An 11-year-old girl was trapped by a spa-pool suction force of 350kg, so powerful that three adult men could not free her, an Australian inquest has been told.
Shannon Rankin drowned on 25 March 2006 while playing with a friend in the spa at the Sevan Apartments in Forster on the mid-north coast of New South Wales.
She spent almost seven minutes under water and had a bruise 27cm by 34cm on her abdomen after a filter pump suctioned onto her stomach, creating a vortex or whirlwind effect.
During the final day of submissions on Thursday, the inquest at Glebe Coroner's Court heard that the existence of the "whirlwind" would have raised alarm bells for an experienced and highly-qualified spa builder.
But because of legislative flaws, builders with a general licence could construct pools and spas without specialist training in that area, as happened in this case.
Certification process 'systemically flawed'
Earlier, counsel assisting coroner Chris Hoy praised the efforts of the people who tried to rescue Shannon.
Her mother, Donna Rankin, sobbed quietly during discussion about failed resuscitation attempts by apartment residents and later by ambulance officers.
Mr Hoy told the inquest the certification process for pools and spas was systemically flawed.
"Such flaws were perpetuated on this occasion by ignorance, buck- passing and paper shuffling," he said. "It's revealed a system where no one checks the checker."
Mr Hoy recommended a raft of reforms to prevent further tragedies. These included a recommendation that upon installation, pools and spas receive written certification from a qualified hydraulic engineer stating that Australian standards had been met and tested.