Denis Cronin

Dear HM Coroner, On behalf of BSAC I note your letter of the 16 September 2016 and your report made in accordance with paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. We note particularly your finding that although the regulator freeflow occurred the situation was retrieved by Mr Cronin and his buddy and they were able to complete their ascent to the surface. However, at the surface Mr Cronin struggled and was unable to release his weightbelt and after swimming away from his buddy and sank. Had he been able to re~~~e F~'rs weigi~~k~~1t, remained with his buddy and use the alternate supply available to him, on the balance of probabilities he would have survived. BSAC in common with all concerned would wish to take any steps that might help prevent any similar or indeed any deaths and would assure the court that we continually strive to improve training and diving safety. Coroner's concerns The concerns raised by the Coroner follow the same numbering below and each is followed by BSAC's response together with an indication of the proposed timetable for action.
1. No Training record is kept to evidence when training/practice took place. Currently other than recording 'completed' training it is correct that there is no formal method or rolling programme of recording training. BSAC is currently rewriting its core Diver Training Programme. As part of the new programme a skills sheet for instructors to sign off individual skills rather than full lessons is to be provided for each grade to facilitate keeping an accurate training record in the branch. Additionally the proposed modularisation of aspects of training will further improve recording of any partial training completion. This skills record will be implemented upon release of the new Diver Training Programme. An initial release of the revised Ocean Diver syllabus is planned for early 2017 with other grades to follow over a period of 2017-2019. BSAC is also working to develop a new digital platform with which the organisation plans to make training records an integral part of the process so instructors can confirm diver's skill completion online in order Telford`s Quay, Sough Pfer Road, Ellesrnsre "~ ; t, Cl ~esi7irc; CHG~-~ =~~L
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.. , ~ ~ ~✓✓~~' ~ ~ ~ _ L1i~r~ ~rit~ ~r~~~c~~ that the student, their instructor, branch and the BSAC will have a record of training. This work is underway but there is no completion date or finalised solution as yet for the digital version. 2, Training was not in accordance with BSAC Sports Diver training. BSAC has a flexible approach to Diver Training. At Sports Diver level it would be acceptable to conduct lessons out of sequence as the pre-requisite skills are in Ocean Diver (the previous grade). The proposed new Diver Training Programme actually looks at a more self-contained modular approach from Sports Diver upwards that reflects these skills as separate dives rather than sequenced sl<ilis. We do not believe doing the lesson out of sequence was unreasonable, The plan for the second dive was for Mr Cronin to inflate the DSMB from a depth of around 17 metres. It took place at 20 metres. The BSAC instructions for Sports Diver are for the exercise to be conducted at 10 metres. We will send a reminder to all BSAC Instructors to follow the guidance for skills in the BSAC Diver Training Programme in the next issue of BSAC Instructor News to go out in February/March 2017.
4. A diver without the necessary qualifications and experience was permitted to teach Mr Cronin with no instruction otherwise. We will send a table to all BSAC Instructors in the next issue of BSAC Instructor News to go out in February/March 2017 reminding them of the instructor requirements for teaching each of the BSAC Diver Training grades.
5. No written risk assessments/templates were completed to ensure those responsible for the dive have focussed their minds to relevant circumstances. Currently we provide members with guidance and resources on our website i~tt~://w~rrw,bsac.c~rn(pa~~.asp?section..=15.86&sectionTitfe=Risk+Assessment .Included within this current section there are outline examples of Risk Assessment information for a selection of inland managed dive sites including for Stoney Cove http•//www bsac comf ~a~e asp~sectian=1596~sectiarsTitle=Risk+Assessment+--~inlaa~d+sites .We will review this information and look at how we could provide more interactive materials via a new digital platform. This review will be completed by the end of 2017.
6. The dive was not properly planned. A Safety and Development Manager employed by BSAC said he would not have done the final dive in the way that it was planned and conducted. Telford's Quay, Sot~tf7 Pier Road, Ellesmere '~ ~ t, Che:-"lire CH65 ~tFL "C: ~-4~ 0)251 U 0 62001 F: ~44~ {E7)~ ~~'' '_ ;~ ~''1 ~ E: ir~foC~~~s~c.cn~ : is"~": www.t~sac.~^~r~,,
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} ~► er~,~~, r '; y r ~.. ~~~ t,~°I~~ fr~l~. r ~ ~s We are conscious that any individual dive can be conducted in many different ways taking account of both prevailing and changing conditions. Instructors and divers each need to use their own respective skills and experience in planning and conducting a dive and be prepared to cope with factors that occur during the dive. Consequently we believe there is no single and/or simple means of highlighting a specific message in this instance but we will maintain and continue our efforts to educate divers and instructors appropriately. We will continue to utilise BSAC Talk (our member email), Instructor Bulletin and SCUBA Magazine to feature articles reminding all divers of the importance of dive planning and how to conduct it. Mr Cronin had previously dived to a maximum depth of 16.5 yet he was permitted to dive to 20 metres after an 8 month gap since his last open water dive. The depth limit for our entry diver grade is 20m and it would not be unreasonable for someone who had dived to 16.5m to progress to 20m after a gap. BSAC Diver Training programme incorporates depth progression for example within Ocean Diver training with for example 001 having a maximum depth of 6m and 002 is 10m. Should both dives be conducted on a single day the second deeper dive would be 2nd The primary reason for advising the deeper dive first derives from a common sense approach to decompression management. There is currently no documentary evidence to support nor contradict this advice. BSAC has ensured that progressive increases in depth between subsequent dives within the training programme do not exceed a 6m increment. At present we have no evidence that this recommendation presents a risk to divers. Indeed an international symposium on the subject in 1999 arrived at a similar conclusion with subsequent agreement that for dives shallower than 40m reverse profile dives were reasonably safe providing the difference between repetitive dives is 12m or less.
8. Signs containing important information and clearly displayed at several sites at the Dive Centre were not read. Evidence was heard that it was believed that there was not a need because it was not the first visit to the Dive Centre and a map of the site had been printed off the Internet in advance of the visit. One witness said that if he had seen the signs then it would possibly have made him think twice about doing the DSMB inflation exercise on another day. Diving and training takes place throughout the year in the UK in cold water and DSMB deployment in particular is a safety skill and should not be limited to training and/or practice only when water temperatures were convenient. The signs raise awareness to divers but in the admission of the operators of Stoney Cove are "overly cautious". In order to appropriately quantify the risks and if necessary revise any guidance BSAC would propose to interrogate its incident data, take industry advice and speak to experts in this field before if necessary issuing any revised guidance to ensure that all information gathering can be completed and carefully considered. Tel~orcl's Quay, Scrr,~h ('ier Road, Ed6esrtter~ Port, Cheshire Ck~~5 4FL ~~~~ ~.nr~ ;~ ~?~~ ~~~ ~7(t0 €a X44. s ~1~~ ~i~~ 621 ~. i~ ~.7r'=.~sa~ e~ ~~ ; ~~v: w~~;.~h- ,~,^.com _ ~ ~ J~ ~ ~ ~ E,~ ~,Y f~, i. i- ~ ~ 1~~' ~ a ~ f E' ~ t ' I r~ ~ 1 l ~ ~.:~ R ~ '.t . t ~ ~ ~ tPi ~ I~ ~ :~~~~ } f ~ A cvit~~ ~ re dsb~, -d a7 En;~i~r , , ;, ',. t ~ ~- -~r~J ~ t~itea~l `,~, " ~,=-oniee F r of ~ ~t: HRH ~i I c~ k7ul ~ ~ ~F ~ rbri~. ~ h~ ~- Kt. V tr ern Cl~,. ~: 3 t r.'E 1i

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9. The belt configuration meant that there was a foreseeable risk that it could not easily be released. The weightbelt and BCD configuration is not uncommon. BSAC training already requires practice of removal (own and buddy's) at every stage of the Diver Training Programme (DTP) and encourages regular practice (especially with new equipment). BSAC will feature weightbelt removal and its importance by producing a guidance document by February 2017 and subsequently remind instructors in the next issue of BSAC Instructor news about the importance of teaching this skill as outlined in the DTP. If the Coroner so desires we will forward copies of any of the above proposed communications and comments as they are completed. Once again BSAC is committed to promoting and encouraging the safe enjoyment of our sport by all divers and will continue to develop advice and training as appropriate and to take account of the lessons learned from any situation.

Dear Mrs Mason, Senior Coroner Dulwich BSAC 102 are keen to engage with and are fully committed to supporting the process of improving the safety of our sport for the future. However we are finding it challenging to see how many of the points raised can be effectively incorporated into recreational diving withoutfurtherguidance. As a branch of the British Sub Aqua Club we are reliant on the organisation for training, advice, and guidance. We understand BSAC have responded to this report and we will follow and comply with anyguidance produced by BSAC. In the meantime Dulwich would like to respond to each element:
1) A training record is kept in every divers log-book that they should have with them on every dive, this details dive time, depth and any training undertaken. The instructor has to sign off exercises. Where partial training has been completed the club will develop a means of recording this.
2) We will seek clarification from BSAC regarding sequencing of lessons.
3) The plan in the briefing was for DC to inflate the DSMB with an Assistant Instructor on hand when ascending from the Stangarth within sight of the fixed shot line (20 metres max or 15 metres from Deck). We had been assured Denis had completed dry practice, used a DSMB in the pool and confirmed to the instructor that he had done it "many times". We will remind all instructors to follow BSAC guidance in the training programme.
4) DC was accompanied by a Dive leader/Assistant diving Instructor another Assistant Diving Instructor and another Open Water diver, with a Full Instructor/Training Officer on shore. When separated by visibility he was with an Assistant diving instructor and no instruction was delivered from that point, All Instructors within the club have been reminded about instruction and supervision levels.
5) No written risk assessments are currently required when visiting a known site, this is in line with the current guidelines. We always produce a dive plan, log the dive and use a marshalling slate and follow BSAG safe diving practices with a full briefing and buddy checks before the dive.
6) The BSAC safety manager said that he would not necessarily have carried the dive out it in the same way, he subsequently confirmed that dives are carried out in different ways, by different people and this does not make them wrong or unsafe. We will seek further guidance form BSAC and advise all our members accordingly.

7) This is incorrect, he had dived to 18 metres over 3 hours before, the correct calculations for Nitrogen uptake were carried out before the second dive to ensure a sufficient and safe surface interval for a second dive at 2 metres deeper. This meant the second dive to a maximum of 20 metres was safe in accordance with the current guidelines. Denis was qualified to dive to 20 metres and Phil to 35 metres. It is our usual practice to dive the deeper dive first particularly when the first dive is for instance - a boat dive at 35 metres and the second dive may well be restricted to a 15 metre dive as the surface interval maybe restricted due to tides etc. This was not considered an issue when the second dive was only 2 metres deeper than the first and the correct calculations to ensure a safe surface interval were carried out.
8) The site is very large and 3 small signs were apparently displayed, one on the back of a door one in the lavatory and one on a map of the lake, none of these areas were visited by any of the divers, it is not a case of ignoring them, it is a case of not having seen them at all. Even if they had seen them the divers were briefed by their Instructor before the dive on what to do if they have a free flow, we do not consider it a "special" risk until5 degrees C as it can happen at any time. All divers on the day were using regulators designed for cold-water use. There is no temperature ceiling in any BSAC safe diving guidelines. We currently consider it unsafe not to use a DSMB, we are seeking clear guidance on what the best practice is going forward.
9) The weight belt and kit configuration is personal choice there are no existing guidelines governing this, the correct procedure -for removal of DC's weights was discussed in the briefing before the divers entered the water and DC informed Phil of the need to remove the harness crotch strap before the weights can be removed. DC also participated in a weight removal exercise that morning were he demonstrated the correct procedure for dumping weights to another diver, stressing the importance of ensuring they are held at arms length away from the body before being jettisoned. It had also been practiced dry and in the pool. We will continue to encourage students and qualified divers to follow their training and to practice regularly with their chosen configuration.