas, D. A. & Hale, A. R. (1991). Near miss reporting as a safety tool. Butterworth-Heinemann.Tags: THD-English| THD-Learning, Incidents & Just Culture