Karen Lee, a 42-year-old recreational scuba diver with 55 dives experience, drowned during a dive to the SS Coogee wreck in Port Phillip Bay. She demonstrated poor buoyancy control during her first dive and had difficulty managing her ascent during the second dive. She exceeded the planned 30-meter depth limit, and her buddy lost sight of her at 11 meters during ascent. The coroner found she likely ran out of air either at depth or during ascent, and failed to jettison her weight belt—basic protocol that could have assisted her survival. Contributing factors included inadequate buoyancy control proficiency despite formal certification, non-use of available shot lines and surface marker buoys, and a dive cylinder two months overdue for hydrostatic testing (though unlikely causative). The case highlights gaps in post-qualification competency testing for divers.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Poor buoyancy control despite formal qualification
Difficulty managing ascent rate during dive
Possible air depletion during ascent or at depth
Failure to jettison weight belt to assist ascent
Non-use of available shot line during ascent
Failure to deploy surface marker buoy
Dive cylinder two months overdue for hydrostatic testing
Dive cylinder contents gauge over-reading by 10-15 Bar
Coroner's recommendations
That consideration be given by Standards Australia and relevant stakeholders to amending the Australian Standards so as to require periodic assessment of qualified SCUBA divers in key techniques including, but not limited to, buoyancy control
That consideration be given by Standards Australia and relevant stakeholders to amending the Australian Standards so as to require Dive Charter operators to ensure divers carry a surface marker buoy and are instructed to use it appropriately
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