Update on the death of diver Judy Swann April 13, 2012

ONTARIO 2012: Fatalities - Summaries & Recommendations

I am assisting the Ontario Underwater Council with the writing of fatality reports following the death of any scuba diver in provincial waters.  I have posted an earlier version of the report - what follows is current as of April 29, 2012. 
The report was put together by:
Stephen Weir          Sport Safety Consultant
Ayisha Hassanali   Sport Safety Consultant
Raimund Krob        Sport Safety Advisor

One can see a more complete version of this report at the Ontario Underwater Council's website 

Fatalities - Summaries and Recommendations are listed in chronological order.


Dive Site:
On Friday, April 13th, a 58-year old Caledon woman (Judy Ann Swann) and her husband (Eric Tolton) were planning on doing a dive to check out her brand-new dry-suit. The locations they considered for doing so included Welland Scuba Park and Humber Bay Park West. They chose Humber Bay Park West because it was closer. As this would be their first time diving at this site, they obtained a briefing on the site beforehand.

Satellite image of incident site (blue dot):

Photo of North Beach Entry Point:

Photo by Raimund Krob

Dive Site Description:
The entry point is a rock beach a few metres/yards away from a parking lot. From shore, the bottom has about a 1:6 gradient, or 1 foot / metre of depth for every 6 feet / metres out. The day of the incident was sunny with mild winds and waves out of the south-west. Water temperature at the surface was 6 degrees C.

Dive Plan:
Eric and Judy’s dive plan was to first have Judy get geared up and go out to a depth just above her head and then do a buoyancy check, while Eric stood by on shore with additional weights if she needed them.
o      If Judy was able to descend, then she was to inflate & come back to the surface, wait for Eric to get geared up, and then the two of them would go on their dive.
o      If Judy was not able to descend, then the plan was for her to swim into shore, get the additional weights from Eric, and then do the buoyancy check again. If she was then able to descend, then she was to inflate and come back to the surface, wait for Eric to get geared up, and then the two of them would go on their dive.

When they arrived on site in the parking lot, they met another diver (Elliott Cristofoli) who was already preparing to go on his dive. Eric and Judy discussed the conditions with Elliott and then decided to use the north entry instead of the south entry because conditions while good in both locations were slightly better on the north.

Elliott then went on his dive while Eric and Judy unpacked and geared up.

Shortly after Elliott returned from his dive, Eric and Judy made their way from the parking lot to the north entry, a rocky beach a short walk from the parking lot.

Elliott recollected that Judy was fully geared up, and Eric had his dry-suit half on and was carrying two yellow two-pound weights.

Eric described Judy as feeling fine and excited about checking out her new dry suit.

Shortly after that, Judy entered the water with her snorkel in her mouth, but when she got out far enough to do her buoyancy check, something (not yet known) happened to her to cause her to become completely unresponsive. Eric shouted to Judy several times to put her regulator in her mouth, but she did not respond and then slowly sank under the surface.

Eric then entered the water with his dry-suit still half on. Judy had by then sunk to the bottom and was in a head-down, feet-up orientation. Eric described trying to reach Judy to inflate her suit, but with the flooded suit and underwear and cold water (6 degrees C at surface), it was impossible for him to do so, and so he began shouting for help.

A passing cyclist heard Eric’s cries and alerted Elliott, who was disassembling his gear and loading it into his trunk. Elliott grabbed his mask and ran to the beach. He helped Eric (who Elliott described as being in a state of hypothermia / shock) out of the water, and then swam out to help Judy. Elliott saw Judy outlined below but had no means of getting down to her.

Elliott then swam back to shore, ran to his car and got his bail-out bottle & regulator. He borrowed Eric’s fins, and then holding his bail-out bottle in one hand swam out to rescue Judy. With his other hand, he grabbed one of Judy’s legs, towed her into shallower water, inflated her BCD, and then proceeded to give her rescue breaths.

Bystanders assisted in the rescue effort, EMS was activated, and shortly afterwards the Metro Marine Unit responded, followed by land ambulance.

Judy was taken to St. Joseph’s Health Centre a short distance away, where she was kept on life support until approximately 5:00 p.m. on Sunday, April 22nd.

As of the revision date of this report, the Coroner’s office has not yet completed their testing and/or analysis of those test results, and has not yet notified the family of the cause of death or the reason for Judy becoming unresponsive in the first place.

Carotid Sinus Reflex was considered as a contributing cause but was ruled out as the neck seal of the dry-suit had previously been trimmed at the store during the fitting process.

OUC Recommendations to Prevent Recurrence:

1.     Buddy teams of divers should make every effort to do as much as possible together, including gearing up together, entering the water together, and checking buoyancy together.

2.     Dry suit divers should ensure their dry-suits are zipped completely closed before entering the water.

3.     Certain types of scuba equipment such as dry suits may be easier and safer to use with           appropriate Instruction / Training / Supervision beforehand. If you have any questions as to whether Instruction / Training / Supervision might apply to your scuba equipment acquisition, ask your local scuba professional (Retailer, Instructor, etc.).

4.     When checking out dry-suits for the very first time, divers should strongly consider doing so in a confined-water pool-like setting, rather than in an open water setting (many retailers and clubs book pools for this purpose).

5.     This incident was similar in many respects to the fatality of Robert Cupick in 2006, so OUC should make its “Ontario Scuba Diving Incident and Prevention Reports” more visible. . 

For public domain information of this incident, please refer to Section C, Appendix #1 of this document.


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