Scuba Diving and Snorkeling Safety on Australia's Great Barrier Reef

REVIEW ARTICLE

Scuba Diving and Snorkeling Safety on Australia’s Great Barrier Reef Jeffrey Wilks The Great Barrier Reef is one of the world’s most popular marine tourism destinations. In 1997, there were 1.5 million visitors to the reef, with marine tourism contributing around $650 million to the regional economy.1 Major tourist activities on the reef include snorkeling, scuba diving, fishing, swimming, glass bottom boat rides, reef walks and sailing.2 Industry figures show that in excess of one million recreational scuba dives are made from commercial vessels on the reef each year.3,4 Up to 80% of commercial reef visitors participate in snorkeling activities.5 International visitors consider snorkeling (19.6% mentioned) and diving (12.1%), to be the best feature of their trip to the Great Barrier Reef.5 Figure 1 shows the dimensions of the Great Barrier Reef Marine Park, and its position in relation to the Queensland coast. According to Windsor,4 the most concentrated scuba diving areas are in the Cairns Section of the reef, and the Whitsunday Islands off Mackay. At the level of individual dive sites, among the most popular, and internationally well known locations are, the Cod Hole (Cairns Section), Yongala wreck (Central Section off Townsville), and Heron Island in the Mackay/Capricorn Section off Gladstone.4,6 Snorkeling is undertaken throughout the Great Barrier Reef, especially on the islands, and from a range of commercial vessels. In June 1997, there were some 660 commercial operations in the Great Barrier Reef Marine Park, using 900 vessels.7

marine environment.9 For scuba diving, the overall safety record in Queensland appeared commendable for many years.10 Government sources suggest that only 1 in 430,000 Queensland dives results in a fatality, compared to 1 per 120,000 dives in the rest of Australia. In the United States, the rate is 1 death per 100,000 dives, while in Japan there are 6.5 deaths per 100,000 dives.11 Since there has never been a comprehensive audit of diving and snorkeling activity in Queensland, these fatality ratios are only best estimates. As noted by Hargarten12 in the context of international travel and motor vehicle crash deaths: It is difficult to assign risk to a cause of death and nonfatal injury if the numerator is incomplete and the denominator is virtually unknown. The same epidemiological constraints apply to diving and snorkeling fatalities. When it comes to nonfatal injuries the picture is even less clear. Early reports from the Queensland Dive Tourism Association13,14 showed a total of 27 accidents (including 3 fatalities) in 1989, and 34 accidents (including another 3 fatalities) in 1990. Unfortunately, this industry series was discontinued after the second report. However, information collected by the government’s Division of Workplace Health and Safety, from various sources, identified a further 14 deaths, and 260 injuries, resulting from underwater diving in Queensland between 1990 and 1996.15 The Division acknowledges that these figures probably underestimate the true level of morbidity, since some injuries may be missed in official reporting procedures, due to limitations on access to information held by hospitals and medical surgeries. This conclusion has been confirmed in other studies, which show that hospitals do not routinely distinguish between commercial and recreational dive injury treatments.10 In addition, apart from decompression illness, it is difficult to identify scuba diving related injuries, from general hospital records. In a recent study of seven Queensland coastal hospitals, 69 cases of decompression illness in tourists were identified over a 12-month period. For overseas tourists in Queensland, decompression illness was the second most fre-

Diving and Snorkeling Safety Safety has always been a concern for the Queensland marine tourism industry. However, as in other areas of tourist health and safety,8 very little reliable research is available on the incidence of illness and injury in the Jeffrey Wilks, PhD, LLB (Hons): Consultant Psychologist and Principal Research Fellow, Centre for Accident Research and Road Safety, Queensland, Australia. Reprint requests: Dr. Jeffrey Wilks, CARRS-Q, School of Psychology, Queensland University of Technology, Beams Road, Carseldine, Queensland 4034, Australia. J Travel Med 2000; 7:283–289.

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Figure 1 The Great Barrier Reef. (map courtesy of the Great Barrier Reef Marine Park Authority, used with permission)

quent type of injury requiring hospitalization (following fractures).16 Where information is available, it appears that many of the dive injuries officially reported tend to be serious injuries, including decompression illness, SCUBA related drowning,or CAGE (cerebral arterial gas embolism).13,14,17–19 No reliable figures exist for the number of snorkeling injuries in Queensland,20 though media reports periodically highlight snorkeling injuries, and fatalities, involving overseas tourists.21,22 While it can be argued that Queensland scuba diving and snorkeling are relatively safe, considering the large number of participants each year, a series of recent deaths and injuries, including the disappearance of American scuba divers Thomas and Eileen Lonergan,23 has again

raised questions about overall safety standards in this area of marine tourism.24 For travel medicine practitioners it is important that these questions be addressed. As Behrens and his colleagues25 note: A crucial prerequisite for giving balanced advice and assessing health risks is accurate epidemiological data on travel morbidity and mortality, preferably related to geographical risk. In order to understand the relevant risk factors, and to comment on current government safety initiatives, the following analysis of scuba diving and snorkeling fatalities in Queensland was undertaken.

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Scuba Diving and Snorkeling Fatalities

Table 2 Scuba Diving Fatalities in Queensland by National Group and Age: 1995–1998

Based on internal statistics provided by the Division of Workplace Health and Safety, Table 1 presents the number of fatalities recorded in Queensland for the period 1995–1998. A total of 13 scuba diving and 20 snorkeling deaths were reported, as required under the Workplace Health and Safety Regulation 1997, sections 52 and 53, which provide for the notification and recording of injuries, illnesses and dangerous events.26 Table 2 describes the scuba diving fatalities according to national group and age. A majority of the diving deaths involved Australians (7/13). All fatalities occurred on the Great Barrier Reef. Ages ranged from 19 to 58 years, with a mean (average) age of 40 years. There were 10 male and 3 female fatalities. The cause of death most frequently recorded was drowning. Unfortunately, no specific details of the contributing factors could be provided by the Division of Workplace Health and Safety. This lack of detail is an ongoing problem for researchers and policy makers, stemming from the nonstandardized reporting formats used by police, coroners, and marine transport authorities. However, discussions with officers from the Division of Workplace Health and Safety confirm that medical conditions, inexperience, failure to dive according to a set plan, and panic, are the major contributing factors to scuba fatalities.20 Table 3 presents the snorkeling fatalities according to national group and age. A majority of the snorkeling deaths involved overseas visitors (18/20), especially older people. Ages ranged from 14 to 78 years, with a mean (average) age of 52 years. All fatalities occurred on the Great Barrier Reef. There were 14 male and 6 female fatalities. The cause of death most often recorded was drowning, but again specific details were not available. Discussions with officers from the Division of Workplace Health and Safety confirmed that preexisting medical conditions, notably epilepsy, and cardiac disease, as well as fatigue, and panic, were the major contributing factors to snorkeling fatalities.20

National Group Australian American British Asian

Number

Age(s)

7 3 2 1

26, 30, 40, 45, 47, 49, 54 29, 34, 58 19, 45 45

Eileen Lonergan, and other incidents occurring around the same time, on 6 February 1998, the Queensland government commissioned a taskforce to review the appropriateness of workplace health and safety standards relating to recreational diving and snorkeling. The taskforce’s final report27 has recommended increased statutory regulation of the industry, and in particular, that more emphasis be given to certain safety procedures, especially site supervision, people counts, activity briefings, and medical and physical fitness to undertake recreational diving and snorkeling. As part of the review process, the government’s Division of Workplace Health and Safety has drafted new industry Codes of Practice for both scuba diving,28 and snorkeling.29 These Codes are currently available for public comment, and if approved by the parliament, will become law in Queensland. For the travel medicine physician advising patients about safely undertaking scuba diving and snorkeling activities on the Great Barrier Reef, or in other holiday locations throughout the world for that matter, a few important points can be highlighted from the Queensland experience. Health and Fitness Scuba Diving. In a recent report it was noted that scuba

In response to the worldwide media publicity surrounding the disappearance of scuba divers Thomas and

diving is generally not a physically demanding activity, but that it does require a reasonable level of health and fitness.30 In their review of 100 consecutive scuba diving deaths in Australia and New Zealand, Edmonds and Walker,31 found that in 25% of the cases there was a preexisting medical contraindication to scuba diving. In 9% of cases, the deceased had been specifically advised by a diving medical practitioner, and sometimes by a dive

Table 1 Recreational Diving and Snorkeling Fatalities in Queensland: 1995–1998

Table 3 Snorkeling Fatalities in Queensland by National Group and Age: 1995–1998

Year

Diving

Snorkeling

National Group

1995 1996 1997 1998

3 2 1 __7 13

1 6 10 __3 20

Government Safety Review

British American Asian European Australian

Number

Age(s)

6 5 4 3 2

29, 46, 67, 67, 72, 78 64, 65, 69, 72, 75 21, 24, 31, 51 21, 46, 60 14, 70

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instructor, that they were unfit for scuba diving. The leading causes of death for the 100 dive fatalities were drowning, pulmonary barotrauma, and cardiac disease. Also noteworthy were eight cases of asthma, and seven cases of respiratory disease. Edmonds and Walker31 concluded: Physicians and dive instructors are still confusing physical fitness (needed for many sports) and medical fitness (a freedom from medical diseases incompatible with safe diving). Both are required. To address the issue of medical fitness to dive, the Draft Code of Practice for Recreational Diving28 proposes that any person doing resort diving (alternatively known as introductory diving),32 must complete a medical declaration prior to starting the course. The Medical Declaration for Resort Diving, from the Draft Code of Practice, is presented in Appendix 1. If any medical condition is disclosed on this form, the draft code suggests that medical advice should be sought from a diving medical practitioner, before any diving takes place. An interesting item on the Declaration concerns alcohol use. If the information on the form indicates the prospective diver has consumed alcohol within 8 hours prior to the diving, the draft code recommends that he or she should not dive. Given that holidays are often a time of increased alcohol use, especially among young people,33 it is important for intending divers to know that drinking alcohol may preclude them from participating in scuba diving activities. In relation to certified divers, that is, divers who have completed a full open water training program,3 the draft code proposes that if the dive operator “has serious concerns regarding the medical fitness of a potential diver,” then the diver should be advised not to dive. In some situations, the diver’s fitness will be fairly obvious. For example, in the 100 fatalities reported by Edmonds and Walker,31 there were eight cases recorded as “gross obesity,” and a further four cases described as “very physically unfit.” However, in other situations, such as with asthmatics choosing not to disclose their condition,34 it remains extremely difficult for a dive operator to discover medical conditions that could be problematic. The types of medical conditions that preclude a person from participating in scuba diving are well documented. These include asthma, respiratory tract infections, poor lung function, pneumothorax, previous chest surgery, severe scarring of the tympanic membrane, cardiovascular disease, epilepsy, and diabetes.35,36 The advantage of knowing in advance about the Medical Declaration screening measure proposed for use on the Great Barrier Reef, is that travel medicine physicians can

better advise their patients about health requirements before they leave home. This in turn may avoid disappointment and embarrassment, if a patient is refused an opportunity to participate in scuba diving when they arrive at the marine destination. In a Queensland study on the legal content of adventure tourism brochures,37 it was clearly demonstrated that travelers cannot rely solely on tourist literature for health information. In that study, none of the 23 operators offering resort scuba diving courses mentioned, in their brochures, the requirement that candidates would need to complete a medical questionnaire to determine their fitness before diving for the first time. Similarly, Australian standards require a full medical examination of each candidate wishing to take a full scuba diving certification program.38 Only 6, of the 11 dive schools in the sample, mentioned this requirement. Since some studies show that approximately 20% of candidates fail a diving medical examination,35 appropriate medical advice prior to leaving home will greatly assist the traveler intending to scuba dive. Snorkeling. The Draft Code of Practice for Recreational Snorkeling29 also recognizes the possible risk posed by medical conditions: Snorkeling can be a strenuous exercise and some people may panic while snorkeling, especially if they are not experienced and they get into difficulty. Panic or strenuous activity can aggravate some medical conditions and certain medical conditions such as heart disease may result in cardiac arrest and death. Similarly, epilepsy may lead to unconsciousness and drowning, and some medical conditions are made worse through exposure to cold water or salt water mist. The draft code recommends that operators should ensure that people are advised not to snorkel if they have any medical condition which may be made worse because of strenuous activity. Heart disease, epilepsy, and asthma are specifically identified. Recognizing that some people will still go ahead with snorkeling despite a medical condition, the draft code further advises operators to request that the customer snorkel in an area that can be closely supervised, and that they wear a flotation device which is able to support them. While operators have a clear responsibility to increase site supervision, and people counts, to further enhance safety on the reef,39 at the same time travelers must take some responsibility for their own behavior. In particular, travelers must be encouraged to ask questions, seek help, and follow all directions given by staff at the marine destination.30 This includes the recommendation not to

Wilks, Scuba Di ving and Snork eling Safety

scuba dive or snorkel, if there are serious concerns about their fitness to participate in these activities. Recommendations and Conclusions Scuba diving is often presented as a high risk adventure activity,40 whereas snorkeling is generally perceived as a low risk form of recreation.20 For all adventure activities Brown41 suggests that: The best time to influence participants is during their choice and preparation phase—before they arrive. This early preparation and educational approach has been adopted by the Australian Water Safety Council,42 which recently recommended that all inbound tourists be provided with water safety information, and identification of appropriate aquatic locations and activities. According to the Council, the current drowning rate for overseas tourists is 13 per year (based on a 5 year average), and this represents 3.9% of all drownings in Australia each year. Similar figures have been provided by Mackie,43 who reports that 88 tourists, from 12 countries, drowned in Australia during 1992–1997. A total of 1,551 people drowned in that 6 year period. Whereas the total number of international visitors to Australia is increasing each year (from 2.9 million in 1993 to 3.7 million in 1995 to 4.3 million in 1997),44 the Council acknowledges that there is still little accurate statistical information to provide a true picture of the difficulties overseas tourists experience in the water. Scuba diving and snorkeling appear to be making a disproportionate contribution to national drowning figures, especially considering that many fatalities are occurring in supervised workplaces. Clearly, some preexisting medical conditions are being aggravated by panic, or strenuous activity, leading to life threatening situations. Two strategies are required to prevent morbidity and mortality in this area of marine tourism. The first is adequate medical advice, and preparation, before the patient leaves home. This is the domain of the travel medicine practitioner. The second strategy is to develop a high level of supervision, and support, for travelers in the marine setting. Current legislative reforms in Queensland are aimed at delivering “best practice” in marine safety, with standards and procedures that can be adapted for snorkeling and scuba diving at other destinations. For the travel medicine practitioner, the Queensland Codes of Practice for Recreational Diving and Snorkeling provide a useful framework for advising patients about water safety issues prior to departure on their vacation. The common types of medical conditions that preclude

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a person from participating in scuba diving are covered on the Medical Declaration for Resort Diving. This form can be used as a basic screening measure for patients intending to either dive or snorkel, and also as a tool for initiating general discussion about water safety issues at the marine destination. Snorkeling, in particular, has been identified as an activity that may pose difficulties for some overseas visitors to the Great Barrier Reef, especially older tourists. Based on current research findings, and the government’s draft Codes of Practice, it is recommended that patients with any medical condition which may be made worse through strenuous activity, should be advised not to snorkel. Acknowledgments An earlier version of this paper was presented at the 6th Conference of the International Society of Travel Medicine, Montreal, Canada, 9 June, 1999. Data provided by the Queensland Division of Workplace Health and Safety is gratefully acknowledged. Special thanks are extended to Anne Quinnell for advice and assistance. References 1. Great Barrier Reef Marine Park Authority. Tourism and recreation—information sheet. Townsville: Great Barrier Reef Marine Park Authority, 1998. 2. Coopers & Lybrand Consultants. Reef tourism 2005. Structure and economics of the marine tourism industry in the Cairns section of the Great Barrier Reef. Final report. Sydney: Coopers & Lybrand Consultants, 1996. 3. Wilks J. Calculating diver numbers: critical information for scuba safety and marketing programs. SPUMS J 1993; 23:11–14. 4. Windsor D. A study into the number of dives conducted on the Great Barrier Reef in 1994. SPUMS J 1996; 26:72–74. 5. Burns D. A profile of marine tourism marketing and future options. Cairns: Reef Tourism 2005, 1997. 6. Wilks J. Choice dive spots in Queensland. Scuba Diver 1991; August/September: 26–28. 7. Tourism Review Steering Committee. Review of the marine tourism industry in the Great Barrier Reef World Heritage Area. Part 1: key findings and recommendations. Townsville: Great Barrier Reef Ministerial Council, 1997. 8. Wilks J, Grenfell R. Travel and health research in Australia. J Travel Med 1997; 4:83–89. 9. Wilks J, Atherton T. Health and safety in Australian marine tourism: a social, medical and legal appraisal. J Tourism Stud 1994; 5:2–16. 10. Wilks J. Scuba safety in Queensland. SPUMS J 1993; 23:139–141. 11. Santoro S. Ministerial statement. Workplace health and safety in the diving industry. Queensland Parliamentary Debates 6

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August. Brisbane: Queensland Legislative Assembly, 1996: 1997–1998. Hargarten SW. International travel and motor vehicle crash deaths: the problems, risks and prevention. Travel Med Int 1991; 9:106–110. Queensland Dive Tourism Association. Dive tourism accident bulletin, issue no. 1, June 1989. Brisbane: Queensland Dive Tourism Association, 1989. Queensland Dive Tourism Association. Dive tourism accident bulletin, issue no. 2, June 1990. Brisbane: Queensland Dive Tourism Association, 1990. Division of Workplace Health and Safety. Regulatory impact statement. Workplace health and safety (underwater diving) compliance standard 1996 under the Workplace Health and Safety Act 1995. Brisbane: Division of Workplace Health and Safety, 1996. Wilks J. Diving safety in Queensland: some observations. SPUMS J 1997; 27:77–79. Walker R. 50 divers with dysbaric illness seen at Townsville General Hospital during 1990. SPUMS J 1992; 22:66–70. Walker D. Project Stickybeak. In: Wilks J, Knight J, Lippmann J, eds. Scuba safety in Australia. Melbourne: JL Publications, 1993: 54–63. Marks A, Fallowfield T. A retrospective study of decompression illness in recreational scuba divers and scuba instructors in Queensland. In: Safe limits: an international dive symposium. Symposium proceedings. Brisbane: Division of Workplace Health and Safety, 1994: 52–59. Wilks J. Applying risk management to snorkelling and scuba diving activities on Australia’s Great Barrier Reef. Paper presented at the 6th Conference of the International Society of Travel Medicine, Montreal, Canada, 9 June, 1999. Reid R. Battle to keep tourists safe. Sunday Mail, 27 October 1996: 71–73. Wright J. Dive industry defends safety despite deaths. Courier Mail, 11 January 1999: 2. Nunan N. Findings in the matter of an inquiry into the cause and circumstances surrounding the disappearance of Thomas Joseph Lonergan and Eileen Cassidy Lonergan. Transcript of proceedings, no. 52 of 1998. Cairns: Coroner’s Court, 1998. Metcalf F. Lawyers call for dive industry overhaul. Courier Mail, 27 June 1998: 19. Behrens RH, Steffen R, Looke DFM. Travel medicine. 1. Before departure. Med J Aust 1994; 160:143–147. Workplace Health and Safety Regulation 1997. Workplace Health and Safety Act 1995—subordinate legislation 1997 No. 409. Brisbane: Queensland Legislative Assembly, 1997.

27. Diving Industry Taskforce. Review of workplace health and safety arrangements for recreational diving and snorkelling. Final report to the Minister for Employment, Training and Industrial Relations. Brisbane: Queensland Workplace Health and Safety Board, 1999. 28. Division of Workplace Health and Safety. Recreational diving using compressed air. Draft industry code of practice. Brisbane: Division of Workplace Health and Safety, 1999. 29. Division of Workplace Health and Safety. Recreational snorkelling. Draft industry code of practice. Brisbane: Division of Workplace Health and Safety, 1999. 30. Wilks J. Scuba diving safety on Australia’s Great Barrier Reef. Travel Med Int 1999; 17:17–21. 31. Edmonds C, Walker D. Scuba diving fatalities in Australia and New Zealand. Part 1. The human factor. SPUMS J 1989; 19:94–104. 32. Wilks J. Introductory scuba diving on the Great Barrier Reef. Aust Parks Recreat 1992; 28:18–23. 33. Ryan C, Robertson E. New Zealand student-tourists: risk behaviour and health. In: Clift S, Grabowski P, eds. Tourism and health: risks, research and responses. London: Pinter, 1997: 119–138. 34. Cullen R. Novice recreational scuba divers and asthma: two small surveys reported. SPUMS J 1995; 25:8–10. 35. Parker J. The diving medical and reasons for failure. SPUMS J 1991; 21:80–82. 36. Edmonds C, Lowry C, Pennefather J. Diving and subaquatic medicine. 3rd Ed. Sydney: Butterworth-Heinemann, 1992. 37. Wilks J, Atherton T, Cavanagh P. Adventure tourism brochures: an analysis of legal content. Aust J Hosp Manage 1994; 1:47–53. 38. Standards Association of Australia. Australian Standard 4005.1—Training and certification of recreational divers. Part 1: Minimum entry–level SCUBA diving. Sydney: Standards Association of Australia, 1992. 39. Wilks J, Davis RJ. Risk management for scuba diving operators on Australia’s Great Barrier Reef. Tourism Manage 2000; 21: (in press). 40. Pedersen DM. Perceptions of high risk sports. Perceptual and Motor Skills 1997; 85:756–758. 41. Brown I. Managing for adventure recreations. Aust Parks Recreat 1989; 25(4):37–40. 42. Australian Water Safety Council. National water safety plan. Sydney: Australian Water Safety Council, 1998. 43. Mackie IJ. Patterns of drowning in Australia, 1992–1997. Med J Aust 1999; 171:587–590. 44. Bureau of Tourism Research. International visitor survey 1997. Canberra: Bureau of Tourism Research, 1998.

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Appendix 1

289

Medical Declaration for Resort Diving

Surname

Given name

Address

Date of birth

Phone

/ / . Sex:

Male or Female

Have you suffered from, or do you now suffer from, any of the following Yes

No

Yes

No

Yes

No

Asthma or wheezing Brain, spinal cord or nervous disorder Chest surgery Chronic bronchitis or persistent chest complaint Chronic sinus conditions Collapsed lung (pneumothorax) Diabetes mellitus (sugar diabetes) Ear surgery Epilepsy Fainting, seizures or blackouts Heart disease of any kind Recurrent ear problems when flying Tuberculosis or other long-term lung disease Are you currently suffering from Breathlessness Chronic ear discharge or infection High blood pressure Other illness or operation within the last month Perforated eardrum

Are you currently taking any medicine or drug (excluding oral contraceptives)? Have you ingested any alcohol within the 8 hours prior to diving? Are you pregnant? Do you understand that concealment of any condition incompatible with safe diving might put my life or health at risk? Signature Witness (Appendix 1 reproduced from reference 28, with permission)

Date