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-stop

Links: 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-investigation

LFEO program: https://www.thehumandiver.com/lfeo

HFiD 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.2009.01.004

What you find is what you fix: https://doi-org.ludwig.lub.lu.se/10.1016/j.aap.2010.07.003

Blog about agency/organisation standards: https://www.thehumandiver.com/post/beyond-the-floor

Speaking truth to power: https://www.thehumandiver.com/post/when-im-fine-isnt-true

Structural conditions that produce decisions: https://www.thehumandiver.com/post/the-structure-is-normal-the-scale-is-not

Other references: