A SOLDIER died while training at the National Diving Activity Centre near Chepstow after part of his course had been skipped, an inquest heard.
The Ministry of Defence, which was taking the course in March 2018, was censured last year for failings following a Health and Safety Executive investigation.
And an inquest jury in Gloucester ruled last week that the death of 27-year-old Lance Corporal George Partridge involved “significant points of failure”.
The soldier was close to completing the five-week military dive course when both of his cylinders ran out of air at a depth of 27m at the Tidenham quarry lake.
Divers on the course at the now closed centre had been due to go down to 21-23m, but a decision was taken to skip that part and dive deeper to attach a rope to a submerged helicopter, because it was “more interesting”.
Medical experts told the inquest the fatality was linked to a cardiac issue, after a post-mortem revealed that L/Cpl Partridge had a minor undiagnosed issue in his right coronary artery.
The soldier had previously experienced five medical episodes while carrying out endurance-related training, but they had not been acted on or flagged up by officers or Army medics.
An inquiry by the Royal Navy in 2020 concluded that “action may have been taken” if the previous incidents had been properly signposted.
In a narrative conclusion, the jury said his death had been caused by a cardiac event due to to a lack of air.
The three-day inquest heard that L/Cpl Partridge from Yeovil was one of 12 soldiers diving on the course.
The usual communication system was not working when he was attaching the line to the sunken helicopter, and surface colleagues relied on him tugging his lifeline to maintain contact.
He and another diver then overstayed the 10-minute planned submersion.
And when there were no further signals on the lifeline, a rescue diver went down to bring him to the surface within a minute, but he could not be resuscitated.
The jury’s conclusion said: “There have been significant points of failure with regards to process and training, both within the advanced diving course and supervisor training which led to George Partridge’s death.”
It highlighted specific failings, including that the supervisor and L/Cpl Partridge had not been taught how to properly calculate how quickly air would run out in deeper water, and that the dive exceeded the 10-minute limit.
Other failings included letting novice divers go underwater without reliable two-way communications; failing to ensure that the diver had enough experience and appreciation of air endurance at depth while tying a distance line; using a distance line (53m) that was three times longer than needed which risked it getting tangled; failing to carry out a risk assessment; and failing to ensure that gauges were checked more often then every 10 minutes.
The MoD is immune from prosecution, but last year the HSE served two Crown Improvement Notices after ruling that it had failed to train divers about making air endurance calculations and the risk of running out of air.
L/Cpl Partridge was married and expecting his first child with wife Zoe when he died.
Army comrades paid tribute at the time to the popular and dedicated member of 26 Engineer Regiment who loved sport and passed out in 2010 as fittest recruit.