Farrell, Bethany Emily

Contributing factors

• inadequate pre-dive skills training and assessment
• lack of controlled environment (pool) practice before open water dive
• poor dive site risk assessment
• inadequate instructor supervision - instructor looked away for 10 seconds
• separation of novice diver from instructor in poor visibility conditions
• failure of surface watch personnel to observe distressed diver
• deliberate negative weighting of novice diver without adequate BCD training
• poor visibility (3 metres)
• inadequate instruction on achieving and maintaining surface buoyancy
• lack of emergency signalling equipment training
• delayed rescue response

Coroner's recommendations

1. Office of Industrial Relations (WHSQ) within six months review Code of Practice to address: maximum 2:1 introductory diver to instructor ratios, 1:1 ratios in poor conditions (visibility, current, surface chop)
2. Rename 'resort dive' to 'introductory dive' in Code of Practice
3. Instructor must always be within arm's length of introductory divers; link arms if conditions are poor or very poor
4. Dive instructors must conduct formal dive site assessment including: secchi disk visibility measurement and in-water (at depth) visual inspection for horizontal visibility and current assessment
5. Elementary dive skills (mask clearing, regulator clearing and recovery, buddy breathing, BCD inflate/deflate, emergency weight belt dropping) must be taught to competency in controlled environment (pool) before open water dive
6. Dive groups should be staggered and routes planned to avoid underwater group interaction
7. Dive instructor, not skipper or tour operator, must have sole final decision on whether dive proceeds or is terminated
8. Surface watch person must have emergency grab bag containing weighted lost diver marker
9. Dive instructors must carry underwater marker system to indicate last known position of separated diver
10. Implement fin-safe style retainer straps for swimming fins
11. Consider policy that if any diver becomes separated, all divers in group must immediately surface and inflate BCD
12. Consider whether diving Code of Practice should be mandated as minimum standard rather than guidelines
13. Re-establish Dive and Snorkelling Death Review Panel within Office of Industrial Relations, comprising diving experts, government representatives, and industry personnel (not majority industry), with appropriate resourcing and separation from coroner's investigation function

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