The Shipwreck - SS President Coolidge
The SS President Coolidge is the largest easily accessible real shipwreck in the world. It was a luxury US passenger liner that was taken over by the US Army before the start of World War II and utilised as a troop and equipment ship. It was used on the cross Pacific run, taking men and urgently needed war supplies from the US to Australia and New Zealand.
On 26 October 1942 while entering Segond Channel (the harbour for Luganville) on the island of Espiritu Santo in the New Hebrides (now called Vanuatu), she hit two US mines and was run aground by the Captain. Within 75 minutes, the ship had turned over and slipped off the shore and sunk to the bottom. Only two lives out of over 5,500 men on board were lost (they were a fireman and an Army captain).
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Copyright Kevin Green and used with his permission The door marked "Sea Door" is Euarts Door |
The Coolidge now lies on her port side on a very steep sand slope. The bow faces the shore and is in about 20 metres (66 feet) of water. The shallowest section is a section of the starboard hull which is about 18 metres (60 feet) and the deepest section is under the stern where it is 70 metres (220 feet).
Diving Operators and Protocols
Since the late 1970s the wreck has been a major dive travel location, especially for Australian and New Zealand divers. There are at least three dive operators who dive the wreck. One has been doing it for more than 35 years under the same management and one other has been in existence for over 25 years, although it has had a new owner for the past four or five years (as of 2013).
The guides used by all these companies are very experienced. They are generally locals (called Ni-Vanuatuans), although most shops also employ on a short term basis some divemasters and instructors from Australia and New Zealand etc. The local guides do not (as far as I know) have qualifications as divemasters, but they are certainly more experienced and capable divers than most divemasters I have ever met.
The rules adopted by the shops here (right from the start) has been that the only way you can dive the wreck is with a guide. It is a shore dive, although at times operators have used boats to access the deeper parts of the boat. From the shore you walk out till it is too deep, then put on your fins and swim out to the starting point. This depends on whether you are diving the bow area or a deeper section. If doing deeper parts, it is common to snorkel out 100 to 150 metres from the shore before descending on one of the buoys. The only parts of the wreck where guides were not always compulsory were dives to the front two holds without serious penetration.
Guides place spare tanks on a line that leads from the bow to the shore as well as deeper on the wreck. On very deep dives, guides carry a drop tank or twins. Until recent years (say 2005), it was rare for divers to use twin tanks on the wreck unless doing a dive to the stern. However, now a lot of "technical" divers only use twins when diving here. Of my dives, I have only used twins three times (I think) and that was for dives to the stern at 70 metres. For most dives, there is a limit of four to six divers with each guide, although some dives have smaller limits.
I have visited the Coolidge six times, in 1991, 1995, 1998, 1999, 2002 and 2007. Over this time I have dived the wreck at least 100 times. On my 2002 trip (for the 60th anniversary of the sinking), I was asked by the then owner of Aquamarine to lead some of the members of the group I took there on all the dives on the wreck. This was because they had so many people there for the anniversary that they did not have sufficient guides, even pulling old retired ones back from other jobs.
Again, on my 2007 trip (with my wife Kelly for our honeymoon), Kelly and I were permitted to dive the wreck without a guide, although for one dive we did ask for one as although I was pretty sure I knew the way to a location, I was not 100% certain that I knew it as it was 12 years since I had been to that part of the wreck. It certainly was very rare then for visiting divers to be permitted to do dives on the wreck without a guide.
As mentioned, the dive operations run a very strict protocol for diving the wreck. Only two dives are permitted in a day. If you want to do the night dive, you have to not dive in the afternoon. The dives are generally that you get picked up from your hotel at about 8-8:30 am and again at about 1-1:30 pm. This gives a surface interval between dives of five hours or so.
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Deck plans of the Coolidge I drew in about 1995 from the master plans of the ship "The Lady" is now located on D Deck near the ss where it says First Class. Laila's body was found somewhere on D Deck near the L inside a circle (Lobby) left of the First Class Dining Room. Straight above is Euarts Door. |
As you can imagine, the average dive here is deep. The minimum depth for a dive to see any real part of the wreck is about 27 to 30 metres (the front holds). Dives are regularly done to 40 to 55 metres (the swimming pool for example). Each dive is planned in advance, with strict bottom times and decompression stops on the way back. It is a certain fact that every dive in the morning will be a decompression dive and most afternoon dives will be as well. The dives generally have a 20 or 25 minute actual bottom time limit (before starting ascent back to the bow and shore) although deeper dives may be limited to 15 minutes. The actual time is based on the maximum depth of the dive.
Decompression has been worked out for each dive using very conservative tables (the Canadian DCIEM tables I think) and consists of deep stops. I know that the stops were always deeper and longer than my Aladin computers required. The stops are done on the sandy slope that runs from under the bow to about four metres (at low tide) next to the coral gardens near the shore. You are not permitted to move up to the next stop till your guide indicates it is time.
After an initial checkout dive to the front holds, divers are taken deeper on the wreck and also into more remote parts of the wreck if they show that they are capable (and of course willing). Certifications mean nothing, you only get to go deeper if you perform satisfactorily.
I have explained all this to help you understand the safety protocols put in place by the operators as a risk management process to ensure the safety of all their customers.
In about 2008 or 2009, the ownership of Aquamarine changed from the three partners (the original founders and their new British partner) to Rehan Syed.
Previous Deaths on Wreck
Since the wreck was first dived by recreational divers in the 1970s, as far as I am aware there have only been three deaths on the wreck. These were a visiting Swiss professional diver (not Dutch as has been reported in a book, his wife was Dutch) who was on a boat called Barracuda who dived the wreck on 5 November 1980 with his eight year old son. The son ascended from 30 metres alone and the father continued the dive. The father was reported to have surfaced suffering from a severe case of the bends and later died. However, I have been told that his wife says he died not of the bends but from a brain hemorrhage.
On 8 November 1996 two divers, Andrew Gunst from Cairns in Australia (a master instructor) and Stephen Rayner from Wales (a rescue diver) dived the wreck without any guides. I seem to recall that Gunst was a friend of one of the instructors/dive masters working for one of the dive operators, Santo Dive Tours (Alan Power). They somehow got access to tanks to do a dive by themselves. In any case, they entered into a part of the engine room that was never dived due to the silt there. This was behind and under the bottom electric motor. They presumably stirred up the silt and became lost. They then ran out of air and died.
On 29 December 2017 there was another death of a diver. This was a 55 year old woman (name known to me) from Port Lincoln in South Australia who was diving with her husband and two sons. It seems she may have had a heart attack while doing decompression. One of my friends was diving the wreck at the same time.
Lailande (Laila) Osunsade
Lailande (Laila) Osunsade was the daughter of Festus and Vicky Osunsade. She was born on 28 June 1979 in Washington DC and was 33 years old. At some time Festus and Vicky divorced and both appear to have remarried. Her mother is now known as Vicky Geiger. She had a brother Olalesai (also a doctor in US) and sister Aba (Abadesi) who lives in London. She also had a half brother and two half sisters (from her father I think). She qualified as a doctor in the US and at some time met Damien Healy who I believe is Irish but now a New Zealander. I am not sure if she met him in NZ or if they met elsewhere. In any case, they married in Fiji in the late 2000s and she moved to NZ. Here she worked as a registrar at the Auckland City Hospital in the otorhinolaryngology (or otolaryngology - ear, nose and throat) department. Dr Osunsade was a United States citizen.
Her sister Aba has told me that Laila learnt to dive when she was at medical school. However, despite what has been published elsewhere, she was what I would call a novice diver (more about this below).
She did her first course, the Open Water, in 2004 and her certificate was issued on 13 August 2004. After this she did Advanced Open Water (8 July 2006 - Red Sea, Egypt), Nitrox (15 April 2010 - Rarotonga, Cook Islands), Rescue (5 August 2010 - Port Vila, Vanuatu), Deep (25 Nov 2011 - Phuket, Thailand), Peak Performance Buoyancy (26 Nov 2011 - Phuket), Digital Underwater photographer Level 2 (26 Nov 2011 - Phuket) and Diver Propulsion Vehicle (27 November 2011 - Phuket). All these were PADI courses and I all were done in tropical locations.
As of mid-April 2013 she had completed 40 dives according to her logbook. This means that virtually every one of her dives had been done as part of a dive course. Purely looking at the certifications, some people may think that she was an experienced and competent diver, but as I will show later, Laila was anything but experienced or competent. She seems to have only dived on two occasions when she was not doing a dive course. These were in March 2011 when she did one dive at Noumea, New Caledonia, and July 2012 in Bali when she did four dives. Therefore its seems that she had only done five dives outside a dive course.
A member of the St George Scuba Club (Rob) who dived with her a few days before she died thought that she had said she was a divemaster but this cannot be as you need more dives than this to qualify.
I believe that she did not own any dive equipment, apart from a dive computer (Suunto D9) and a mask. She also had a lycra top (only from her waist up) for protection instead of a wetsuit. It should also be noted that Laila was very overweight. Photos on the internet show that she is large, but the paramedic who attended to her after the incident told be she was obese and it took seven males to lift her into the ambulance. Someone else who was there said it took five Australian males to get her up onto the beach. Her weight was estimated at 130 kilograms (I know now that she was 120 kg and 173 cm tall with a BMI of 40 - obese). I have attached a photo taken on 30 April 2013 before she did a dive, you can see that she is very overweight, but I am not sure that I would have said she was 130 kilograms. She was also a heavy smoker.
Lead-up to Fatal Dive
At 12:05 pm on Saturday 27 April 2013, Dr Laila Osunsade flew from her home in Auckland on Air Vanuatu flight NF51 to Port Vila, the capital of Vanuatu. She arrived in Vila at about 2:20 pm. At 5 pm Laila flew on flight NF208 to Luganville on Espiritu Santo (both the town and island are sometimes simply called Santo). It was just after 6 pm when she cleared the airport and travelled to the Espiritu Hotel which is in the main street of Luganville. This newish hotel is owned or managed by Rayman Leung. She booked in for six nights.
As I mentioned above, Laila was reported in the media to be an experienced diver, although what one person may consider to be experienced is not necessarily what I may consider to be experienced. As I mentioned above, she had done a lot of courses, and presumably, very few real dives. I also do not know for certain what sort of dives she had done before or where she had dived, but I have been told by Rob (who dived with her on 30 April 2013) that all her diving was done in the tropics. She booked dives with Aquamarine which is now owned by Rehan Syed.
Over the next four days Laila dived the wreck of the Coolidge on at least three days. It was later reported in the press that she had done four dives on the wreck by 1 May 2013. I would have expected that she would have dived on the next day, Sunday 28 April 2013 as well as on the Monday 29 April 2013, but it was reported that she did not. However, in late 2015 I discovered that she did indeed dive earlier than reported.
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Simon Toa and Laila before the 30 April 2013 dive Photo by Rob |
Dive One
On Monday 29 April 2013 she did a dive, I think in the afternoon, to a depth of 33.8 metres on the Coolidge. This is consistent with diving to the forward holds. Her logbook shows that she started with 200 bar and ended with 10 bar. I do not know how long she was in the water nor whether she had to use another tank once she got low (see next dive). This dive was led by guide David Tony.
Dive Two
On Tuesday 30 April 2013 Laila did another dive. On this dive was a bloke called Rob (surname withheld) who is a member of St George Scuba Club (of which I am a life member). I have spoken to Rob in detail about this. He told me that he thought she was a divemaster (from what she said, but he admits he may have been mistaken). On that day, he booked in to do two dives with Aquamarine. The first one was to the forward holds on the Coolidge and the second to Million Dollar Point. He said that he was not asked to show his certification card and the dive operation seemed very lax.
I now have access to five videos and some photos taken by Rob on the dive. The videos show the start of the dive as well as when travelling past the bow gun and exiting Hold 1, as well as at the deco stop.
Rob was put in a dive group that was lead by a guide called Simon Toa. The only other person in the group was Laila. He believed that this was Laila's first dive on the wreck and this was confirmed to me by another person but does not appear to be correct (as shown above). As her dive gear shows that she had some weights attached to the tank strap (this is not a normal situation), they were probably put there to counteract a problem that she had encountered before of being feet heavy (due to her size and lack of full wetsuit). They were using what appear to be 100 cubic foot tanks (confirmed to me by Rob). These are approximately 12 litres in internal size. Rob's computer printout shows that his was filled to 225 bar, so it could be expected that Laila's was filled to at least 220 bar, although Laila recorded in her logbook that most dives she did on this trip only started with 200 bar. The water temperature was a warm 28°C.
Rob's computer shows that they started the dive at 10:00 am. The date stamp on the videos I have access to says the first one was taken at 11:16 am, so the time of the video is out by about 1:09 hours (not sure how this happened nor does Rob). They walked and swam out to the deco stop area (which is about five metres deep). At about 10:03 am they descended and followed the line that runs from the shore to the bow of the wreck.
In this first video, Laila is visible part of the time and her breathing is also visible for most of it. One of the easiest ways to tell if someone is relaxed and competent when diving is to look at their breathing. As there was no current affecting this descent, the only impact on breathing rates must be the state of relaxation that the diver is in and their fitness.
Generally when I dive I breathe about once every 12 seconds. At the most, in a non-current situation, I might breathe once every 10 seconds. This is very slow breathing. Most other experienced divers breathe about once every six to 10 seconds. On the video, Rob (who is of course taking the video) can be heard to breathe about once every six seconds. Laila can be seen to be breathing about once every two seconds. This indicates she is not relaxed at all or indicates that she is extremely out of condition (I expect it is both).
Anyway from Rob's description and the videos, they swam down to the bow and then across the bow between the two bow guns. At this spot, Laila stopped and was attended to by the guide. This shows that she is swimming almost vertical, a sure sign that she was not properly balanced. As mentioned, Laila had a couple of weights attached to the tank strap, presumably in an attempt to counteract a "legs heavy" situation (remember she was not wearing any covering on her legs so there was no lift provided by a wetsuit down there). She also appears to be overweighted as she is sinking and continually finning to stop sinking. This uses air. She was using 10.5 kg of lead, that is, just over 23 lbs.
From here they went into Hold 2 (7 minutes into the dive) and then into the wreck. They dived to the back of Hold 2 reaching 34 metres. From here they then went into Hold 1 and then exited out the front of Hold 1 (17 minutes). Another video, shot as they come out of Hold 1, shows Laila for a lot longer than the previous videos. I have calculated that she was breathing once every 1.7 seconds at this time. This is extremely fast and would have not only used a lot of air, but probably led to a lowering of carbon dioxide in her blood system due to shallow breathing. This can lead to light headedness and confusion when the body restricts the flow of blood to the brain. Eventually this can cause fainting and unconsciousness.
Rob told me that Laila was a very bad diver, with her buoyancy all over the place. This means that she was either sinking or floating and not able to stay level at the one depth. The videos confirm this. In addition, Rob has told me that the dive guide, Simon Toa, did not regularly check on them or look back to see that they were still with him. This is relevant later.
The time they exited the wreck was 10:20 am, meaning that they had been underwater for 17 minutes. This is an extremely short bottom time for this dive (should have been about 25 minutes before starting back in my experience).
From here they went back to the bow and then ascended to the deco stop area, reaching there at 10:24 am (21 minutes). At this spot, the dive guide gave Laila an additional tank of air (an 88 or 100 cubic foot tank) which he had dropped off somewhere at the start of the dive. He attached it to her BCD. This was because Laila had almost totally run out of air on the dive. When they got to the deco stop she had used all but 40 bar of a 100 cubic foot tank (so I was told - her logbook says she ended up with 10 bar but this was probably after she used her tank to swim back to shore). Rob still had 100 bar (just under half) at this time and the guide 150 bar. Note that Rob told me that the air was not tainted at all with oil (this is also relevant later).
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Simon Toa and Laila at the deco stop on the 30 April 2013 dive Photo by Rob |
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.
I have done some calculations (using the printout from Rob's computer) which show that Laila's air consumption on this dive must have been about 31 litres per minute (RMV or SAC) to use this much air (assuming she started with 220 bar and ended with 40 bar). If she started with 200 bar as she wrote in her logbook and ended with 40 bar at the deco stop, then the consumption was about 28 litres per minute. On this dive, I would use about 10 to 10.5 litres per minute. Most experienced divers would use about 12 to 15 litres per minute.
When someone breathes so rapidly, it is generally shallow breathing, meaning that a full interchange of air is not happening in the lungs. As mentioned above, this leads to less carbon dioxide in the blood (which can cause confusion). This is also serious. Eventually this can cause unconsciousness. I would guess that after this dive Laila had a headache at the minimum.
The dive appears to have ended at about 10:42 am.
Dive Three
After this, in what appears to be a changed method of operation, the divers were taken the short distance to Million Dollar Point. The procedure used to be to take divers back to their accommodation for a rest and then do the second dive much later in the day. Million Dollar Point is where the US dumped a huge amount of equipment (trucks, bulldozers, earth moving equipment and more) at the end of the war.
Laila and Rob started another dive at 12:00. Again, video of Laila shows her breathing very rapidly. The dive went to 31.2 metres and lasted 32 minutes. From the fourth minute till the 15th minute was spent below 22 minutes and then the next 6 minutes spent ascending to the 14 to 18 metre area. The last 11 minutes were spent at 4 to 6 metres. I know that Laila did not run out of air on this dive, but based on her breathing rate in the video and her previous air consumption, my guess was that she used about 25 to 29 litres per minute (this would leave her with 40 to 10 bar in her tank at the end). I now know that she had 20 bar at the end of the dive and 200 at the start (according to her logbook). This means she used about 26 litres per minute.
Other Divers There
The same day a group from a Brisbane dive shop arrived at Santo and on 1 May 2013 they began diving with Aquamarine. The leader of this group (John) has advised me that the air they used was very bad and tasted extremely strongly of oil. This indicates that the compressor filters were not being replaced at the time they should be. The dive medical "bible" Diving and Subaquatic Medicine (now called Diving Medicine for Scuba Divers and available free on the internet at www.divingmedicine.info) says that while oil in air will make you feel bad, it will not kill you. Generally the presence of oil in compressed air does not indicate that it contains too much carbon dioxide or carbon monoxide.
Anyway, John complained to the owner of Aquamarine, Mr Syed, about the quality of the air supplied. He attempted to empty and refill some tanks but they still were tainted with the oil. In addition, it was reported to me that none of the tanks had been tested since about 2007 or so. John insisted that Mr Syed get tanks from one of the other operators for them to use the next day. This happened and they had tanks owned by Santo Island Dive when they went diving on 2 May 2013.
Dive Four
On Wednesday 1 May 2013 Laila did a dive in the morning to "The Lady" which is at about 42 metres. On this dive she dived to 39.7 metres which means she probably did not actually get to "The Lady". The total dive time was only 21 minutes. However, during the dive she went to 15 metres, then surfaced and descended again. Discounting the time on the surface, this dive was only 12 minutes from the second descent (I am not sure this includes decompression stops). She ended up with 20 bar in her tank.
On this dive she was again guided by Toa.
Dive Five
At about 2:30 pm in the afternoon did another dive, this time to the Medical Supplies (not to be confused with the Doctors Office). Once again Laila resurfaced, this time after 8 minutes. She then descended again. She did not record her air for that dive. I do not know her bottom time, but she went to the Forward Cargo Holds again.
After this dive, three of the divers who were diving with Laila and Toa on both these dives complained to Syed about the short length of the dives due to Laila running out of air. He made arrangements for Laila to dive alone with a guide for the next day.
Sixth and Fatal Dive
On Thursday 2 May 2013 Laila was again diving the wreck. She was still diving with Aquamarine and today was being guided by the same local Ni-Vanuatu guide (Simon Toa) as on her 30 April 2013 dives with Rob. She was the only diver with him. Laila's tank was one owned by Aquamarine and thus, was probably carrying oil tainted air.
The dive plan was said to be to the Doctors Office (according to newspaper reports) although John believed they were going to The Lady. Whilst The Lady is a relatively simple dive (she is now at the front of the First Class Dining Room rather than at the stern end of this room), the Doctors Office is one of the harder dives in that it goes to a place almost in the centre of the wreck at a depth of about 42 metres. To get there you may even go to about 45 metres, although there are a number of routes that can be used.
Personally I find it strange that they would agree to take Laila to either of these locations considering her apparent inability to dive in a correct orientation as well as the fact she ran out of air on a simpler and shallower dive two days earlier and also the dives the day before were drastically shorten due to her running low on air.
Simon Toa's Version of Dive
The following is based on statements given to the police as well as conversations I have had with people present on the day. Note that I do not believe that many parts of this story are accurate and I will explain this later.
I had assumed that they swam out a bit before descending, but this might not be correct. I based this on reports that give the time when the dive was called (see later). My description of the dive is based on how it is normally done and information in Toa's statements and police reports. Visibility was reported to be about 10 metres on the day and the water temperature would still have been 28°C.
Anyway, Toa and Laila descended and swam along the starboard side of the wreck (17 metres at first and then deepens on a slope) and entered the wreck via what is called Euarts Door. This is the door that was the main access door for passengers to enter the ship when she was tied up at a wharf. It is at 23 metres and leads into the Main Lobby. The First Class Dining Room comes off this lobby on the stern side. This should have taken no longer than five to six minutes.
From here they travelled through the dining room and then to the Doctors Office. They would have gradually dropped from about 30 metres at the bow end of the dining room to 42 metres. This is a very small room where they would have ascended a metre partially into the room through the cabin door (the ship is on its side so the door is above you). In here they would have looked at the medical equipment and supplies that are still present over 70 years after the Coolidge sank.
Simon Toa reported that when in here Laila indicated "she could not dive any further" (from police report). At this point I do not know if this is an accurate recording of what she indicated nor how she indicated this. It is also reported that this was 10 minutes into the dive. In my experience, this also indicates to me that they had started the dive right at the deco area and swum to the bow and down across the starboard railing of the wreck as I stated above. I base this on the fact that the last time I dived the Doctors Office (2007) I departed the room at 8 minutes but we had we had swum out further and entered via the area near the Swimming Pool which is a bit deeper. In 1999 when I dived this spot, we arrived at the Doctors Office at 9 minutes having started near the deco area.
As I have already mentioned, leaving the room at 10 minutes seems to mean that they left as soon as they arrived. Toa reported that they left the wreck and started back for the bow area. Presumably he meant they went back through the dining room and then ascended up and out through Euarts Door. This would take 4 minutes at least. Once outside, they headed towards the bow.
When he checked behind when nearing the bow to see how Laila was going, she was not there. The police report does not make it clear when and where this happened, but I have been told by certain people that they were outside the wreck when this happened (later police reports imply this as well).
It is alleged that this was witnessed by another diver (his name is Justin Auld but he calls himself Jack - I believe he might be American but perhaps living in Melbourne). I attempted many times to speak to him via email and phone and actually spoke to him for a few seconds before the line dropped out. I also SMSed him in an attempt to talk to him. There was no discussion between us as to what happened as it appears that he deliberately decided not to talk to me about this matter.
I am told that he told Rayman Leung, owner/manager of the hotel where Laila was staying, that he (Jack) saw Laila re-enter the wreck via Euarts Door. I have also been told this by John (the leader of the Brisbane group) who was also told this directly by Jack.
John told me that Jack said he saw Laila swimming back along the starboard side (the shallowest part of the wreck) and re-entering Euarts Door. As mentioned, this is the simplest way in and out of the wreck if diving The Lady and Doctors Office. It is not known why she would do this (she did not as we now know). In any case, it seems that she could not find her way out of the wreck. The time when she reached the spot where she was found, if all that was stated above did occur, was 17 minutes.
Note: the alternative to above is that Jack actually saw Laila entering the wreck at the start of the dive following Toa, but that Toa was not seen by Jack. I believe that if Jack saw Laila, this is what he actually saw.
John told me that Toa said that when he looked behind for Laila, she was not there. This was said to be before he got to the bow. It is about 100 metres from Euarts Door to the bow, so assuming that he confirmed she was with him as they came out of the door and then again a minute later, I expect that he was probably approaching the bow when he again looked and noticed her missing. I would not assume that they were swimming beside each other as I very rarely see people do that when being led by a guide.
If this is what happened, then if Laila turned around soon after the first time she was checked on after exiting the door, she could have easily swum back to the door and re-entered before Toa would know she was missing. Remember that visibility was said to be only 10 metres, so a pair of divers swimming in opposite directions will be out of view in only a few seconds. I assume that Toa tried to find her but at this depth (probably 20 to 25 metres) he would not have had much time to look for her considering he would have already had a reasonable decompression obligation.
He also probably assumed that she had perhaps stopped to look at something and then not seeing Toa, had followed a different part of the wreck (say the railing) towards the bow or even perhaps dropped a bit deeper across the top of the forward holds. It would be almost impossible to try to refind a diver at this location in my opinion (remember I have done over 100 dives on this wreck).
No matter what, Toa then decided to head back to the bow area and ascend. I am certain that he would have had to do decompression by now. Of course he would have had to complete this before ascending as to do otherwise would have endangered his own life.
Once back at the bow area and then after ascending, Toa alerted the other staff of Aquamarine and customers that he was missing a diver. A dive guide with ear problems and John (who had just surfaced) swam out and snorkelled over the wreck. A short search would have been made to look for bubbles at the decompression site and over the wreck and also to check on any divers still in the water to see if she had accidentally got linked to another group (this can be common). More later.
What Really Happened - Based on Dive Computer
The dive computer was downloaded by the New Zealand police (see later for details) and the profile was sent to me (and maybe others) for comment. The profile (shown below) clearly shows that the claims by Simon Toa about what happened are lies. I was asked to advise what I thought the profile showed happened.
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This is Laila's dive profile from her computer on the fatal dive. This clearly shows that she did not leave the wreck as claimed by Toa and was probably unconscious at 13 minutes when she started a very constant descent from 33 metres down to 42 metres. |
I indicated to the police the following:
I also found a profile from a dive I did to The Lady and it was very similar to the one above.
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This is my profile from a dive to The Lady in 2007 with my wife Kelly. You can see it is very similar to Laila's profile till 13 minutes. |
As you can see, it clearly shows that Laila never left the wreck, as she only ascended to 33 metres whereas Euarts Door is 23 metres, so she never got closer than 10 metres to exiting the wreck. Remember, Toa claimed in his statements to local and NZ police that she came out of the wreck (and was seen by him outside) and was lost on the way back to the bow. This also puts paid to the other witness's claims that he saw her re-entering the wreck.
The profile seems to show that Laila ascended to 33 metres and then fell unconscious. I base this on the fact that the descent from 33 metres to over 40 metres is absolutely constant and the line straight. I suspect that the tiny blip at the bottom of this descent is her body bouncing down inside and then rolling over and the computer moving till it rested in the one spot.
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The plan for D Deck with depth contours |
Recovery of Laila's Body
Finally, a number of divers went back into the water (David Tony and Tulah Jeremiah - dive guides) using three-quarter empty tanks and carrying unused stage bottles and they entered the wreck and found Laila. Toa did not go as he was said to be a quivering wreck (and he could not have considering he had only surfaced then).
For some reason (strange considering Toa reckoned that Laila had come out of the wreck with him), they appear to have gone straight to Euarts Door and gone inside. Laila was found at the bottom of the main lobby that leads to The Lady. She was at 42 metres (140 feet) and not breathing. Her regulator was out of her mouth but she still had about 100 bar (I have also been told it was 50 bar but more have said 100, including John who looked at her gauge). I was told that her finger nails appeared to have debris that would indicate she had scrapped at the inside of the wreck (witnessed by John). More about this further down. Her torch was off (but still working) and her fins missing.
Her dive computer was beeping and one of the people took it off her wrist (at least this is what has been thought to have happened but it may not be true) as the beeping was annoying them. Her Suunto D9 dive computer has optional air integration, but from the video and photos I have access to, she does not seem to have a transmitter on her first stage (now confirmed by coroner's report). Therefore, it is unlikely that the computer was beeping because she did not have enough air to complete the dive considering the decompression that would have now been required. The computer also indicates an error message if the bottom time is too long. I am not sure what is considered "too long" or if this also includes a beeping sound.
Laila was then brought towards the shore and John and perhaps another of the snorkellers took her body from the divers as they had decompression to do. From all reports she was missing at least 20 minutes before being brought to the surface. Her dive computer was handed by the divers to Rehan who later witnessed giving it to the police. Rehan would not let John view the computer.
For the first 10 or 15 minutes after she surfaced, "there was clear/white froth coming out of her mouth. Her mouth had froth coming out of it as soon as her body was brought to the surface. After the first ten or 15 it was intermittent as we managed to get a small amount of air into her lungs having pumped out all of the other foam" (quote from John).
One of the other divers present diving with Aquamarine was an Australian anaesthesiologist (from South Australia) who started attempts to revive Laila. She and others attempted to get oxygen gear from the Aquamarine vehicle but there was nothing there. Meanwhile, someone made a phone call and as a result, Rayman Leung (owner/manager of Espiritu Hotel) or one of his staff, phoned an Australian called David Ellaby.
Ellaby is an intensive care paramedic who works for the Queensland Ambulance Service and also crews on the Sunshine Coast Helicopter Rescue Service helicopter. He was present in Luganville with a Christian group who are in the process of establishing a medical clinic. Ellaby was in town when he received the call and he hailed a taxi and headed to the clinic to grab some equipment. Meanwhile, the hotel sent a car to collect him and then took him and the equipment (including some drugs and a defibrillator) to the dive site.
On the way, Ellaby phoned the ambulance. It seems that they had not been called before this, although there are claims they had been called by Syed. Note that there is only one ambulance serving the whole island (almost 4,000 square kilometres) and it has no real medical equipment as would be found in an ambulance in the US or Australia and is normally only operated by a wardsman or at best, a nurse.
When he arrived at the site where the dive shops base their dives, Ellaby found the Australian doctor and the other divers still performing CPR. She was very glad to see him as he had far more experience in this sort of work than she did. Despite a lot of work, Laila never regained consciousness. The ambulance finally arrived 40 to 45 minutes after Ellaby called it, although this had no impact on the chances of Laila surviving.
The froth that was reported to come from Laila's mouth when she surfaced is an indication that Laila died from drowning. She was declared dead by the doctor at about 11:50 am.
At 12:05 pm, the police were finally called. The call came not from staff of Aquamarine, but from the owner of another dive shop. The police record that they arrived on site at 12:10 pm, but I personally think it would have been later considering the time taken to drive out to the site from town (or the phone call was a lot earlier). There were a number of police officers who attended, but I am not sure who they were as the report does not even mention who the writer is. At least two were considered to be "investigators", but you should be aware that the training and equipment they have is very basic compared to that of police in Australia.
At this time Laila's body was lying on the sand/coral beach and covered with towels. At 12:25 pm the police officer who wrote the report stated that he had completed his work.
Laila's body was taken to the hospital in Luganville (again this is very basic and really survives to a degree on New Zealand medical schools sending their partly trained doctors there for "work experience"). Here she was examined by a doctor and a Death Certificate (No 163) was issued by an unknown doctor who stated that Laila died from "unknown cause - awaiting corona (sic) report". The same day Senior Magistrate Rita Bill Navita visited the hospital and two days later he issued an Order for Buriel (sic).
The police seized at least some of the equipment involved in this incident. The dive computer and tank were taken (the computer was witnessed being handed to them). The dive computer was a very important clue to what happened, as you can see from the profile above. Like all newer dive computers, it has an on-board memory that retains the profile of the dive. This can be viewed by accessing the log book function or, even better, downloaded via USB cable to a computer and viewed using certain software programs. Her fins were not found for many months. The first was recovered near where she was found and give to Syed. The second was found and given to the NZ Police who were investigating the death.
Statements were taken from most of those involved, seemingly by the other dive operator and the dive organiser from Australia, John. They also checked all Laila equipment and agreed that it was all working perfectly.
Testing the air would also show if there was a correct oxygen level and if there was too much oil, carbon dioxide or carbon monoxide. I have spoken to Dr Carl Edmonds (lead author of Diving and Subaquatic Medicine) and he indicated to me that the normal physical observation of carbon monoxide poisoning, cherry red colour under the victim's fingernails, is not very obvious in diving related carbon monoxide poisoning. Therefore, it is likely that if this is the problem, it may not have been noticed by David Ellaby (the paramedic), the female doctor doing the CPR or John. John confirmed to me that there was no colouring at all and he said that he specifically looked for this. Therefore it is unlikely that carbon monoxide poisoning is relevant to what happened.
On 11 May 2013 Laila's body was then taken to New Zealand. A post mortem was done in Auckland. I do not have any real indication of what was found other than on 13 May 2013 the Coronial Services Unit wrote to Laila's husband, Damien, and advised that the early result of the post mortem was "unascertained pending investigations". Dr Edmonds also indicated to me that the blood samples should show if carbon monoxide levels were too high. I had hoped that the full post mortem results would reveal something about this.
Alternative Scenario - My Theory Before I Had Access to Police Information and Dive Profile
The only real alternative to what happened as outlined above is that Laila never actually exited the wreck. This actually has a lot of credence, as based on the amount of air she used on the dive (120 bar), I cannot reconcile this with the dive as stated. For example, if she used air at the same rate that she used it on the dive on the wreck on 30 April 2013 (31 litres per minute if she started with 220 bar), then she would have used 172 bar leaving 48 bar in her tank. Remember that when the tank was found it had 100 bar.
To fit the amount of air used into the timeframe as described by Simon Toa, I used the dive profile from my dive in 1999 to the Doctor's Office and then backtracked to end the dive at 17 minutes. To get the ending tank pressure of 100 bar for this dive, Laila's air consumption would have had to be 18 litres per minute.
Therefore, it seemed impossible to me that Laila's air consumption improved from 31 to 18 litres per minute in only a few dives. The only solution to this quandary for me was that she died much earlier than has been reported. If I put her air consumption of 31 litres per minute into the scenario, she stops breathing at 11 minutes, not the 17 minutes that the reports indicate what happened. If I put it at 28 litres as per her first dive on 30 April 2013 (assuming 200 bar start) and increasing to 35 and 50 litres per minute for the last two minutes, it exactly fits with her stopping breathing at 13 minutes as we now know to be the case. Therefore, my original estimate about this before I had access to her profile was pretty correct.
Things that I stated back in 2013 need to be investigated further
Her dive computer needs to be examined and the profile downloaded. This will show definitively what she did on the dive. If she did indeed exit the wreck, swim a short way along the wreck and then re-enter, it will be shown. If there is no indication that she ascended to 23 or so metres, then someone is telling lies.
Further Relevant Information
In mid-June 2013, three members of St George Scuba Club visited Santo and dived the Coolidge with Aquamarine. These divers dive most weekends in Sydney to depths of over 45 metres and are very experienced divers. They advised me that their guide was Simon Toa. Independently, their comments about his guiding style were identical to those of our other member, Rob, as reported above. That is, he did not look around for the people he was guiding and he swam far too quickly for a proper tour of the wreck.
At one stage Toa disappeared ahead and the closest diver to him had to stop to wait for the last two divers to catch up. They were not swimming slowly, he was swimming too fast through the wreck. When they dived the stern, Toa only used a single tank and ended the dive with only 30 bar. They complained about this to the owner that he should be using twins, but the owner said it was up to the guide.
The section of shore where Aquamarine bases its dives has changed. I am not sure if this was before 2 May 2013 or after. It apparently happened because the owner of the land they previously used (right next to Alan Power's spot and straight in front of the wreck) revoked their right to use the land. I was told that this was because Aqumarine had not paid their rent. This land is now being used by the new Coral Quays dive operation. Aquamarine's new spot is located to the east of their previous spot and requires a longer swim before you get to the wreck.
When the group was in Port Vila on the way to Santo, they dived with Nautilus. They noticed that there were dozens of tanks there from Aquamarine waiting to be hydro tested. It seems that what happened to Laila has perhaps shaken them into spending some money (not really as I will show).
Post Mortem
The following are the principle pathological findings from the post mortem carried out in New Zealand:
Blunt Force Injuries
Bruise dorsum of left hand
Abrasions dorsum of right hand
Multiple abrasions to both lower limbs.
Obesity (body mass index 40)
Hepatic steatosis
Postmortem toxicology (day 11 after death) - no drugs or alcohol
The bruises and abrasions to her hands and lower legs is very interesting. It shows some sort of interaction with the wreck. The question is, of course, did she suffer this while having a fit trying to get out in the dark or did it happen when she panicked?
NZ Police Investigation
Vanuatu is a second or third world country, with no expertise to investigate incidents like this. Their investigation was very, very basic. New Zealand sought approval of the Vanuatu government to investigate on behalf of the NZ Coroner.
The NZ Police sent a very experienced member of their dive squad to Vanuatu. He is also a qualified PADI and TDI instructor. He interviewed Simon Toa, the owner of Aquamarine, Rahan Syed and many others. He also interviewed via questionaires Australian divers who were present and involved in the recovery as well as my friend. He also got his video and photos and examined the tank, dive computer and other items of gear. He also contacted me and provided me with the printout from Laila's computer and also consulted with me about a number of things about the dive and the wreck.
How Did Laila Die?
Quite clearly she drowned as shown by the autopsy.
What Caused Laila to Die?
This is harder to answer. The original options I posted here back in 2013 obviously had some wrong ones which were based on Simon Toa having told the truth. Considering he did not, I have modified to take this into account.
Option 1
Laila did not exit the wreck and she panicked when she first came inside and passed out. The dive guide was not able to assist her due to her panicking and being inside the wreck and also her size. Once passed out, her regulator fell out of her mouth and she then sucked in water and drowned. The guide panicked and left the wreck without her.
Option 2
Laila did not exit the wreck and she got separated from the guide when inside the wreck. She panicked and passed out. The dive guide was not able to find her or if he did, she was already unconscious or dead. Once passed out, her regulator fell out of her mouth and she then sucked in water and drowned. Due to her size, he was not able to assist her out of the wreck. The guide panicked and left the wreck without her.
Option 3
Laila did not exit the wreck and she got separated from the guide when exiting the wreck. He left without here and did not realise she was missing till he was well on the way back to the bow. She could not find her own way out, panicked and passed out. The dive guide did not go back to look for her. Once passed out, her regulator fell out of her mouth and she then sucked in water and drowned.
For all of the above, she would have passed out because the rapid shallow breathing (hyperventilation) reduces the amount of carbon dioxide in the blood and this causes the blood vessels in the brain to restrict, drawing oxygenated blood away from the brain. This then causes light headedness and fainting.
The other matters to be considered:
was the air tainted and did this contribute to what happened?
did the dive guide keep a close enough track on Laila and fulfil his obligations?
should the dive operator have let her do this dive (to a hard part of the wreck) considering her previous event of running out of air and her obvious bad diving skills?
Finally, on 16 November 2015 the Coroner's report and the accompanying police report were released to family and involved parties. As indicated above, the report is very damning, that is for sure, and vindicates my views on this matter.
I also have access to are two memoranda produced by NZ Police on this matter. One dated 12 December 2014 has the following findings:
Laila's dive tank had water and other contaminants in it
Her regulator first stage had a sinter filter that was "in extreme dire condition" probably caused by water contanimation and appeared not to have been serviced for "some time"
Laila was overweighted by 9 kg (almost 20 lbs)
Her dive booties and fins were too big for her (this would limit her ability to fin efficiently)
These reports both recommended that the findings be passed onto the Vanuatu High Commission in NZ. It is not known if this happened.
The Police Findings
The NZ police report includes many findings. My summary:
The tank contained raised moisture levels, elevated carbon dioxide, and free water/corrosion particles
The tank had never been tested in the six years since it was purchased and the owner's claims that they were regularly tested was false as the only people who could test had never done any in the time he had owned (over three years)
Her booties were far too big as well as fins, meaning she would not be able to swim efficiently
She was grossly overweighted considering the lycra suit she was wearing, probably about 21 lbs more than needed
Her regulator sinter filter was almost totally blocked with residue (probably similar to the crap found in her tank) and appears to have not been serviced in many years
Despite claims by the owner that gear was regularly serviced, evidence was given by former staff and backed up by the Australian distributors that service kits to service only 14 first stages and 8 second stages had been purchased over the past four years (they had at least 20 sets of regs)
No regs appear to have been serviced in the three years before Laila's death
Despite claims by the owner that the compressor was regularly service, evidence was given that only one out of three was working, it had been filled at one time with normal car engine oil and no filter items had been purchased in almost three years from the Australian distributor of the compressors (yes, may have been purchased elsewhere but dive operator did not provide any evidence to show this when asked)
After Laila's death, a considerable amount of compressor spares were purchased from the Australian distributor
Compressor filters were changed at 40 hours but based on average temperature for Santo, it should have been every 23 hours
Aquamarine had no records at all to show when the regs or compressor had been serviced
The lack of maintenance of the dive compressor is also consistent with that of the equipment used by Laila
Some quotes from the NZ police report:
"Based off the dive profile from the Deceased's dive watch, I believe Mr TOA's statements that he provided to Corporal SOLWIE on Thursday 2 May 2013, the Vanuatu Police CID Investigator on Friday 3 May 2013, and subsequently the statement to myself in March 2014, cannot be relied upon, as there are discrepancies between his statements and the Deceased's dive profile in their entirety".
"In all interviews, Mr TOA told Vanuatu Police and me, both he and the Deceased exited the wreck of the SS President Coolidge and they swam towards the bow. I believe this did not occur...."
"However, I believe there are doubts that Dr OSUNSADE exited the wreck through Euart's Door (located at a depth of 28 metres approximately) as her depth is too deep and there is no change in the ascent rate at Euart's Door on the Deceased's dive profile."
Some of the NZ police findings:
Aquamarine have failed to detect what I believe to be early warning signs of the Deceased's ability to complete deep, technical dives on the SS President Coolidge. These include:
Buoyancy control issues due to being over weighted
Rapid breathing rate which lead to out of air scenario's due to being over weighted and being issued ill-fitting dive gear (dive boots and fins)
Her lack of dive experience, especially relating to deep dives and wreck penetration
Feedback from other divers who complained about
From tests and examinations, I believe that the dive equipment used by Dr OSUNSADE, and the circumstances in which she found herself in have contributed to her death.
From being an ex PADI / TDI dive instructor and currently a Commercial Diver / Dive Supervisor, I find it incomprehensible that a dive guide can lose a customer in relatively good visibility, on a one on one dive. This is compelled further by the fact that the dive guide should have been aware of the Deceased's problems in the water, particularly when they were diving one on one.
There are a couple of things that I thought would have been covered by the Police report and the autopsy but which do not appear to have been looked at. One is the presence of carbon monoxide in Laila's blood. As I indicated above, Dr Edmonds says that this shows up if a test is done. As there is no mention of it, all I can guess is that it was not looked at.
Read NZ Police Report
To download a copy of the NZ Police Report, click here (2 Mb). Note that some if not most of the photos and maps/diagrams are blank or black.
NZ Coroner's Findings
The NZ Coroner's office appointed Coroner H B Shortland to investigate. His findings are very long, but the important ones are:
Laila drowned
Mr Toa's version of the event is inconsistent with the technical recording of Dr Osunsade's dive computer which I prefer
...Dr Osunsade should not have been lost/misplaced during the fateful dive
In my [coroner's] view the death was unnecessary and avoidable
Read Coroner's Report
To download a copy of the NZ Coroner's Report, click here (4 Mb). Note that some if not most of the photos and maps/diagrams are blank or black.
FINALLY
I am happy to advise that as of March 2017 Aquamarine has now gone out of business and Rehan Syed has left the country.
For more information about the wreck and dives, see SS President Coolidge.
References:
EXAMINATION OF DIVING EQUIPMENT USED DURING THE DEATH OF
Dr Lailade OSUNSADE (The NZ Police Report) dated 15 January 2015 authored by Bevan SHEFFIELD-CRANSTOUN - Police National Dive Squad
Certificate of Findings (The NZ Coroner's Report) by Coroner H B Shortland - 15 December 2015
Police report of Death of Deceased Late Mrs Lailande Osonsande (sic) dated 4 May 2013 by Inspector Samson Sam, Acting Officer Commanding, Criminal Investigation Department, Sanma Province, Vanuatu Police Force
Vanuatu Police Force "Flash Report" 42/13 of sudden death dated 2 May 2013 by unknown police officer
Death Certificate 0163 issued 2 May 2013 by unknown doctor
Order for Buriel (sic) - Lailade Osunsade dated 4 May 2013 by Rita Bill Navita, Senior Magistrate
Emails from Vicky Geiger (mother) dated from mid May 2013
Emails from Damien Healy (husband) dated from 5 June 2013
Emails from Olalesai Osunsade (brother) dated from 24 May 2013
Emails from Abadesi Osunsade (sister) dated from 24 May 2013
Phone discussion with David Ellaby (paramedic) dated 24 May 2013
Phone discussion with John, leader of Brisbane dive group dated 29 May 2013 and follow up emails
Emails and conversation with Rob, the Sydney diver who dived with Laila 30 April 2013
Long phone conversation with John Lippmann, head, DAN Australasia Pacific
Phone discussion with Cherie Howie, journalist with NZ Herald on Sunday newspaper
The Lady and the President by Peter Stoner
Diving and Subaquatic Medicine - lead author Dr Carl Edmonds
Phone conversation with Dr Carl Edmonds dated 13 June 2013
Conversations with three members of St George Scuba Club - 13 and 14 July 2013
Email from Dutch citizen 29 March 2014
Email from Person A (who I will not name at the moment) dated 13 February 2015
Two NZ memoranda dated 12 December 2014
Email from the Coronial Case Manager, Whangarei Coronial Services Unit dated 23 November 2015
The Advertiser dated 10 January 2018
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