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Safeguard OSH Solutions - Thomson Reuters

Safeguard OSH Solutions - Thomson Reuters



Safeguard Magazine

Incident investigation—Supervision failure

Summary

A Taiwanese tourist drowned during an introductory dive trip when she was left unsupervised and swam away from the group into open water. She spoke no English and was fitted with inappropriately sized gear.

CONTEXT

  • • 
    The dive company had run its “PADI Discover SCUBA” course for many years.
  • • 
    The company had used the enclosed bay near Hahei for years without problem.
  • • 
    Only one of the four Taiwanese tourists in the family group spoke or understood some simple English.
  • • 
    All of them were novice divers.

DETAIL

  • • 
    The members of the group were fitted with equipment and briefed for 45 minutes.
  • • 
    Two dive company staff took the group by boat to the dive site.
  • • 
    After a further briefing the four tourists got into the water.
  • • 
    One of the staff accompanied the victim for a ten minute dive before returning her to the surface and leaving her there in her dive equipment.
  • • 
    He then took her son for an individual dive of longer duration.
  • • 
    She is believed to have swum out of the bay, however this was not witnessed.
  • • 
    Her son returned to the dive boat at the conclusion of his dive.
  • • 
    No one realised the victim was missing from the bay for several more minutes.
  • • 
    Attempts were made to locate her within the bay and then beyond.
  • • 
    Emergency services were contacted 20 minutes after company staff began searching, resulting in local boats and the police helicopter joining the search.
  • • 
    An hour and 25 minutes after the 111 call she was located floating 1.3km away.
  • • 
    Her tank air supply had been exhausted.

BACKGROUND

  • • 
    The Coastguard had not been notified of the trip.
  • • 
    Staff on the boat were unable to provide an accurate location or coordinates of the bay to emergency services.
  • • 
    Staff had assessed the height and weight of participants by eye rather than by measurement.
  • • 
    As a result the victim was fitted with a BCD (buoyancy compensation device) that was too large for her.
  • • 
    This device would have made it more difficult for her to lift her head out of the water once her air supply had run out.

BROADER LESSONS

  • • 
    Close supervision is essential for high-risk adventure tourism activities.
  • • 
    Essential training and safety briefings must be delivered in a language or other way so that they are positively understood.
  • • 
    Their understanding should be positively determined before proceeding.
  • • 
    Adventure tourism operators need to stick to their safe operating procedures and guard against drifting away from them over time.

Thanks to WorkSafe New Zealand for its assistance with this column.

Thomson Reuters

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