The findings could also have a wider effect on how introductory scuba sessions are conducted.

The Coroner also indicated that the tour operator and three individuals involved in Farrell’s death could all be liable for prosecution under Australia’s health & safety in the workplace legislation.

The four-day inquest proceedings were reported on Divernet earlier this week. Farrell died on 17 February, 2015, during an introductory dive from the sailing catamaran Wings III at Blue Pearl Bay in the Whitsunday Islands.

The instructor leading her group at a depth of around 7m was said to have taken her eyes off her charges “for around 10 seconds”, during which time Farrell had become separated and ascended, but had been unable to maintain her surface buoyancy for more than 40 seconds, and subsequently drowned. Witnesses had heard her calling for help but the boat-crew had not seen her.

Coroner David O’Connell said that the separation had probably resulted from a combination of poor underwater visibility and lack of adequate instructor supervision. Farrell had died because she was in an unfamiliar environment and had been inadequately trained in using scuba equipment.

Her group had been briefed and tested on practical skills on the boat but had not been properly instructed about achieving and maintaining surface buoyancy. Farrell was also said to have experienced difficulties in operating her BC and regulator.

The Coroner’s report will now be considered by the Office of Industrial Relations (OIR) to decide whether it provides enough evidence to prosecute operator Wings Whitsunday Adventures, skipper Steven Croucher and trainee skipper Peter Hall, and dive instructor Fiona McTavish. The latter two no longer work for Wings.

The Coroner said that changes to the diving industry were vital to prevent a similar tragedy happening again, and is asking the OIR to review and consider his recommendations that:

  • There should be a maximum introductory diver-to-instructor ratio of 2-1, or 1-1 in poor conditions (such as current, visibility or surface chop).
  • The term “resort dive” should be renamed “introductory dive”.
  • Instructors should always be within arm’s-length of introductory divers, and link arms if conditions are assessed as poor.
  • Dive instructors must assess the dive-site using a Secchi disc to assess visibility, and carry out an in-water visual inspection at depth to assess horizontal visibility and current.
  • Elementary dive skills, including mask-clearing, regulator-clearing, regulator-recovery, buddy-breathing, BC inflate/deflate and emergency weight-belt dropping are taught until competently demonstrated, within a controlled environment such as a swimming pool.
  • Dive-groups are staggered and their routes determined to avoid interactions under water.
  • Diving instructors have the final decision on whether a dive proceeds or is terminated - not the tour operator or skipper, who could be influenced by commercial considerations.
  • Surface-watch personnel should have an emergency “grab-bag” including a weighted lost-diver marker, and instructors should carry a suitable underwater marker system.
  • Fins must have “Fin Safe”-style retainer strap.
  • If any diver becomes separated, all divers in a group must immediately surface and inflate their BCs, even though it is an emergency ascent.
  • The relevant Code of Practice be mandated as the minimum standard for operations, rather than being “guidelines” - to be considered within six months.
  • The Dive & Snorkelling Death Review Panel be reformed, preferably within three months.
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