Coroners Inquest Findings recommendations

I urge recreational divers to take these matters into account when diving.

The loss of a life is always a tragedy. Diving fitness is an important part of any SCUBA diving being undertaken.
Although we are unable to release information regarding this incident, the Police and Coroner has suggested we provide these recommendations to help prevent another incident.

Recommendations(a) Divers should wear a watch or other timing device to assist in planning their dives and be familiar with how to use it.

(b) Dives should be planned and recommended dive tables should be used to determine depth and time limits.

(c) Divers should ensure that they are medically fit to dive and should seek medical advice when:
(i) There are changes in health.
(ii) When the diver uses or changes medications.
(iii) When the diver turns 45 years of age and at least every five years after.

(d) Divers should monitor their air supply and end their dive at 50 bar.

(e) All members of a dive trip should be aware of what to do in an emergency.

(f) Divers should stay together for the duration of the dive.

(g) Divers should ensure that their dive equipment is of the correct size, is functioning correctly and is serviced annually.

Tragically, the cases reported to the Coroner demonstrate a continuation of the most common contributing factors as seen in previous years.

Those factors can be seen in detail in previous reports to save repeating, however we would like to emphasise the importance of regularly checking the safety and integrity of dive equipment, only diving when fit to do so, and always diving with a buddy.

We continue to see that in almost all cases, the dive flag ‘alpha’ was not displayed. Although not a contributing factor in the previous fatalities it is only a matter of time when it will feature in an unfortunate event if it’s not displayed to warn others that people are in the water, this can also help remind and reinforce in our own minds that when divers are in the water, the skipper and those on the vessel hold a fundamental responsibility to ensure they get back on board safe and sound.
We frequently hear of ‘near misses’ and there is much to be learned from these, in particular when divers have become separated from the vessel due to weather or other circumstances. These experiences highlight the often-underrated value of having equipment such as safety sausages and a whistle, and the importance of having a plan in place before initiating a dive. Everyone knowing the plan in case of an emergency, is also helpful in maintaining a sense of calm if the unexpected does happen and can have a positive result in finding the divers safe and well.

We encourage all divers to continue to develop their skills, understanding and knowledge of their equipment and processes. Spend the extra time before diving to create a plan, talk through possible scenarios and ensure everyone knows what to expect if the unexpected arises. Assess all the dive conditions thoroughly - this includes one’s own health and fitness in relation to diving, the equipment being used, and the weather.

Over one third of dive fatalities in New Zealand list a contributing factor as not being medically fit to dive, and almost fifty percent were not diving with a buddy. If we had one area our team would love all divers to make a huge effort in addressing, that would be to to always dive with a buddy for the whole dive.

To read  more on Water Safety NZhttps://www.watersafetynz.org/drowning-report-2023

We do hope our work on reviewing these tragic cases will contribute to everyone’s efforts to improve water safety for all the community including education/training of divers.