Inquest into the death of Mark MURPHY

Contributing factors

• Accidental full face mask dislodgement during underwater task
• Sudden facial exposure to cold water triggering diving reflex
• Physiological stress and autonomic conflict
• Inadequate risk assessment for standby diver capacity
• Inadequate daily risk assessments prior to dive
• Informal and incomplete briefing regarding evening drill
• Task loading not appropriately assessed for trainee divers
• Standby diver assigned concurrent attendant duties
• Standby diver lacking current fitness verification
• Lack of documented risk assessment for task location suitability
• Medical screening failure to identify recent chest pain and hospital admission
• Entanglement during rescue attempt

Coroner's recommendations

1. ADAS to review verification that trainee divers have obtained necessary medical certificates prior to commencing any diving, including chamber dives
2. ADAS to consider requiring applicants to provide contact details for treating medical practitioners when completing medical questionnaires
3. ADAS to review structure ensuring daily risk assessments are performed prior to every dive and trainees fully understand safe task performance
4. ADAS to review that documented risk assessments determine whether a standby diver can effectively and safely provide cover for particular numbers of trainees
5. ADAS to review accurate record-keeping of dives performed, minimum surface intervals, and repeated exposure to full dive experience
6. ADAS to amend procedures to explicitly require standby diver simulated rescue drill prior to first use in any course to assess fitness
7. ADAS to review that diver's attendant is not assigned other tasks interfering with attendant duties
8. ADAS to review appropriate assessment of task loading before trainee performs tasks introducing new competencies
9. ADAS to ensure 29 July 2015 notification changes reflected in Training Management System updates
10. ADAS to clarify that dedicated life line attendant should only attend upon one trainee diver at a time
11. Standards Australia to consider amending AS2815.1 to require standby divers carry additional second stage regulator deployable underwater and all trainees have alternative second stage regulator