‘Significant failures’ led to soldier’s dive death
AN inquest jury has found there were “significant points of failure” during a military diving training course that claimed the life of soldier Lance Corporal George Partridge four years ago.
L/Cpl Partridge, 27, of Yeovil, Somerset, was one of 12 soldiers taking part in the five-week course at a flooded quarry near Chepstow in March 2018 when tragedy struck.
On the first day of the fifth and final week of the course he died after running out of air in both his cylinders while at a depth of about 27 metres at the National Diving Centre in Tidenham, Gloucestershire.
He and another soldier had been sent down with a heavy 53m rope to attach to a submerged helicopter wreck as part of the training exercise. But during the dive, which exceeded the planned ten minutes of submersion, both L/Cpl Partridge’s main air cylinder and his second ‘bail out’ tank ran out of air.
The DTWC (diver through water communications) system was not working between him and his lakeside attendant during the dive and they were generally relying on signals by tugging on his lifeline, the inquest was told.
When lifeline communications from him stopped an emergency diver was sent down.
L/Cpl Partridge was brought to the surface within one minute but his face mask was hanging off and he was unconscious. Attempts to resuscitate him at the lakeside failed. The dive had begun at 11am and L/Cpl Partridge was brought to the surface at 11.17am.
At the end of a three-day inquest in Gloucester the jury returned a narrative conclusion stating: “There have been significant points of failure with regards to process and training, both within the AD2 (advanced diving) course and supervisor training which led to George Alastair Charles Partridge’s death.”
The jury went on to spell out in detail the training and supervisory failings it found had contributed to the tragedy. The jury’s finding followed a Health and Safety Executive investigation that led to a ‘Crown Censure’ of the Ministry of Defence in September 2020.
The HSE served two Crown Improvement Notices to the MoD at that time after finding there had been failures to train military divers how to undertake air endurance calculations and to assess the risk of running out of air.
The MoD is immune from prosecution but a Crown Censure highlights a failure to comply with health and safety law that would have been sufficient to secure a conviction in the criminal courts.
This week’s inquest was told by medical experts that L/Cpl Partridge’s cause of death was ‘sudden death in adult’. The postmortem examination had revealed he had a minor and previously undiagnosed anomaly in his right coronary artery. There was evidence he had suffered five separate medical ‘episodes’ during different endurance events at work but these had not been linked or ‘signposted’ by management.
A Royal Navy investigation into the tragedy in 2020 concluded that had “a clear audit trail of past issues with endurance events been visible” then “follow-on action may have been taken”.
The jury found that the cardiac event that ended L/Cpl Partridge’s life was due to depletion of air during the dive – either directly, or because of exertion and shock resulting from the lack of air.
The jury also listed other factors it found had contributed to his death, including failure to ensure the dive supervisor had been taught how to carry out air endurance calculations and therefore did not know how much faster a diver’s tanks would run out during deep dives and failure to ensure the dive did not extend beyond the planned and briefed 10 minutes.
The jury was also concerned that novice divers were allowed to complete dives without reliable two-way voice communications and that the use of a distance line (the 53m rope) that was three times longer than necessary – thereby increasing the likelihood of it becoming tangled – was permitted
At the end of the inquest the jury asked why the DTWC radio communications system that had failed during the incident was still in use at that time. They pointed out that it was brought into service in February 2002 and was intended to be in use for up to 15 years yet it was still being used in March 2018 despite “all the problems associated with it”.
The coroner said it was a “very pertinent question”.
He called into the witness box Ian Taylor, a diving life support manager in the Navy, who told the jury that the system was still being used because it remains the “market leader”.
“We know all the problems but it is basically the best out there,” he said. “We have now improved the system.”
L/Cpl Partridge’s family did not add any comments as they left the court after the inquest.