Thwaites, Andrew John
Deceased
Andrew John Thwaites
Demographics
44y, male
Date of death
2016-08-10
Finding date
2018-07-24
Cause of death
Carbon monoxide toxicity causing loss of consciousness and fatal drowning
AI-generated summary
A 44-year-old experienced recreational scuba diver, Andrew Thwaites, died during a dive on 10 August 2016 at Cherubs Cave, Moreton Bay, Queensland. He inhaled compressed air containing dangerously high levels of carbon monoxide (2,366 ppm compared to safe limit of 5 ppm), which caused loss of consciousness underwater and drowning. The air was filled at an amateur dive club's compressor that was poorly maintained by well-intentioned but unqualified volunteers. The compressor lacked proper maintenance records, temperature monitoring, and air quality testing. It had suffered overheating with evidence of lubricating oil ignition, causing carbon monoxide production. Critical lessons include: all breathing air compressors must comply with Australian Standards 3848 and 2299; regular air quality testing is essential; maintenance must be performed by competent persons using manufacturer guidelines; compressors require carbon monoxide detection systems; and divers should routinely test filled cylinders before use.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Inhalation of compressed air containing 2,366 ppm carbon monoxide (safe limit 5 ppm)
- Overheating of air compressor due to inadequate maintenance and ventilation
- Ignition of lubricating oil within overheated compressor cylinders
- Lack of formal maintenance system and records
- Lack of temperature monitoring on compressor
- Exhausted and ineffective filtration media
- Poor condition of oil with evidence of high temperature operation
- Absence of carbon monoxide detection or alarm systems
- Lack of air quality testing since 2011
- Volunteers operating compressor without technical qualifications or manufacturer manuals
- No compliance with Australian Standards for breathing air production
- Inadequate ventilation of compressor room
Coroner's recommendations
- All breathing air compressors should be fitted with a carbon monoxide alarm (threshold of 50-100 ppm would be sufficient to prevent death)
- Australian Standard 3848 for breathing air from compressors should be promoted to inform appropriate selection and use of compressors with proper filtration systems
- Compressor systems for production of breathing air should be maintained and repaired by competent persons trained according to manufacturers' recommendations and using approved parts
- Targeted information and education about safe use of breathing air compressors, including proper maintenance, should be provided; government funding should support Divers Alert Network to deliver targeted education and awareness campaigns about risks of carbon monoxide contamination
- Registration of all high-pressure breathing air compressors that are intended for or actually used to supply humans with compressed breathing air
- Three-monthly gas analysis of air from compressors and following any modification or repair (for dive clubs and commercial operators)
- Testing of at least one cylinder filled at each operation of a breathing air compressor
- Creation of appropriate training and certification system for filling compressed breathing gas tanks for diving
- Inclusion of diver recall procedure in boat safety and pre-dive briefings
- Encouraged use of written pre-dive briefing checklists to ensure coverage of important information
- Bare boat charterers should provide checklists detailing services provided and not provided, with signed confirmation from hirers
- Legislation relating to recreational diving (Safety in Recreational Water Activities Act 2011, Work Health Safety Act and Regulations, and Recreational Diving Code of Practice 2011) should be reviewed
- Dive vessels' capacity to immediately respond to drifting divers should be reviewed, with consideration of tender availability and anchor systems
- Police Dive Squad should be equipped with suitable initial testing device for air quality prior to formal laboratory testing
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