A New Zealand coroner is urging Vanuatu authorities to adopt a better safety regime in its diving industry following the death of a tourist who had hired substandard dive gear.
In an unusual case where he has been able to investigate a death outside of New Zealand's jurisdiction, coroner Brandt Shortland today released his findings into the drowning of US-born doctor Lailade Osunsade.
The 33-year-old Aucklander drowned in Vanuatu in May 2013 while diving the wreck of the SS President Coolidge, a troop ship which sank in about 42m of water during World War II.
Dr Osunsade had been diving for nine years and was on her fourth dive of the wreck, a one-on-one tour with a guide from local dive company Aquamarine when she signalled something was wrong..
However, they became separated and despite her guide heading to the surface for help, searchers later found Dr Osunsade's body was later found in the wreck.
Vanuatu police gave permission for the New Zealand police dive squad to investigate.
Mr Shortland refers heavily to the police report - not yet released - in his findings, which said some of her hired equipment needed immediate servicing and collectively led to her death.
"They found the equipment provided to Aquamarine to Dr Osunsade was substandard and the chartered dive ... was ill-fated," Mr Shortland said.
The air in her dive cylinder, which had a high water content, would have failed New Zealand standards and the cylinder contained foreign material, most likely from cleaning.
The cylinder valve may have been damaged and possibly overfilled. There were no records of when it was last tested.
Her regulator was in "extreme dire condition" and should have been replaced.
With 10kg of weights, she was overweighted and had dive boots and fins that were too big. She would have been working harder in the water and become more tired.
Dr Osunsade wasn't experienced enough to know her equipment wasn't safe, Mr Shortland said.
In his defence, Aquamarine owner Rehan Syed said he had bought the gear from an Australian dive company a year earlier and it had only been in use for two months.
He also said the gear was in storage in Vanuatu's hot and humid conditions for about 10 months before police examined it.
But Mr Shortland also said Dr Osunsade's lack of experience should have been clear to Aquamarine, as would have been her ill-fitting equipment.
Her death was unnecessary and avoidable, he said.
He backed police recommendations to prevent a similar death.
Mr Shortland said Vanuatu authorities should consider them.
"The recreational diving activities in Vanuatu are world famous and reported to be some of the best diving in the world. These recommendations can only but strengthen a thriving industry."
According to Vanuatu's Daily Post, Tourism Industry Trade and Commerce director George Borugu has established minimum safety standards for dive operators and they have to be certified and registered by an international body.
The president of the Vanuatu Scuba Operators Association Mike Crawford told the paper this month the majority of operators were above average, and there had been just one death in the past 25 years - a better record than many countries.