clownfishsydney
Contributor
I will summarise again for those who do not want to read the original post or my web site. I will then summarise what the police and coroner's report say.
SS President Coolidge
The largest easily accessible real shipwreck in the world. She was a luxury passenger ship launched in 1931. She was 654 feet long, 81 feet wide, 34 feet deep and with a gross tonnage of 21,936 tons. During WWII she was used as a troop and equipment ship. On 26 October 1942 while entering Segond Channel in Espiritu Santo, New Hebrides (now Vanuatu), she hit two US mines and was run aground. She sank shortly after with the loss of two lives (interestingly, the bones of one were finally found earlier this year). She now lies 50 metres off shore on her port side. Her bow is in about 20 metres, the stern is 70 metres to the bottom. Shallowest part is about 18 metres. The shallowest dive is really about 30 metres (110 feet) all put one or two dives are very intense penetration dives. Dives are regularly conducted to over 45 metres. Until 2013, no diver had died on a dive conducted by one of the dive operators (three had died, but none were diving as part of a dive operator run dive).
Laila
Laila Ounsande was a 33 year old female US doctor who was living in New Zealand. She had learnt to dive in 2004 and since then had done many courses, but had only completed 37 dives. Virtually all of these were done as part of a dive course. She was 120 kg (obese). She travelled to Vanuatu and starting 29 April 2013 she did five dives, four of which were on the wreck. She had only a mask, dive computer and a lycra type short suit. All other gear was provided by Aquamarine (the dive operator she used). This included 10.5 kg (23 lbs) of lead weight, booties three or four sizes too big and fins that were also two sizes too big.
On her first dive on the wreck, she ended up with 10 bar in her tank (11.4 litres, about 95 cubic feet). It is not known if she had to use an emergency tank to complete the dive. The next day she did two dives, one on the wreck and the other at Million Dollar Point. A person I know dived with her and took photos and video which I have. In the video, when diving the wreck, she is breathing once every 1.7 seconds (I breathe once every 12 seconds normally). She ran out of air before they got back to the deco stop and had to use the emergency tank. Using my friend's dive computer profile, I have calculated that her RMV was about 28 to 31 litres per minute till she had to use the other tank. I use about 10 litres per minute on this same dive, most people would use between 11 and 15 litres I believe. She was also swimming vertically.
She did two more dives on the wreck, again, mostly ending up with 10 bar of air at the end (again it is not known if she used the emergency tank). ON both these dives she surfaced part way through the dive before descending again. After these dives, the people who were diving in her group complained as the dives were drastically cut short due to her bad air consumption. Also, most people reported oil tasting air on these and other dives.
On 2 May 2013 she again dived the wreck. Her guide once again (as it had been for all but the first dive), Simon Toa. The plan was to dive to the Doctors Office or The Lady (a ceramic figurine). There is confusion about which spot they were going to. Both these dives are over 40 metres and in the middle of the ship. According to the guide, they swam to the bow and followed the hull down to 23 metres to Euarts Door. This gives access to the middle sections of the ship and is a very common way to get in and out. Once here, they dropped down and entered the First Class Dining Room. Here Laila advised the guide she was not comfortable, so they turned around and exited the wreck via Euarts Door and started swimming back along the hull towards the bow. At some time, the guide (remember this is his story) looked around and Laila was not there. He quickly searched around but did not find her. He went back to the shore and raised the alarm.
People who had dived went out snorkelling looking for her or her bubbles. Two other guides took partly filled tanks and emergency tanks and went (apparently) straight to Euarts Door and went down and and found Laila in the lobby area with her regulator out of her mouth, her torch off and her fins missing. They brought her back to the deco area and released her and she went to the surface and was towed back to the shore. Despite CPR, she was declared dead about 20 minutes later.
Another diver claimed to have seen Laila swimming back alone to Euarts Door.
NZ Police Investigation
Vanuatu is a second or third world country, with no expertise to investigate incidents like this. Their investigation was very, very basic. New Zealand sought approval of the Vanuatu government to investigate on behalf of the NZ Coroner. The NZ Police sent a very experienced member of their dive squad to Vanuatu. He is also a qualified PADI and TDI instructor. He interviewed Simon Toa, the owner of Aquamarine, Rahan Syed and many others. He also interviewed via questionaires Australian divers who were present and involved in the recovery as well as my friend. They also got the video and photos and examined the tank, dive computer and other items of gear.
Dive Computer Profile
The dive computer was downloaded by the police and the profile was sent to me (and maybe others) for comment. The profile (shown below) clearly shows that the claims by Simon Toa about what happened are lies. It clearly shows that Laila never left the wreck, as she only ascended to 33 metres whereas Euarts Door is 23 metres, so she never got closer than 10 metres to exiting the wreck. Remember, Toa claimed in his statements to local and NZ police that she came out of the wreck and was lost on the way back to the bow. This also puts paid to the other witness's claims that he saw her re-entering the wreck.
The profile seems to show that Laila ascended to 33 metres and then fell unconscious. I base this on the fact that the descent from 33 metres to over 40 metres is absolutely constant and the line straight. I suspect that the tiny blip at the bottom of this descent is her body bouncing down inside and then rolling over and the computer moving till it rested in the one spot.
The Police Findings
The NZ police report includes many findings. Will summarise:
* The tank contained raised moisture levels, elevated carbon dioxide, and free water/corrosion particles
* The tank had never been tested in the six years since it was purchased and the owner's claims that they were regularly tested was false as the only people who could test had never done any in the time he had owned (over three years)
* Her booties were far too big as well as fins, meaning she would not be able to swim efficiently
* She was grossly overweighted considering the lycra suit she was wearing, probably about 21 lbs more than needed
* Her regulator sinter filter was almost totally blocked with residue (probably similar to the crap found in her tank) and appears to have not been serviced in many years
* Despite claims by the owner that gear was regularly serviced, evidence was given by former staff and backed up by the Australian distributors that service kits to service only 14 first stages and 8 second stages had been purchased over the past four years (they had at least 20 sets of regs)
* No regs appear to have been serviced in the three years before Laila's death
* Despite claims by the owner that the compressor was regularly service, evidence was given that only one out of three was working, it had been filled at one time with normal car engine oil and no filter items had been purchased in almost three years from the Australian distributor of the compressors (yes, may have been purchased elsewhere but dive operator did not provide any evidence to show this when asked)
* After Laila's death, a considerable amount of compressor spares were purchased from the Australian distributor
* Compressor filters were changed at 40 hours but based on average temperature for Santo, it should have been every 23 hours
* Aquamarine had no records at all to show when the regs or compressor had been serviced
* The lack of maintenance of the dive compressor is also consistent with that of the equipment used by Laila
Some quotes from the NZ police report:
* Based off the dive profile from the Deceased’s dive watch, I believe Mr TOA’s statements that he provided to Corporal SOLWIE on Thursday 2 May 2013, the Vanuatu Police CID Investigator on Friday 3 May 2013, and subsequently the statement to myself in March 2014, cannot be relied upon, as there are discrepancies between his statements and the Deceased’s dive profile in their entirety.
* In all interviews, Mr TOA told Vanuatu Police and me, both he and the Deceased exited the wreck of the SS President Coolidge and they swam towards the bow. I believe this did not occur....
* However, I believe there are doubts that Dr OSUNSADE exited the wreck through Euart’s Door (located at a depth of 28 metres approximately) as her depth is too deep and there is no change in the ascent rate at Euart’s Door on the Deceased’s dive profile.
Some of the NZ police findings:
* Aquamarine have failed to detect what I believe to be early warning signs of the Deceased’s ability to complete deep, technical dives on the SS President Coolidge. These include:
• Buoyancy control issues due to being over weighted
• Rapid breathing rate which lead to out of air scenario’s due to being over weighted and being issued ill-fitting dive gear (dive boots and fins)
• Her lack of dive experience, especially relating to deep dives and wreck penetration
• Feedback from other divers who complained about
* From tests and examinations, I believe that the dive equipment used by Dr OSUNSADE, and the circumstances in which she found herself in have contributed to her death.
* From being an ex PADI / TDI dive instructor and currently a Commercial Diver / Dive Supervisor, I find it incomprehensible that a dive guide can lose a customer in relatively good visibility, on a one on one dive. This is compelled further by the fact that the dive guide should have been aware of the Deceased’s problems in the water, particularly when they were diving one on one.
NZ Coroner's Findings
The NZ Coroner's findings are very long, but the important ones are:
* Laila drowned
* Mr Toa's version of the event is inconsistent with the technical recording of Dr Osunsade's dive computer which I prefer
* ...Dr Osunsade should not have been lost/misplaced during the fateful dive
* In my view the death was unnecessary and avoidable
Finally, my comments. This is another dive death that should have been 100% preventable. Proper assessment of Laila's diving ability should have shown that she was incapable of safely diving this wreck. In addition, the dive equipment provided to her (weights, regulators, booties, fins and dive tank and air) was either poorly maintained, the wrong size or totally in excess of what was needed, that any diver of any sort of experience should have recognised this. However, a diver with only 37 dives, virtually all of which have been conducted as part of a dive course, would have no ability to judge this.
I am happy to answer any questions on this matter. Note that my web site will be updated with all the above and more over the coming week. I will also post the NZ police report and the NZ Coroner's Report as soon as possible.
Avoid Aquamarine Santo at all costs!
SS President Coolidge
The largest easily accessible real shipwreck in the world. She was a luxury passenger ship launched in 1931. She was 654 feet long, 81 feet wide, 34 feet deep and with a gross tonnage of 21,936 tons. During WWII she was used as a troop and equipment ship. On 26 October 1942 while entering Segond Channel in Espiritu Santo, New Hebrides (now Vanuatu), she hit two US mines and was run aground. She sank shortly after with the loss of two lives (interestingly, the bones of one were finally found earlier this year). She now lies 50 metres off shore on her port side. Her bow is in about 20 metres, the stern is 70 metres to the bottom. Shallowest part is about 18 metres. The shallowest dive is really about 30 metres (110 feet) all put one or two dives are very intense penetration dives. Dives are regularly conducted to over 45 metres. Until 2013, no diver had died on a dive conducted by one of the dive operators (three had died, but none were diving as part of a dive operator run dive).
Laila
Laila Ounsande was a 33 year old female US doctor who was living in New Zealand. She had learnt to dive in 2004 and since then had done many courses, but had only completed 37 dives. Virtually all of these were done as part of a dive course. She was 120 kg (obese). She travelled to Vanuatu and starting 29 April 2013 she did five dives, four of which were on the wreck. She had only a mask, dive computer and a lycra type short suit. All other gear was provided by Aquamarine (the dive operator she used). This included 10.5 kg (23 lbs) of lead weight, booties three or four sizes too big and fins that were also two sizes too big.
On her first dive on the wreck, she ended up with 10 bar in her tank (11.4 litres, about 95 cubic feet). It is not known if she had to use an emergency tank to complete the dive. The next day she did two dives, one on the wreck and the other at Million Dollar Point. A person I know dived with her and took photos and video which I have. In the video, when diving the wreck, she is breathing once every 1.7 seconds (I breathe once every 12 seconds normally). She ran out of air before they got back to the deco stop and had to use the emergency tank. Using my friend's dive computer profile, I have calculated that her RMV was about 28 to 31 litres per minute till she had to use the other tank. I use about 10 litres per minute on this same dive, most people would use between 11 and 15 litres I believe. She was also swimming vertically.
She did two more dives on the wreck, again, mostly ending up with 10 bar of air at the end (again it is not known if she used the emergency tank). ON both these dives she surfaced part way through the dive before descending again. After these dives, the people who were diving in her group complained as the dives were drastically cut short due to her bad air consumption. Also, most people reported oil tasting air on these and other dives.
On 2 May 2013 she again dived the wreck. Her guide once again (as it had been for all but the first dive), Simon Toa. The plan was to dive to the Doctors Office or The Lady (a ceramic figurine). There is confusion about which spot they were going to. Both these dives are over 40 metres and in the middle of the ship. According to the guide, they swam to the bow and followed the hull down to 23 metres to Euarts Door. This gives access to the middle sections of the ship and is a very common way to get in and out. Once here, they dropped down and entered the First Class Dining Room. Here Laila advised the guide she was not comfortable, so they turned around and exited the wreck via Euarts Door and started swimming back along the hull towards the bow. At some time, the guide (remember this is his story) looked around and Laila was not there. He quickly searched around but did not find her. He went back to the shore and raised the alarm.
People who had dived went out snorkelling looking for her or her bubbles. Two other guides took partly filled tanks and emergency tanks and went (apparently) straight to Euarts Door and went down and and found Laila in the lobby area with her regulator out of her mouth, her torch off and her fins missing. They brought her back to the deco area and released her and she went to the surface and was towed back to the shore. Despite CPR, she was declared dead about 20 minutes later.
Another diver claimed to have seen Laila swimming back alone to Euarts Door.
NZ Police Investigation
Vanuatu is a second or third world country, with no expertise to investigate incidents like this. Their investigation was very, very basic. New Zealand sought approval of the Vanuatu government to investigate on behalf of the NZ Coroner. The NZ Police sent a very experienced member of their dive squad to Vanuatu. He is also a qualified PADI and TDI instructor. He interviewed Simon Toa, the owner of Aquamarine, Rahan Syed and many others. He also interviewed via questionaires Australian divers who were present and involved in the recovery as well as my friend. They also got the video and photos and examined the tank, dive computer and other items of gear.
Dive Computer Profile
The dive computer was downloaded by the police and the profile was sent to me (and maybe others) for comment. The profile (shown below) clearly shows that the claims by Simon Toa about what happened are lies. It clearly shows that Laila never left the wreck, as she only ascended to 33 metres whereas Euarts Door is 23 metres, so she never got closer than 10 metres to exiting the wreck. Remember, Toa claimed in his statements to local and NZ police that she came out of the wreck and was lost on the way back to the bow. This also puts paid to the other witness's claims that he saw her re-entering the wreck.
The profile seems to show that Laila ascended to 33 metres and then fell unconscious. I base this on the fact that the descent from 33 metres to over 40 metres is absolutely constant and the line straight. I suspect that the tiny blip at the bottom of this descent is her body bouncing down inside and then rolling over and the computer moving till it rested in the one spot.
The Police Findings
The NZ police report includes many findings. Will summarise:
* The tank contained raised moisture levels, elevated carbon dioxide, and free water/corrosion particles
* The tank had never been tested in the six years since it was purchased and the owner's claims that they were regularly tested was false as the only people who could test had never done any in the time he had owned (over three years)
* Her booties were far too big as well as fins, meaning she would not be able to swim efficiently
* She was grossly overweighted considering the lycra suit she was wearing, probably about 21 lbs more than needed
* Her regulator sinter filter was almost totally blocked with residue (probably similar to the crap found in her tank) and appears to have not been serviced in many years
* Despite claims by the owner that gear was regularly serviced, evidence was given by former staff and backed up by the Australian distributors that service kits to service only 14 first stages and 8 second stages had been purchased over the past four years (they had at least 20 sets of regs)
* No regs appear to have been serviced in the three years before Laila's death
* Despite claims by the owner that the compressor was regularly service, evidence was given that only one out of three was working, it had been filled at one time with normal car engine oil and no filter items had been purchased in almost three years from the Australian distributor of the compressors (yes, may have been purchased elsewhere but dive operator did not provide any evidence to show this when asked)
* After Laila's death, a considerable amount of compressor spares were purchased from the Australian distributor
* Compressor filters were changed at 40 hours but based on average temperature for Santo, it should have been every 23 hours
* Aquamarine had no records at all to show when the regs or compressor had been serviced
* The lack of maintenance of the dive compressor is also consistent with that of the equipment used by Laila
Some quotes from the NZ police report:
* Based off the dive profile from the Deceased’s dive watch, I believe Mr TOA’s statements that he provided to Corporal SOLWIE on Thursday 2 May 2013, the Vanuatu Police CID Investigator on Friday 3 May 2013, and subsequently the statement to myself in March 2014, cannot be relied upon, as there are discrepancies between his statements and the Deceased’s dive profile in their entirety.
* In all interviews, Mr TOA told Vanuatu Police and me, both he and the Deceased exited the wreck of the SS President Coolidge and they swam towards the bow. I believe this did not occur....
* However, I believe there are doubts that Dr OSUNSADE exited the wreck through Euart’s Door (located at a depth of 28 metres approximately) as her depth is too deep and there is no change in the ascent rate at Euart’s Door on the Deceased’s dive profile.
Some of the NZ police findings:
* Aquamarine have failed to detect what I believe to be early warning signs of the Deceased’s ability to complete deep, technical dives on the SS President Coolidge. These include:
• Buoyancy control issues due to being over weighted
• Rapid breathing rate which lead to out of air scenario’s due to being over weighted and being issued ill-fitting dive gear (dive boots and fins)
• Her lack of dive experience, especially relating to deep dives and wreck penetration
• Feedback from other divers who complained about
* From tests and examinations, I believe that the dive equipment used by Dr OSUNSADE, and the circumstances in which she found herself in have contributed to her death.
* From being an ex PADI / TDI dive instructor and currently a Commercial Diver / Dive Supervisor, I find it incomprehensible that a dive guide can lose a customer in relatively good visibility, on a one on one dive. This is compelled further by the fact that the dive guide should have been aware of the Deceased’s problems in the water, particularly when they were diving one on one.
NZ Coroner's Findings
The NZ Coroner's findings are very long, but the important ones are:
* Laila drowned
* Mr Toa's version of the event is inconsistent with the technical recording of Dr Osunsade's dive computer which I prefer
* ...Dr Osunsade should not have been lost/misplaced during the fateful dive
* In my view the death was unnecessary and avoidable
Finally, my comments. This is another dive death that should have been 100% preventable. Proper assessment of Laila's diving ability should have shown that she was incapable of safely diving this wreck. In addition, the dive equipment provided to her (weights, regulators, booties, fins and dive tank and air) was either poorly maintained, the wrong size or totally in excess of what was needed, that any diver of any sort of experience should have recognised this. However, a diver with only 37 dives, virtually all of which have been conducted as part of a dive course, would have no ability to judge this.
I am happy to answer any questions on this matter. Note that my web site will be updated with all the above and more over the coming week. I will also post the NZ police report and the NZ Coroner's Report as soon as possible.
Avoid Aquamarine Santo at all costs!
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