Coroner's Finding: SR
Deceased
SR
Demographics
58y, male
Date of death
2019-12-18
Finding date
2024-04-11
Cause of death
drowning
AI-generated summary
A 58-year-old man died by drowning while hookah diving off the Tasmanian coast. He was using second-hand equipment purchased online that had multiple safety deficiencies: inadequate filtration allowing contaminants and rust into the air supply, no snorkel increasing carbon monoxide exposure risk, excessively long hose (173m) reducing air pressure and flow, and an unsuitable scuba regulator designed for high-pressure systems rather than low-pressure hookah application. Contributing factors included his poor physical fitness (morbid obesity), lack of buoyancy compensator, heavy weight vest, and diving in thick bull kelp. The coroner noted the compressor's air delivery was compromised, forcing him to struggle for adequate breath. He panicked, ascended rapidly, removed his regulator at surface, became entangled in kelp, and drowned. The case highlights risks of unregulated home-made diving equipment and lack of mandatory training or fitness assessment for hookah divers in Tasmania.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- unsafe hookah diving equipment with inadequate filtration system
- unsuitable scuba regulator not designed for low-pressure hookah application
- excessively long air hose (173 metres) compromising air flow and pressure
- lack of snorkel allowing carbon monoxide exhaust gas inhalation
- rusted particle screen contaminating air supply
- morbid obesity and poor aerobic fitness
- lack of buoyancy compensator
- heavy weight vest without ability to release
- entanglement in bull kelp at dive site
- lack of formal diving training or qualifications
- no pre-dive medical fitness assessment
- inadequate understanding of diving safety principles
Coroner's recommendations
- Consideration of regulatory oversight of recreational hookah diving equipment in Tasmania, including equipment inspection systems and maintenance schedules
- Mandatory equipment safety standards for hookah diving apparatus
- Consideration of formal training and qualification requirements for hookah divers
- Promotion of pre-dive medical fitness assessments, particularly for divers over 45 years or those with medical conditions
- Continued promotion of MAST hookah diving safety educational video and safety messaging to recreational divers
- Awareness that hookah apparatus is a life support system that must be fit for purpose, well-maintained, and produce adequate quality breathing air
Full text
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