Inquest into the death of Mark Murphy

Case Number: 2015/52737

Date of Findings: 1 July 2022

Magistrate: Deputy State Coroner, Magistrate Derek Lee

Catchwords: CORONIAL LAW – occupational diving, sudden cardiac event, drowning, full face mask dislodgement, standby diver, risk assessment, The Pit, Australian Diver Accreditation Scheme, Occupational SCUBA to 30m (Part 1) Course, Standards Australia

Responses

Recommendations

To the Executive Director, Australian Divers Accreditation Scheme (ADAS):

1. I recommend that ADAS review how the structure and operation of the ADAS Occupational SCUBA to 30m (Part 1) Course by Professional Divers Training Academy verifies that a trainee diver has obtained any necessary medical certificate prior to commencing any diving (including any chamber dive) during a course. 
2. I recommend that ADAS give consideration to whether applicants for the ADAS Occupational SCUBA to 30m (Part 1) Course should be required to provide the contact details for their treating medical practitioner (if any) when completing any medical questionnaire for the purpose of seeking certification of fitness to dive. 
3. I recommend that ADAS review how the structure and operation of the ADAS Occupational SCUBA to 30m (Part 1) Course by Professional Divers Training Academy (a) provides for daily risk assessments to be performed prior to every dive; and (b) ensures that trainee divers fully understand all the steps to perform a dive task safely. 
4. I recommend that ADAS review how the structure and operation of the ADAS Occupational SCUBA to 30m (Part 1) Course by Professional Divers Training Academy ensures that documented risk assessments are conducted to determine whether a standby diver can effectively and safely provide cover for a particular number of trainees at once, under the circumstances pertaining at a particular dive site. 
5. I recommend that ADAS review how the structure and operation of the ADAS Occupational SCUBA to 30m (Part 1) Course by Professional Divers Training Academy ensures that (a) accurate records are kept in relation to the number of dives performed by trainee divers; (b) minimum surface intervals between dives are accurately recorded; and (c) trainee divers are given repeated exposure to the full dive experience, in accordance with the ADAS Course Requirements Manual. 
6. I recommend that ADAS give consideration as to whether the ADAS Administration and Operation Procedures Manual should be amended to explicitly require that prior to a standby diver being used for the first time in any course, a standby diver simulated rescue drill is to be conducted so that the standby diver’s current fitness to perform the role can be assessed and verified. 
7. I recommend that ADAS review how the structure and operation of the ADAS Occupational SCUBA to 30m (Part 1) Course by Professional Divers Training Academy ensures that a diver’s attendant is not assigned or performing any other task which would interfere with the duties of the diver’s attendant. 
8. I recommend that ADAS review how the structure and operation of the ADAS Occupational SCUBA to 30m (Part 1) Course by Professional Divers Training Academy appropriately assesses the degree of task loading for a trainee diver prior to the trainee driver performing a task which introduces new competencies and/or requirements.
9. I recommend that ADAS ensure that the changes made in its 29 July 2015 notification are reflected in any updates to the ADAS Training Management System if such updates have not already occurred. 
10. I recommend that ADAS give consideration as to whether the change made it its 29 July 2015 notification requiring that each diver undertaking in-water training must have their own and dedicated life line tender/attendant requires clarification that the attendant should only attend upon one trainee diver at a time.

To the Chief Executive Officer, Standards Australia:

1. I recommend that a copy of the findings in the Inquest into the death of Mark Murphy be provided to Standards Australia for consideration as to whether AS2815.1 ought to be amended to provide that (a) all standby divers are to carry an additional second stage regulator that can be deployed in the water to a diver in distress; and (b) every scuba diver undertaking in-water training is to have an alternative second stage regulator that can be deployed should the primary breathing stage be lost or fail.