Finding into death of Logan Saminathan

Contributing factors

• Adverse weather conditions (high waves, strong surge, cold water, 14°C air temperature)
• Cold water exposure causing hypothermia or reduced dexterity and mental comfort
• Inadequate risk assessment by dive instructor for prevailing conditions
• Absence of formal written emergency plan for extracting unconscious diver from water at the pier
• Failure to cancel or modify dive when conditions were unsuitable for inexperienced student
• Possible panic response in inexperienced diver in cold water with mask displacement
• Strong surge under pier potentially dragging inexperienced diver into rough water
• Lack of practiced emergency procedures and appropriate rescue equipment

Coroner's recommendations

1. Informal recommendation (not formal per section 72(2)) that Parks Victoria consider trialling the provision of lifebuoys at Mornington Pier and other piers along the Mornington Peninsula where dive schools frequently operate for a three-year period and assess their availability and usefulness at the end of that period
2. Dive leaders and professionals should carefully assess site suitability under prevailing conditions, particularly for inexperienced divers, and consider worst-case scenarios
3. A plan to remove an unconscious diver from water should be developed for every dive site and should include consideration of special equipment that may be required
4. Where a site is in common use, a formal emergency plan should be devised and practised by dive professionals involved