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    Tina Watson Death - Workplace Health and Safety Investigation Report
    When Tina Watson died diving the wreck of the SS Yongala on 22 October 2003, this incident was investigated by the Queensland Police as well as investigators from the Queensland Workplace Health and Safety, in particular, Chris Coxon, Principal Workplace Health and Safety Inspector (Diving).

    I have a series of articles on my web site about this incident and all that flowed from it. Click here to read about it.

    As mentioned, Chris Coxon investigated the matter as any death that happens in a workplace (and the ocean is a workplace when diving from a commercial operation) comes under their jurisdiction. It may also be that Leon Thomas investigated the matter before Chris Coxon's involvement.

    Coxon's investigation was done for their event ID number 12428. His report dated 26 August 2004 eventually led to the prosecution of the operator, Mike Ball Expeditions, for breaches of Queensland law.


    The Workplace Health and Safety Act 1995 placed obligations on people at workplaces to ensure workplace health and safety. To ensure workplace health and safety, the organisations need to identify and manage exposure to the risks at all their workplaces.

    Under the act, there are three types of instruments made to help meet these obligations. These are regulations, advisory standards and industry codes of practice.

  • If there is a regulation about a risk, then you MUST do that the regulation says.
  • If there is an advisory standard or industry code of practice about a risk, you MUST either:
  • do what the standard or code says; or
  • adopt and follow another way that manages exposure to the risk and take reasonable precautions and exercise proper diligence about the risk
  • If there is no regulation, advisory standard or industry code of practice about a risk, you must choose an appropriate way and undertake reasonable precautions and exercise proper diligence to ensure you meet your obligation.
  • In 1999 the Queensland Department of Employment, Training and Industrial Relations, Workplace Health and Safety unit, issued an Industry Code of Practice (ICOP) called Code of Practice Compressed Air Recreational Diving and Recreational Snorkelling. This was valid till 2005 when it was replaced by a similar code and basically, it is still in force with small changes.

    It seems that Mike Ball Dive Expeditions (MBDE) decided to implement its own code of practice. They created their own Dive Manual and Code of Practice and something they called the Safe Scuba System (SSS). The Manual and Code says (in part):

  • Dive Manual (Staff) - 4: Trip Director - Management Responsibilities = As directed by Government Regulations, the Trip Director is responsible for implementation of the Diving and Snorkelling Code of Practice.
  • Dive Manual (Staff) - 3: Trip Director Dive Duties, Duty of Care = Trip Director ensures that divers are correctly tagged according to the SSS prior to dive 1
  • Dive Manual (Staff) - 3: Trip Director Dive Duties, Safe Scuba System = Ensure all elements of SSS are implemented
  • Dive Manual (Key Procedures) - various: Dive Site Selection = Yongla, do as last day and a half of expedition. Between April and August can do as first day if weather is okay.
  • Dive Manual (Safe) - 2: Safe Dive Procedures = each guest fills out Safe Diving Procedures form
  • Dive Manual (Safe) - 2: Confidential Dive Status Discussion = confidential meeting with Trip Director (husbands and wives separate). Experience level coded plus orientations required noted on the Safe Diving Procedures form
  • Dive Manual (Safe) - 2: Experience Summary = Trip Director writes up the Dive Experience Summary. These are duplicated on another form and this is shown to dive staff and posted on dive deck
  • Dive Manual (Safe) - 4: Staff = Orientation dives can only be conducted by paid, insured MBDE dive staff, NOT EXPEDITION CREW
  • Dive Manual (Safe) - 4: Procedure = the Trip Director records on passengers Safe Diving form what orientations will be provided
  • Dive Manual (Safe) - 4: Assessment Guide = divers without Advanced Certification or 15 dives are required to do a safety orientation on their first reef, night and wreck dive [implies for each one]
  • there is another part that says if a person refuses to do an orientation dive as required by the SSS, then they must sign a form that warns them of the consequences of this (eg death) - unfortunately I cannot find the details now amongst the tens of thousands of pages of evidence I have
  • On 24 June 2003 Craig Stephen, Operations Manager for MBDE, sent a memo about the SSS which was directed at the Trip Director and said in part "Ensure green, yellow and red highlighter pens used to colour guests names". This was not signed by Wade Singleton, the Trip Director, but signed by most other staff.

    On 19 June 2003 Stephen sent another memo. This one was entitled Dive Procedures and WPHS. It said that staff, including Trip Directors, are not always complying with the MSE dive procedures. It also said that "you may be liable for to litigation" if you do not follow and something goes wrong. This was signed by Wade Singleton.

    The Safe Scuba System has a matrix as follows:

    Diver ExperienceDive Conditions
    GreenLess than 15 ocean divesLess than 0.5 m swell
    Minimum current
    YellowBetween 15 and 50 ocean dives0.5 to 1.0 m swell
    Moderate current
    RedMore than 50 ocean divesMore than 1 m swell
    20 kts or strong current
    25 m depth

    Green Divers
    First dive must do Reef/Wreck orientation dive. First night dive must be an orientation dive.

    After the orientation dive, Marginal skills means they cannot do a dive without supervision. Good skills means no further supervision for similar dives is required.

    Yellow Divers
    Must attend orientation briefing and debriefing prior to first dive [hard to see how you can debrief prior to the first dive - but that is what it says!!].

    Red Divers
    Can still be required to undertake orientation dives under another part. This is not really clear, but I think it means if they have done less than five dives in the past year. The other section that covers this contradicts the first part somewhat as it mentions 15 dives without saying ocean dives. It also requires Japanese divers with less than 50 dives to do ALL their dives as orientation dives.

    My wife Kelly is a risk manager (and a very experienced diver of course) and she considers that the SSS has holes in it everywhere and it does not ensure that divers are appropriately matched to the dive site.


    As indicated above, there is a link to a detailed explanation about what happened on 22 October 2003. A summary of my view about what happened is:

  • Tina had only ever done 5 dives, none in the ocean
  • Gabe had done 55 dives, with only 15 in the ocean and very few in the past four years
  • Gabe and Tina dived by themselves
  • There was a moderate current
  • Tina was grossly overweighted
  • About three to four minutes into the dive Tina indicated she wanted to abort the dive
  • They attempted to swim back to the access line against the current
  • Tina started panicking
  • Gabe attempted to tow Tina back
  • Tina overbreathed her regulator
  • Tina dislodged Gabe's mask and regulator
  • Gabe let go of Tina to replace his gear
  • Tina started sinking deeper
  • Gabe, now also panicking and positively buoyant, could not get to her
  • Gabe made a split second decision to ascend to get help
  • Tina drowned

    The report produced by Chris Coxon stated in point 89 that MBDE "reviewed their system of work and stated that they could find no fault with it" and claimed that advice had been given to Tina to undertake an orientation dive.

    Coxon stated that the Dive Procedures Manual (incorporating the SSS) complied with the relevant provisions of the ICOP (that is, adopting and following another way that manages exposure). He also stated that MBDE said "Singleton's deviation from the system is not a cause for concern other than the issue of the 'refusal to follow advice form'". Coxon says that "if a worker can abandon the system of work without comment, then the system can hardly be relied on as a defence".

    MBDE argued that Gabe Watson was an appropriate supervisory control. Coxon says that he was not as qualified or experienced as a dive supervisor. The MBDE manual in fact says that only paid MBDE staff can run an orientation dive.

    Coxon says that despite strong statements in the SSS, "its application appears lackadaisical. No action has been undertaken by MBDE to enforce the provisions". He also says that a novice diver does not have the skills to make a decision as to whether they need supervision. This responsibility cannot be abrogated in this way by the employer or their agent.

    Coxon's conclusions include "despite the systems...the system was not followed by a worker, Singleton" and " the employer has not identified Singleton's failure as a fault with its system".

    On 9 May 2007 Mike Ball Dive Expeditions Pty Ltd pled guilty in the Cairns Industrial Magistrates Court before Magistrate Suzette Coates. She fined them $6,500 but recorded no conviction. The maximum fine was $187,000.

    This must be viewed as a good result for MBDE, as Gabe and Tina had paid $7,718 for the trip and of course used virtually none of it.

    Click here to return to the main Tina Watson death page.

    Copyright © Michael McFadyen 1990 to 2024
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    This web site has been wholly thought up, designed, constructed and funded for almost 30 years by Michael McFadyen without any help from the Australian Dive Industry.
    Website created 1996!