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    Tina Watson Death - Part 6 - Wreck Re-enactment and Coroner's Inquest

    Click here for the previous part of this article.

    YONGALA RE-ENACTMENT OF THE DIVE

    The Police decided to re-enact the dive on the Yongala. They consulted with Dr Richard Brinkman, an oceangrapher at the Australian Institute of Marine Science, Townsville, to try to find some dates when the conditions (particularly currents) would be similar to those experienced on 22 October 2003. Dr Brinkman had not made any particular study of the Yongala wreck but he did some analysis of the tides around the wreck.

    Brinkman said that there were three things that caused currents in the Great Barrier Reef area, tides, the East Australian Current (EAC) and south-easterly winds. He was apparently not asked to consider currents and the impact they would have on the wreck, only tides!!! I find this very strange as I would have thought that the EAC would be a primary influence on the currents as it is known that the current is generally always from the one direction, that is north or perhaps north-west.

    In fact, on page 519 of the Inquest transcript, a document of emails between Kinghorn, Dr Brinkman and Senior Constable Scott Cornish, was tendered to the Inquest that seems in my view to contradict his own views as presented at the Inquest in person (see below). This document stated "the current regime...will be due to the interaction of the wind driven coastal flow and EAC driven southerly flow".

    Brinkman also advised in a letter dated 17 January 2008 that at the time of the fatal dive on 22 October 2003, the tidal currents would have been running south to north. This, of course, was almost completely the opposite of the real situation and appears to have been totally ignored.

    When Brinkman testified at the Inquest, he advised that he had used tidal data from Stanley Reef which is located 25 miles (40 km) to the east of the Yongala. As far as I can see, Cape Bowling Green is only 12 nautical miles (22 km) to the west and may have also been a possibility [the dive operator I have used to dive the wreck uses Cape Bowling Green tides]. I have checked and Stanley Reef appears to have much higher low and high tides than Cape Bowling Green, by perhaps 0.5 to 0.6 metres, and has many other reefs nearby which would (I think) influence how the tides behave. From when I dived here in November 2014, the operator seemed to use tide times for Cape Bowling Green. The slack water appeared to occur about 2.5 hours after the high tide there.

    In any case, Brinkman advised the Police of three "envelopes of time" when he thought the conditions may have been similar. One of these was 20 to 22 September 2006.

    On 20 September 2006 when the Police went out to the Yongala there was said to be no current at all [video shows that there was a current, from the south or south-west]. The first dive they did was to identify where Tina was found by Wade Singleton. Wade dived with Constable Ricky Murdoch and put a marker (1) on the location where he found Tina. Wade put another marker under the bow (6) [a big conflict of interest here as Wade was really a possible suspect if a proper investigation was carried out]. Another marker was placed at the end of what Kinghorn called "the stack" (7) but which in reality is a fallen mast. It was 8.7 metres from 1 to 7 and 17.2 metres from 1 to 6 and 16.2 metres from 7 to 6.

    Bow MarkerEnd of Drift 1
    Marker 6 under the bow, note it appears
    to be not straight under the bow
    Kinghorn at the end of Drift 1

    Comment: Note that as of November 2014 the bow section has collapsed a little, the first hold is no longer square and the former vertical sections now rest at an angle of at least 45 degrees.

    Note that I believed right from the start that the spatial diagrams produced for the inquest overstated the length of the mast from where it hangs over the starboard side of the wreck. On the diagrams it appears to be about 7 metres long. From the Police video and photos, I believed that it was closer to 4 or perhaps 4.5 metres. This has a big impact on diagrams shown to the Coroner about where Tina ended up and where the re-enactment drift dives ended up. In November 2014 I checked and I think that it is about 4.5 to 5 metres. I also believe that the collapse of the bow has caused the change from what I first thought.

    In addition, I believe that the location of marker 1 was possibly not correct. It looks from photos that it was placed about two metres to the south of the bow, rather than directly under it. The problem is that the spatial diagrams, the bearings from one point to another, the distances from one point to another and the GPS co-ordinates for the wreck do not seem to me to compute.

    The Police do not seem to have tried to recreate Gary Stempler's photograph to enable them to accurately ascertain the location where Tina landed [I find this incredible - I would have thought that this would be the first and most obvious thing you would do]. It would have easily shown Tina's location.

    In November 2014 I attempted to work out where Tina was using the photo as a guide. It was hard to actually do as the visibility on the five dives I did there then was less than the fatal day, so it was hard to get the same view. In addition, the objects in the photo are mostly mobile items (coral, coal? etc) so it is hard to align the view with the photo. However, I think that I was correct that Tina was not the 16 metres off the wreck that the Police claimed. I believe that it was more like 10 metres at the most which is about what most people who saw Tina claimed it was (including Singleton in his original statement).

    Other Police dived that day. The only video taken was by Sergeant Adam Reid (OIC of the Dive Squad) and shows Senior Constable Cornish swimming ahead of him down the DAP to the wreck and along the wreck to the masts south of Hold 1. In this video, both Reid and Cornish smash into the coral on the wreck virtually the whole way. As far as I know, they were full-time members of the Queensland Police Dive Squad. If this is the case, then I really have questions about the training and abilities of these divers and their involvement in this re-enactment. Reid's video is out of focus most of the time, his breathing in the first few minutes is about once every four or five seconds [I breathe underwater about once every 12 to 14 seconds] although it later settles down to about once every 10 seconds.

    Yongala Diagram
    A drawing of the SS Yongala someone sent me
    GT is where I think Gabe and Tina were when she knocked his mask loose
    K is where Kinghorn started his first "drift"
    The back blob under K is Hold 1 where Kinghorn ended up
    7 is under the mast and 6 under the bow
    Created by me based on the evidence at the Inquest
    1 is where I thought Tina ended up but I now think it was to the left of 7 and out a little

    The next day, 21 September 2006, Kinghorn donned Tina's BCD, regulators and mask. However, he wore his own wetsuit and tank and presumably the weights he would normally use. None of this appears to have been recorded and is very relevant. The weight needed to be carried by a diver (using the same thickness wetsuit) is normally related to the weight v height of a diver. A short overweight diver will need a lot more weight than a skinny tall diver. Kinghorn had a BMI (Body Mass Index) of 28 compared to Tina's 21. Therefore while he was not considered overweight, he would need much more weight to get him to sink compared to Tina. He was taking the role of Tina in the re-enactment.

    In the video, Kinghorn appears to be either totally re-enacting an incompetent and novice diver or this is how he normally dives. His arms are waving all over the place and he is moving all over the place and almost crashing into the wreck as he swims along. When he is on the sand he is almost walking in spots. Playing Gabe was Sgt Owen Law.

    The first thing they did was to re-enact the "bear-hug" [which of course was never seen by Dr Stutz as the "bear-hug" was his description of Wade Singleton holding Tina as he bought her to the surface - note that I also do not believe Stutz actually saw Gabe and Tina together]. Note that the re-enactment was not a re-enactment of what Stutz said he saw - that is, Diver 2 [Gabe] with hands or arms UNDER the arms of Diver 1 [Tina]. The re-enactment had Law putting his arms around Kinghorn's arms and then doing it from one side and then the other.

    KinghornBear Hug
    Joshua Kinghorn is obviously nothing
    like Tina in size or weight
    Kinghorn and Law re-enacting what they called the
    "bear hug". Note Law's arms (right) are around Kinghorn
    rather than under his arms as Stutz stated he saw

    From the video and the subsequent re-enactment, it seems that the current this day was from the south or south-west, rather than the north or north-west on the day Tina died [I base this on the facts that the DAP was running back away from the bow of the wreck, the way their bubbles drift back towards the bow and the fact he drifts in a northerly or north-easterly direction]. Therefore, all this makes the re-enactment totally useless as evidence.

    After this, Kinghorn pretended to be unconscious and let all the air out of his BCD so he would sink. This was called the "drift" at the Inquest. Kinghorn started near the southern end of Hold 1, but below the top of the wreck.

    Kinghorn actually travelled north from the starting point and fell onto the deck adjacent to the front starboard side of Hold 1. This spot was 16.7 metres from where Tina was thought to have been (marker 1) [hence the 16 metres that appears to have being later used, especially by the media, to say how far off the wreck Tina was found].

    The problem with this re-enactment is the starting point. Based on the description given at the Inquest [c pg 538] and now from viewing the re-enactment video, it confirms my view that he started above Hold 1, just forward of three mast remains [stacks as Kinghorn called them]. This is, by my calculations, 20 metres from the bow. Again, there is a problem with this in that Gabe said in his interview of 24 April 2007 conducted in Alabama [probably the best description of where he was when he and Tina parted] that he was above the highest point of the wreck and over the deck of the wreck when this all happened. He also said he was about 25 feet (8 metres) from the "anchor rope". Gabe also said the current was coming across the wreck at an angle of less than 45°.

    Comment: From my reading of Gabe's two statements, he indicated that they only went about a maximum of 30 feet (9 metres) [note that his first statement of 22 October 2003 said 30 yards but he meant feet] from the DAP/bow and they were about 20 feet (6 metres) [25 feet in 2007 interview] from it when Tina fell away. This is further confirmed by his statement that he ascended at 45° and arrived at the five metre buoy mark [that is, he went up about 11 metres and must have gone a similar distance horizontally]. He also said that he did not see anything of the superstructure, thus showing he did not go as far as the masts behind Hold 1 and probably not even as far as the start of Hold 1.

    Therefore, the re-enactment was carried out about 10 metres too far from the bow and too close to the port railing. This would have an impact on how a body would fall as the bow area would be under more influence from a current from the north or north-west. This is because the wreck is higher near Hold 1 compared to the bow area.

    The second re-enactment (drift dive 2) was from an almost similar position, perhaps one metre forward. The same thing happened.

    The same day Ricky Murdoch re-enacted an ascent [it is not clear if it was meant to be Gabe's ascent]. However, he started from the sand at 27 metres rather than from about 15 metres on the wreck. In addition, he had a slight current behind him rather than a current into his face. He also appears to have had no air in his BCD as he does not attempt to expel any air from his BCD till he reaches above 10 metres and even then nothing seems to come out. Again, this makes this re-enactment suspect as evidence as it is not clear what it was meant to replicate.

    On 22 September 2006 they went out again. This day there was a current from the north or north-west, which is similar to the day Tina died. In the videos, it can clearly be seen that the current was stronger the further away you get from the wreck, thus showing it was probably from the north-west or north-north-west (assuming the wreck faces north). This time more re-enactments were done. The first one was when Kinghorn started at the bow (drift dive 3).

    The bow "drift" ended up about 8 metres off the wreck and 8 metres to the south of the bow. Therefore, Kinghorn travelled at about 45° to the wreck. Personally, I believe that if this "drift" was started above the middle of the bow section (about 8 metres from the bow), Kinghorn would have ended up in a location very close to where I think Tina's body was found.

    The next re-enactment (drift dive 4) was to test a theory that the Police had come up with. This was that Gabe had taken Tina out off the wreck, perpendicular to the bow. Their theory was that once out of sight of the wreck, he turned off her air and once she was dead, let her drift [it is not clear how the Police reconcile this view with their view that Dr Stutz witnessed the incident - both cannot be correct]. This time Kinghorn ended up about 20 metres along the wreck and 12 metres off the wreck, just past Hold 1 and near the end of the mast. However [and I am getting sick of having to say this], from watching the video, it seems to me that Kinghorn did not actually start from a location off the bow and was already some distance south of the perpendicular when he started dropping. My guess is that he was at least five metres off the perpendicular.

    Thus, the only thing to be gained from all this work was that if drift dive 3 was started where Gabe said he was, then Kinghorn would have ended up near the location where I believe Tina really was found.

    In terms of the Re-enactment Protocol/Concept, only point 4 was met by the Police re-enactments.

    Note that the re-enactments were found by Judge Tommy Nail at the Alabama trial to be so compromised he would not let them be used as evidence.

    TINA'S WEIGHT

    We know that Tina had 20 lb of lead in her BCD and BCD weight pockets from the Police forensic report. I believe that a properly weighted person of her height and weight and using a 3 mm wetsuit and aluminium tank should have used about 6 to 9 lbs. My wife Kelly, who is not as tall and is heavier, only uses 6 to 9 lb. I would use about 3 lb, but I have a short length wetsuit. Again, I am taller than Tina and much heavier.

    As inexperienced divers generally need a little more weight, I believe that Tina was at least 9 lb overweighted and probably 12 lb.

    NOTE: Despite some claims made at the inquest and in some people's statements, there is absolutely no evidence that Tina added more weight to her pockets after the aborted first dive. In addition, the comments by the Judge who sentenced Gabe in Brisbane were totally wrong when he said she was not overweighted.

    On 11 January 2012, Kelly and I both overweighted ourselves by 9 and 12 lbs to ascertain the results. We were a little deeper than Tina was at 18 metres. With even 9 lbs, I could not swim without air in my BCD. I only made about two metres at a go before crashing back to the bottom. It took considerable time to inflate my BCD to enable me to become neutrally buoyant (I will attempt to time how long it takes to inflate my BCD to overcome such weight as this is also relevant). My air consumption during this dive (which also had a moderate current) was about 17.5 litres per minute compared to my normal 11.5 litres (see following section for relevance). This was averaged over the 41 minutes of the dive but I only had the additional weight on for perhaps 10 minutes.

    Kelly had even more problems than me. Her BCD could only just lift her and she has a very good tech BCD, albeit she has pulled in the wings a bit for steamlining reasons, thus reducing its lift capacity.

    AIR CONSUMPTION

    Tina's Tank
    A photo of Tina's tank clearly showing it is a 10.3 litre tank - that is, an 80 cubic foot tank, not 63 cf like the Police claim
    Air consumption is an important indicator that can be used after a dive to show not only if there was a current, but also the state of anxiety of a diver.

    In scuba diving, because you use more air the deeper you go, air consumption of an individual is normally adjusted to be as if you were breathing on the surface. This is referred to as Respiratory Minute Volume (RMV) but is also sometimes called Surface Air Consumption (SAC). It is measured in litres per minute (at least in every country apart from the USA). For example, at 10 metres your lungs require twice as much air to inflate them as fully as on the surface. At 20 metres it is three times as much. Thus, a diver constantly at 20 metres will use 50% more air than one at 10 metres. To measure the air consumption, the amount of air used is converted back to a surface equivalent. If I used 26 litres in one minute at 10 metres, then my RMV would be 13 litres per minute.

    My normal air consumption when diving in Sydney is about 11.5 to 12 litres RMV. If I do a deep wreck (over 45 metres), it increases to about 13.5 litres RMV. This increase is due to more gear (creating increased friction) and possibly nitrogen narcosis and also the fact there is nearly always some current present here. Both these rates are quite low. A rate of 15 litres per minute in Sydney would be considered normal. Less air is normally used in warmer waters as your body does not need to create heat and you normally would have thinner wetsuits meaning less physical constriction. I use about 10.5 litres per minute on the Great Barrier Reef. However, currents mean you use more air. I have recorded an average of 17 litres per minute on a deep wreck in a strong current.

    I have found information that on the surface, normal resting RMV is 5 to 8 litres, light exercise is 12 litres and moderate 40 to 60 litres. I have also found a web site that says:

  • Slow scuba swim - 0.5 knot - 18 litres per minute
  • Average scuba swim - 0.8 knots - 28 litres per minute
  • Fast scuba swim - 1.0 knots - 40 litres per minute
  • I think the above diving figures are a bit high for an experienced diver, but it gives you an idea. I think that an experienced diver's spot consumption can reach as high as 30 or more litres per minute, in fact I have recorded 20 litres for a minute or two in very strong currents. We know that inexperienced divers can empty a tank in less than 10 or 15 metres, even when shallow.

    Tina's Air Consumption

    We know that Tina used a 10.3 litre (80 cubic feet tank) from the photograph of her tank [not an 8 litre tank - 63 cf - as Police claimed]. This had an water capacity (internal volume) of 10.3 litres. It was filled probably to at least 3,000 psi (207 bar) which means it had 2,132 litres of air (volume x bar). At 10 metres this would let me stay down for about 100 minutes and 67 minutes at 20 metres (with no reserve at all). An inexperienced diver with an RMV of 20 litres would only be able to stay for 55 and 35 minutes respectively.

    NOTE: Gabe said in his interview of 27 October 2003 that before the first dive he had about 3,500 psi and he thought that Tina had about 3,200 or maybe 3,100 psi. This makes the figures below very conservative if the tanks were refilled to this same pressure after the aborted first dive.

    Therefore, I have used 3,000 psi as the starting figure. We also know that when Tina was retrieved, her tank had 2,200 psi (151 bar) in it (1,555 litres). This means that at least 577 litres of air was used.

    I have calculated Tina's RMV based on known facts (her depth for the first five minutes of the dive), as well as her presumed death after this (although I have used 50% for the next minute as by then I have assumed that she is dead or at least not breathing) and Wade's ascent to the surface with Tina. The ascent is important, as although Tina was probably dead, Wade used air from her tank as he inflated her BCD and also purged her regulator on the way to the surface. Originally I had no idea if he purged her regulator constantly or once every few seconds, but after his evidence at the Alabama trial, I know that he only purged it for a second or so every now and then. I think my calculations are still conservative.

    The following table details my calculations:

    Minute12345678910
    Depth (m)
    at end of min
    6.69.012.613.515.021.027.027.018.03.0
    Av Depth (m)3.37.810.813.114.315.024.027.022.510.5
    ATA1.31.82.12.32.42.53.42.73.32.1
    RMV203555606030002010
    Litres276211413814638003321
    Total litres2789203342487525525525557578

    ATA = Atmospheres
    RMV = Respiratory Minute Volume (litres per minute) - my guess at this
    NOTE: Only 1/2 of a minute assumed in the 6th minute as Tina falls away.

    Therefore, the air use I have calculated at 578 litres is identical to the actual 577 litres used from her tank. This means that while she was alive, Tina used up to 60 litres a minute, a huge amount. She averaged over 43 litres per minute while she was conscious and except for the first two minutes, she averaged over 58 litres per minute. This either indicates a 2 knot current [which we know was not present] or a lot of panic.

    Therefore we can safely assume that she was panicking big time.

    Tina's Air Consumption if She was Murdered

    One of the most telling things that proves Gabe could not have killed Tina is to look at how much air was used and then make this fit into the time that Tina would have had to have been alive. We know that for the first three minutes Gabe and Tina were descending from the surface and swimming over to the wreck. This is known from Gabe's dive computer profile. As it would have been impossible for Gabe to have turned Tina's air off before this point as he could not have got her to the wreck without been seen by the divers who were only a few metres behind him when they descended.

    The only time that Gabe could have turned off her tank was at three minutes. As we know (from dive medicine expert Dr Carl Edmonds) that a minimum of two minutes and more like three to four minutes is needed to kill someone at this depth, then the three to five minute mark before Gabe started his ascent is the only possible time for this to have happened.

    If this did occur, then I have worked out the air consumption as per the following table. Remember, Tina's tank had 577 litres as a minimum used.

    Minute12345678910
    Depth (m)
    at end of min
    6.69.012.613.515.021.027.027.018.03.0
    Av Depth (m)3.37.810.813.114.315.024.027.022.510.5
    ATA1.31.82.12.32.42.53.42.73.32.1
    RMV75110110000002010
    Litres100196229000003321
    Total litres100296524524524524524524557577

    ATA = Atmospheres
    RMV = Respiratory Minute Volume (litres per minute) - my guess at this

    Therefore, the air use I have calculated at 577 litres is identical to the actual 577 litres used from her tank. This means that while she was alive, Tina would have had to have used up to 110 litres per minute, with an average of over 98 litres per minute for the three minutes. This is plainly an impossible figure, as someone cannot breathe that much air. In addition, if Gabe had decided to dump air out of her tank to make it look like she had used this much [and there is no reason why he would want to as it would be counterproductive], the resulting spa like boiling burst of bubbles on the surface would have been immediately visible to the lookouts on Spoilsport and Jazz II. They did not report any such event.

    Therefore, it is certain that Tina did not have her air turned off at the three minute mark as I assume the Police were trying to insinuate.

    Gabe's Air Consumption

    Until 30 January 2012 I did not think I had any data to calculate Gabe's air consumption as it does not appear anyone checked his air pressure at the end of the dive. I would have expected his computer (which is air integrated) to show the amount of air consumed on not only the computer log book screen but also when downloaded to a personal computer.

    The downloads from Gabe's computer that I had been using (the imperial measurement ones) do not show an air consumption. A mention was made at the Inquest that Gabe's computer had recorded the maximum breathing rate possible at least once during the dive. However, I have now noticed that the metric version of the printout shows an ending pressure of 156.5 bar. This is 2,270 psi. At the moment I am not sure what size tank Gabe was using, but I have assumed at this stage that it was a 10.3 litre (80 cubic foot tank) like Tina used. I will update this if I find out anything different.

    Therefore, if Gabe's tank was 3,000 psi at the start and we know it was 2,270 psi at the end, then Gabe used 525 litres of air.

    The following table details my calculations for Gabe:

    Minute1234567
    Depth (m)
    at end of min
    6.69.012.613.515.06.00.0
    Av Depth (m)3.37.810.813.114.310.53.0
    ATA1.31.82.12.32.42.11.3
    RMV25304040455050
    Litres3353839210910349
    Total litres3387170262371474522

    ATA = Atmospheres
    RMV = Respiratory Minute Volume (litres per minute) - my guess at this
    NOTE: Only 3/4 of a minute assumed in the 7th minute as Gabe surfaced at 6 minutes and 45 seconds into the dive.

    Therefore, the calculated usage of 522 litres is almost identical to the actual usage of 525 litres. This averages out to be just under 40.0 litres per minute. While this is almost identical to Tina's it must be remembered that Gabe is a lot larger and therefore had larger lungs and also would have needed more air anyway. Again, this is a huge amount to use and one that shows Gabe must have been panicking AND swimming very fast during his ascent.

    On 15 September 2003 Gabe dived with Tina at Blue Water Quarry. This was dive 56 on his log book. The printout from his dive computer showed that he ended the dive with 100.5 bar (about 1,457 psi). Presuming he started with 3,000 psi and had an 80 cubic foot tank, this means he used 1,102 litres.

    I have attempted to work out his air consumption, however, it is a bit difficult, as there is little data to use to work out his depth for each minute. In the first minute he dropped to 26 feet (8 metres) and then he came back up through 20 feet (6 metres). He stayed between 10 feet and 20 feet till 31 minutes when he went up through 10 feet. The dive computer does not give any more accurate information than this. At 31 minutes he then went up to 4 feet, back to 10 feet and back to the surface, finishing after a little over 33 minutes.

    If he averaged 12 feet for the period 1 to 31 minutes, then his RMV was 24.7 litres per minute. If he averaged 15 feet, then it was 23.4 litres and if it was 18 feet it was 22.1 litres. This air consumption is higher than what I would consider for an average diver, but probably reasonable for someone who had not dived for 16 months and did not dive all that often.

    Gabe has stated (to me via his lawyer and now personally) that he normally only got a fill of 2,600 psi to 2,800 psi on dives prior to diving off Spoilsport. This is a very low fill. When I dived at Blue Water Quarry on 22 February 2012, my hire tank was only filled to 2,800 psi. If he got only 2,800 psi on the 15 September 2003 dive, then his consumption was 958 litres which works out at: 12 feet - 21.3 litres, 15 feet - 20.2 litres and 18 feet - 19.2 litres. This would be a much more normal consumption for a diver of his experience.

    CORONER'S INQUEST

    An Inquest into the death of Tina Watson was held at the Townsville Coroner's Court starting 19 November 2007. It was presided over by Coroner, David Robert Glasgow. It ran till 30 November 2007 and then from 21 January 2008 to 1 February 2008. 31 January was all taken up with legal argument about what was permissible as evidence and 1 February was similar, although it only sat for a short time. It seems the findings were to be handed down on 23 and 24 April 2008 but this did not happen. On 19 June 2008 final submissions were received and the Findings were delivered on 20 June 2008. Note that the report of the Inquest that is available on the internet has incorrect dates including 23 and 24 April 2008 and that the findings were handed down on 24 April 2008.

    Much of the information/evidence I have mentioned above was presented at this inquest.

    To be honest, when reading the inquest transcript it seems that it was very unorganised, with phone and video links failing, statements not available, reports/graphs of the dive computers being referred to in feet when the witness only had copies of the documents in metres and more. In addition, the order of the witnesses seems illogical to me, with experts testifying about things (like computers, dive gear) before the Coroner heard about the dive itself. Even the order of the divers was not logical. The counsel assisting the Coroner made numerous errors in referring to people by the wrong name (for example Tina's father, Tommy Thomas was called Mr Watson more than once and Mr Johnson another time).

    The transcript also has many errors that if read by a person without dive knowledge would have trouble understanding it all. For example, referring to BCD as VC, unrated instead of underweighted and more.

    The presentation by Det Sgt Gary Campbell which opened the Inquest contained, in my opinion, so many errors and possibly incorrect statements that it had to have prejudiced the Inquest and the thoughts of the Coroner and the counsel assisting the Coroner right from the start.

    Constable Ricky Murdoch was treated as an expert on virtually everything, photos, diving, computers, medical situations and more. However, in my opinion he was not qualified to be considered as an expert on anything related to scuba diving. For example, he claimed that lungs would expand by half when ascending from 10 metres when in fact they will double. Other witnesses were also asked questions that were obviously outside their responsibility or expertise.

    Incorrect Claims Made at the Inquest But Accepted as Fact

    During the inquest many things were stated by people, mostly Police, that are (in my view) patently incorrect and which appear to have been accepted by all as being facts and truth. Some of these are as follows:

  • Detective Sgt Gary Campbell, Townsville Criminal Investigation Branch, who was in charge of the investigation once it became a "murder investigation" said on page 56 that no-one other than Gabe said current was from off to west - this is incorrect - Gavin Docking, skipper of Spoilsport said it was usually from the north-west, Brian Fotheringham said it was from 10° west of north, Dr Stutz and Karl Diggins gave evidence that showed it was from west and even Constable Joshua Kinghorn admitted the current must have been from west if divers were protected below the top of the wreck [which most claimed it was]
  • Campbell also said Gabe's computer did not show him descending after Tina - this is correct as it was not capable of showing this but it was implied it was because Gabe did not descend
  • Campbell repeated the claim that Gabe's computer could not have beeped - seems to have ignored evidence from the Oceanic expert on this as well as Police tests and statements from the Police who observed the tests
  • Campbell claimed that dive squad members said it was "highly unlikely" that you could clear a mask without a reg in your mouth - pg 105 - I do not agree, of course you can if you have even half a breath - I have done it
  • Campbell claimed that dive squad members said "it'd take a - a tremendous amount of force to dislodge" a regulator from a mouth and leave the mouthpiece behind - pg 105 - again I believe this is not true - I have seen it happen and also had it happen to me
  • Campbell claimed that the mouthpiece would have been in Gabe's mouth after the above - pg 112 - not necessarily - I have seen this happen
  • Campbell claims on page 61 that Dr Stutz witnessed Gabe holding Tina in a bear hug - Stutz never, ever claimed this - see next point
  • The term "bear hug" starts to be used by Police as early as in September 2006 as at the re-enactment their documents refer to the bear hug between the diver playing Gabe and the diver playing Tina) to describe how Dr Stutz says he witnessed Gabe and Tina interacting. In fact, Dr Stutz never used the term in relation to Gabe and Tina, he used it to describe how Wade was holding Tina when they came to the surface - somehow it then became the term used to describe how Gabe held Tina
  • The term "bear hug" is used liberally by Police at the Inquest
  • Constable Joshua Kinghorn when showing video of the dive re-enactment (page 535) uses this term to describe how he was held by the Police officer playing Gabe - Det Sgt Campbell had told him of this and he had not read Dr Stutz's statement!
  • Campbell claimed there were 16 different versions of what happened given by Gabe (this is plainly incorrect - most are virtually the same with only slight and inconsequential differences - see part four of this story)
  • Campbell never explained how they decided that there were 16 different versions and no questions ever seem to have been asked about this
  • Sgt Glen Lawrence (page 918 of inquest transcript) claimed Gabe's computer had no rapid ascent alarms activated - it did, he confused Violation Status with ascent alarms - Violation Status refers to ignored decompression
  • Constable Ricky Murdoch, Police diver, (page 636) was read Gabe's statement which included "her hand hit my mask, it knocked my mask sideways" and "I cleared my mask" but then claimed Gabe said "... that his mask was knocked off" - Gabe clearly stated a number of times that his mask was just knocked ajar and filled with water, but in the same interview he did imply that it came off. However, I think it is clear that he meant it just filled up with water. As Murdoch was referring to Gabe's statement, to say that his mask was knocked off was totally incorrect
  • Murdoch (page 639) ridiculed Gabe's statement that when he grabbed his octopus that "I hit the button to push the air in and I remember thinking if I hit the wrong button" by claiming "well, regulators only have the one button...so I don't know the second button he is referring to" - the octopus Gabe used was an "Air 2" type regulator which has three buttons
  • Murdoch claimed (page 779) that when using dive tables "everything between three and six [metres] - the decompression schedule is worked out at a three metre table" - this is wrong - it is six metres, you go to the next deepest depth on the table - you would get bent using Murdoch's method
  • Murdoch (page 780) also says that a dive computer worked like tables, that is, if you came up from 5.9 to 3.1 metres, it would be treated by the computer exactly as if it was being worked out manually using tables using 6 metres as the depth - computers do not work like this, they work on exact depths, using algorithms not tables (that is, a complex mathematical calculation rather than just looking across and down in a table)
  • Murdoch also presented Tina's dive profile (page 629) implying it came from her computer - it could not have as it could not record this into memory
  • Murdoch (presuming he must have read the statement from Adam White from Oceanic about Gabe's computer) in my view totally ignored the evidence about what the graph from Gabe's computer represented - Murdoch implied Gabe came slowly to surface
  • Murdoch claimed witnesses saw Gabe come out of the water like a Polaris missile [pg 782] - I do not believe this was ever stated. McMahon said he came to surface quite dramatically but never said this. Haslet said that Gabe rose out of the water up to his 'sternum'.
  • Constable Joshua Kinghorn, Police diver, when trying to re-enact Gabe's actions, took off his mask and reg, dropped his mask, then could not find it and clear and then find reg without getting air first - problem is Gabe did not say his mask was knocked off, just that it was knocked sideways and filled with water
  • Kinghorn also tried to refind his main reg rather than use the "Air 2" occy which Gabe used!
  • Kinghorn also claimed that tanks used were 63 litres and 88 litres - they are cubic feet (total air capacity) not litres (internal volume) - these tanks would be referred to as 8 and 11 litre tanks - a huge difference
  • Kinghorn refers to tidal flows when talking about the current, but I would have thought that oceanic currents would be more likely to affect the Yongala - these are totally unpredictable
  • Kinghorn also claimed that 88 and 100 litre tanks "they wouldn't be used" - not correct, 88 and 100 cubic foot (11 and 12 litre) tanks are the most common tanks used in recreational diving in Australia
  • Detective Sergeant Knowles (page 687) prepared graphs showing the dives and claimed that he was using data from Tina's computer - he could not have since it was not able to be downloaded - he later came back and admitted this (page 741)
  • Knowles also claimed Oceanic retrieved the data from Wade's Uwatec computer - it was done by Quicksilver Diving Services (he later admitted this)
  • Knowles stated that Gabe's computer printout column called Violation Status shows too fast ascent rates - it does not, it shows missed decompression stops
  • Knowles stated that Wade's Uwatec computer only recorded into memory variations in depth rather than time - not correct, Uwatec computers record every x seconds depending on the computer (older ones it was every 20 seconds but ones of this age it was every four seconds I think)
  • Knowles did not understand what the surface interval of 13 minutes meant (it was the time from when the computer was rebooted by removing and replacing the battery) - page 746
  • Knowles knowledge of how the three computers worked and recorded the information into memory and how the computers recorded too high ascent rates confused the matter greatly - he was treated as an expert on the computers when he had little knowledge of how they worked
  • Stutz claimed that you cannot hear people talk underwater - well, someone should tell my brother that as I can clearly understand him when he talks underwater
  • Stutz claimed that he saw Wade Singleton come from the surface and drop all the way to where Tina was and bring her up - this is known not to be true
  • numerous Police (and Ken Snyder and Doug Milsap) stated that there is no sensation of weight underwater - this is not true in my experience if you are overweighted or trying to lift something heavy
  • The claim that Tina's tank was a 63 cubic foot tank - it was an 80 cubic foot tank
  • Other Very Questionable Actions by Police

  • A statement given by Jacqueline Sherman that she heard Gabe tell Craig Haslet that his computer was not recording the air in his tank was not presented to the inquest
  • Evidence given by Senior Constable Louisa Egerton in a statement dated 19 February 2006 that on 14 February 2005 she witnessed a test where Gabe's computer beeped and showed gas alarm activated when it was put in a decompression chamber was ignored
  • A statement by Constable Robert Enchong dated 21 March 2006 about accompanying SC Egerton to the Hyperbaric Unit where he activated a video recorder to record the examinations conducted by Dr Griffiths and in paragraph 5 he said he recorded:
  • i. Activation of the dive computer and placement into water to depth of 5 metres
  • ii. At 1 metre depth, gas alarm has activated causing a continuous steady beep down to 5 metres
  • iii. Taken back up to 1 metre where beeping stopped (thereafter computer battery turned around and put in backwards etc etc)
  • was also ignored
  • A statement by Craig Haslet that Gabe told him he had a problem with his computer and it was related to the air pressure in his tank was ignored
  • The Police sought advice about tidal currents when oceanic currents would be the predominant influence at the Yongala
  • The advice that tidal currents at the time Tina died would have been running south to north, the opposite to what was the actual situation, was ignored [this probably did have an impact, lessening the oceanic current from the north or north-west]
  • Kinghorn was used for drift re-enactments - he was 77.5 kg and 167 cm, compared to Tina's 63 kg and 174 cm!
  • The re-enactment was carried out with either no current at all or it was running in the opposite direction - all agree there was at least some current on the day Tina died
  • The main re-enactments seem to show the current running south to north or south-west to north-east
  • Kinghorn was also only using 20 lbs of weight, compared to the normal 18 lbs he uses - therefore much lighter than the overweighted Tina
  • Constable Donna Koch (nee Netting) said at inquest Tina only used 4 x 3lb and 1 x 3 lb weights = 15 lbs but her statement of 10 September 2004 says 4 x 3lb, 2 x 3lb and 2 x 1lb = 20lbs - a big difference
  • Koch was used for some re-enactments in Brisbane but she was 70 kgs compared to Tina's 63 kgs and used the same weight [not sure if she used 15 or 20 lbs] - at least she was much closer in size to Tina than Kinghorn
  • Koch also used a long John wetsuit and rash suit which would have had a lot more buoyancy than the suit Tina used (but used the same weights)
  • Koch was not asked anything about the suitability of Tina's weights or why she wore a different wetsuit and wore (relatively) less weights as a heavier person while conducting equipment tests
  • Based on the video of the re-enactment, Kinghorn does not appear to be a very experienced diver [his arms are all over the place - using them to keep himself steady all through the dives] and not a person who should have been attempting to do the re-enactment
  • Campbell repeated the claim that the computer could not have beeped ignoring expert evidence from the Oceanic technician Adam White and the report of Dr Griffith of 18 February 2005 about the tests at his hyperbaric unit decompression chamber - in an exhibit at the inquest, Dr Griffith even underlined a word in this sentence: "However the computer does emit "beeps" if not correctly connected to a source of compressed air, when its battery is fitted correctly" to stress what happens
  • lack of investigation of the possible timeframes for Dr Stutz to have seen all he claims to have seen
  • lack of investigation of Stutz's claim to have been able to see Tina's eyes at a distance of over 12 metres [tests I did with my wife Kelly in good visibility in December 2011 showed that you cannot see someone's eyes unless you are looking directly at them. If a slight angle is introduced for the person being looked at, all you see is a mirror-like effect. We could not really see each other's eyes at a distance of more than about five metres]
  • no appreciation of how inexperienced a diver Stutz was (Police were possibly over-awed by his "doctor" status and regarded him as more an 'expert' rather than a mere 'witness')
  • Police failed to re-enact Gary Stempler's photograph which showed where Tina ended up
  • lack of investigation - or mention of it - into other cases of divers drowning for no apparent reason when teamed with experienced buddies
  • until Zillman (Gabe's lawyer) brought it up in cross-examination with Gary Campbell on the very last day of evidence at the inquest, no mention had been made that Gabe had decided not to go ahead with substantial life insurance on his wife, preferring to revisit the subject after their honeymoon. The police were in possession of notes of an insurance broker, Mark Hughes, that revealed that six weeks before Tina died, Gabe had indicated he would not proceed at that point and Hughes made a note to reconnect in December 2003
  • no-one appears to have read or understood properly the Oceanic DataTrans Plus dive manual which was a prosecution exhibit at the inquest (and thus would have been produced by the police)
  • no investigation of the actual time it would take (in her few minutes underwater) for Tina to have her air turned off and then lose consciousness and have it turned back on and then sink to the bottom. It would be quite a few of those minutes
  • QUESTIONS ABOUT EXPERT EVIDENCE

    An unanswered question is why Coxon, White and others failed to notice and point out in their statements to Police the significance of the fact that Gabe's dive computer was set to "016112" to receive a signal from the corresponding transmitter and the impact this would have on their testing. White did acknowledge at the inquest that the computer was set to receive a signal from a transmitter.

    EVIDENCE OF DR DAVID GRIFFITHS

    Doctor David Griffiths is a medical doctor and was Director of the Townsville Hyperbaric Medical Unit at the Townsville Hospital (he left there in about 2006). Dr Griffiths not only provided a statement to Police, he was involved in some testing of dive computers, particularly Gabe's, and he appeared twice at the Inquest.

    In his statement dated 18 February 2005 he stated that:

  • Gabe's description of what happened fitted well with Tina "becoming progressively more anxious...losing consciousness, stopped swimming and breathing, then having a convulsion, when her thrashing arm movements would be likely to displace her partner's dive mask"
  • "when she stopped convulsing she would have become limp, with eyes open and would have started to sink, probably without starting to breathe again, even if her SCUBA regulator remained in her mouth"
  • the above required Tina's heart to develop an abnormal heart rhythm
  • in the absence of a serious heart disturbance, it was an unlikely explanation
  • panic alone would be likely to cause hyperventilation not unconsciousness
  • he concluded that there was evidence that Tina's death could have been from natural causes
  • As mentioned, at the Inquest he appeared twice. The first time was on 23 November 2007. It was apparent [pg 384] that Dr Griffiths did not understand how Gabe's computer worked as he believed that it recorded into memory the depth every "few seconds, 10 seconds or so" [remember it only recorded when the computer passed through each 10 foot level]. He should never have been asked any questions about testing the computers (which he witnessed) in the hyperbaric chamber, other than ones related to what he saw happen.

    Dr Griffiths also spoke about gas embolisms but said the presence of gas in Tina's body can be discounted as having an influence on her death as it occurred as a result of her rescue and attempted resuscitation. He also said:

  • "it is still possible that even if she had a normal heart, there may have been adysihythmia causing her to lose consciousness. But that is a small possibility, but it is a real possibility."
  • he referred the Coroner to pages 423 to 429 of Diving and Subaquatic Medicine (Third Edition) [this is considered the "bible" of sub-aquatic medicine - see next heading for details]
  • he said hypocapnia could be excluded (hyperventilating, losing consciousness)
  • "panic is well recognised as a cause...in many accidental diving deaths"
  • many other things can be discounted as a cause (marine animal, cold water for example)
  • he referred the Coroner to pages 81 to 94 of Diving and Subaquatic Medicine
  • he quoted statistics where 25% of buddies voluntary separated from victims in diving accidents [this came from the above text book]
  • Gabe probably had grade 3 barotrauma of the ear, which by the time he was first examined would have resolved a little to look like grade 1
  • the examination of Gabe's ears in New Zealand indicated damage not from the descent into Auckland Airport but prior to that
  • Dr Griffiths returned to give more evidence on 22 January 2008 and said:

  • if someone became unconscious, they can have what appears to be an epileptic fit before becoming flaccid and relaxed and sinking
  • there are many reports of divers panicking and leading to death
  • dive accidents normally have more than one issue that causes the accident
  • unlikely that hypocapnia (decreased level of carbon dioxide) played a part in this accident
  • hypercapnia is a possibility (lack of oxygen)
  • DIVING AND SUBAQUATIC MEDICINE

    Authors: Third Edition by Carl Edmonds, Christopher Lowry and John Pennefather, 1992 reprinted 1995. This is available free on line at http://www.divingmedicine.info and is now called Diving Medicine for SCUBA Divers.

    As mentioned above, this book was referred to a number of times by Professor Griffiths. This book, first published in 1976 (second edition 1981) is considered the "bible" relating to diving medicine. It is primarily written for doctors and paramedics, but I know many divers (like me) who have a copy. As mentioned above, there is now a free copy available on line.

    Some relevant sections of this text and comments follow:

    Chapter 8 - Why divers die: the facts and figures - pages 81 to 94

  • there is data based on 2,600 fatalities from 1970 to 1988 by the National Underwater Accident Data Center (NUADC), University of Rhode Island and a smaller Australian and New Zealand (ANZ) study to 1989.
  • 21.4% of NAUDC deaths were recent early open water qualified divers
  • 29% of NAUDC deaths where the mask of victim or buddy was displaced
  • 74% of NAUDC deaths drowned
  • 86% of ANZ deaths drowned
  • 39% of NAUDC victims had panicked
  • 28% of NAUDC victims were suffering fatigue
  • both the above had overweighting and buoyancy problems
  • only 1 in 7 in the ANZ study of the victims ended up remaining with their buddy
  • Chapter 32 - Unconsciousness - pages 423 to 430

    Although this chapter was referred to the Coroner by Dr Griffiths, there does not really seem to me to be much that is relevant as the factors relating to scuba diving do not appear to apply to this case.

    Note:Dr Carl Edmonds was consulted by the defence and he had imput into the questions asked of State witnesses at the Alabama trial. He travelled to Alabama and was also going to appear as a witness.

    ERRORS AND ASSUMPTIONS MADE BY POLICE AND CORONER

    It seems that early on in the second Police investigation, the Police decided (whether high up or at the ground level) that Gabe was guilty of murder and all investigations proceeded along this line of inquiry. This was denied by Detective Seargeant Gary Campbell at the Alabama trial, but it seems obvious that this is what happened as they no longer looked at any alternatives. The following conclusions or assumptions were made to justify the investigation into this matter and that these were then used as fact, despite evidence to the contrary:

  • Police did not understand Gabe's comments about the dive computer beeping
  • Gabe made up the story about his computer beeping since there would have been no beeping if the battery was in backwards
  • this was done to separate Tina and he from the dive group so they could dive alone
  • he lied about going to the other boat while Tina was worked on
  • he played cards on the way back, thus showing he did not care about his dead wife
  • because he lied about the computer, he was lying about other things relating to what happened that day
  • Tina's body was found well off the wreck so Gabe must have taken her there as tests in similar currents showed a body would not sink to that location if what Gabe had said happened was true
  • someone saw a diver holding another diver in a "bear hug" and this was Gabe turning Tina's air off by holding her close and reaching around to the tank valve
  • an inexperienced diver like Tina would have no chance of being able to turn her own air back on or take off her BCD and tank and then turn it back on
  • once Tina was unconscious, Gabe turned Tina's air back on and put the regulator back in her mouth (if it had fallen out)
  • DR STUTZ'S EVIDENCE OVER THE YEARS

    Stutz
    A photo of Dr Stanley Stutz taken when he was showing Campbell and Knowles how Gabe was holding Tina
    Dr Stanley Stutz was the only person who said that he witnessed any interaction between Gabe and Tina. Click here to read a table that attempts to summarise Dr Stanley Stutz's evidence on the five occasions that he has been asked about this matter.

    PROBLEMS WITH STUTZ'S EVIDENCE

    Although I believe that Dr Stanley Stutz is sincere in believing what he saw was Gabe and Tina, his various statements and evidence have to be questioned for the following reasons:

  • he said they got to Yongala at 11 am or 12 noon but it was really about 10 am (shows he is not as observant as he says he is)
  • says you cannot hear people speak underwater - you can, in fact I have had many conversations with my brother and others when diving together
  • had not dived for 10 years and had only ever done as little as 20 dives - means he was probably totally consumed with the pressure of the dive
  • at the Inquest he thought his instructor was called Roger - it was Robert - another incorrect recall of the event
  • said Wade Singleton came from the surface to rescue Tina - false, Wade was already at 22 metres when he saw her
  • said Gabe and Tina were only 20 feet (6 metres) from him
  • said he could see Gabe and Tina from five metres (they were really at about 15 metres) but he could not see the wreck (which was at 14 metres - I can safely say that even in very good visibility the wreck is hard to see from five metres)
  • said he could see fear in Tina's eyes - impossible to see from the distance he was from them
  • said he could see Tina's eyes when Gabe was holding her - this is impossible as they would have had to be right up against each other and the taller Gabe would have blocked his vision of her eyes
  • descended less than a minute or two before Gabe ascended - as witnessed by Painter, McMahon and England - meaning he could not have seen Gabe and Tina together as Gabe took up to 2.5 minutes (he took at least 1.5 minutes) to ascend once he left Tina
  • Wade surfaced about 3 minutes after Stutz descended - again confirms Stutz could not have seen Gabe and Tina together
  • his descriptions of what he says was Diver 1 and Diver 2 (taken to be Gabe and Tina) can be exactly applied to Wade and Tina except for one thing - Wade did not swim away from Tina
  • his description of two divers ahead of three other divers is exactly what would have been seen of Wade swimming out to Tina ahead of the three divers in his group
  • a diver off at an angle could easily look like they were on their back rather than vertical
  • his description of a diver putting his arms under the arms of another diver could easily apply to what may have been seen when Gary Stempler was photographing his wife, Dawn Asano - the photo of her shows her totally vertical [which is not how a good diver dives - a good diver is horizontal in the water] and waving her arms about - Gary would have had his arms in a position when holding his camera that could easily have looked like he had them under her arms
  • his recall of what he saw seems to have improved the longer the time from the incident
  • WHAT DID DR STUTZ SEE?

    I think that what Dr Stutz saw at the start of his dive was Wade Singleton and his group. The diver who swam ahead of the group was Wade heading to Tina on the seafloor. The female diver was Dawn Asano who was swimming vertically with her arms out [photo shows and endorses this] and probably using her arms to steady herself - thus giving the impression of someone flailing about. The larger diver who he observed putting his arms under the arms of the female diver was Gary Stempler when taking the photo of his wife and in a direct line with Stutz's vision - Stempler would have had his elbows sticking out and his hands out of view holding the camera.

    If the two divers were so close that Diver 2 had his hands/arms under Diver 1's arms, then the eyes and face of Diver 1 would not be visible to a diver high up and off at an angle

    The diver swimming down was Jarrod Fisher going down to tell Robert Webster that he could not descend further.

    The diver seen leaving the bottom was either Wade starting up with Tina or perhaps Jarrod heading back up again.

    ALLEGED INCONSISTENCIES AND LIES IN GABE'S STORY

  • a dive computer could not beep if the battery was in back to front - no power equals no noise [now known not to be a lie as he never said this]
  • Gabe claimed that Tina sank quicker than he could swim after her [this is patently not true as it is possible to chase anything that is sinking apart from a lead weight belt, a steel scuba cylinder, a full aluminium cylinder or a very heavy camera. An experienced diver can easily chase and catch a dropped mask or snorkel, a normal camera etc. A diver sinks a lot slower than these items - Gabe probably was positively buoyant due to added air when towing Tina]
  • Gabe did not ascend quickly after he lost Tina [now known that this cannot be proved or disproved by the record of his dive computer]
  • Gabe's claim to have tried to attract the attention of an Asian person on the DAP [this can be reconciled with the timeframe but no questions were ever asked of the three Asians on Jazz II]
  • he told different stories to different people [this is not true - they are all close enough to be the same]
  • he said he hurt his ears when ascending from the dive but he made no mention of this till he was speaking to his mother when Paula Snyder was with him at the Police station [no explanation of this]
  • he repeated this when speaking to Craig Stephen, the Mike Ball Operations Manager, around midnight on 22 October 2003 when he said he could not descend after Tina as he could not equalise
  • he later claimed he had ear problems on the way home when the plane descended into Auckland, New Zealand he got off the plane and went to the hospital
  • he lied (in the view of the Police) to the NZ doctor that he had been diagnosed with "severe" ear trauma in Townsville [in reality he was almost certainly told he had acute ear barotrauma - most people think that the medical term acute means severe - in this case it really means rapid onset]
  • his claims about the ear problem appears to have been an attempt to create an excuse as to why he did not follow after Tina [it probably was at first but the NZ claim was probably so he did not arrive home at the same time as Tina's body and thus have to meet Mr Thomas at the airport]
  • he said that he hurt his ears to friends back in the USA but when asked by Melinda Kayton about how his ears were at the viewing of Tina's body, he was confused and did not at first seem to understand this
  • according to Tommy Thomas, Gabe exaggerated how quickly he ascended [maybe true that he did exaggerate]
  • Mr Thomas said Gabe told him he was "ripping his gear off on the way up" [if he did say this it was a blatant lie]
  • Mr Thomas said Gabe told him he had been with Tina when they were attempting to revive her [again, if he did say this it was a blatant lie]
  • Mr Thomas said Gabe promised to bring Tina's body home and be with her all the way [Gabe appears to have conveniently got an ear problem when descending into Auckland, got off the plane, and as such did not accompany Tina's body home]
  • Click here for the next part of this article which includes the Coroner's Findings.

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