The Coast Guard’s role in combating smuggling and providing famine relief and gruelling night work at sea which was “enough to kill a horse” are recorded in a booklet marking its bicentenary by retired marine radio officer Joe Ryan.

Ryan, who worked in the Irish Coast Guard from 1995 to his retirement in 2014, has put together a commemorative document (downloadable below) that traces the organisation’s history from its establishment by a British act of parliament in January 1822.

He records how its first inspector general, James D’Ombrain, was of Huguenot stock and began construction of station houses in Co Cork. By 1900, there were about 200 stations around the Irish coast, primarily to prevent smuggling but with a secondary lifesaving role.

The many former British navy ratings employed used their gigs and galleys to save lives prior to the establishment of RNLI stations – and often volunteered to crew RNLI lifeboats, he writes. From 1831, when D’Ombrain undertook an annual sail around Ireland, he witnessed the effects of famine on the west coast and was instrumental in organising relief.

This led to clashes with his higher authority which adopted a harsh unforgiving attitude reflected in Seamus Heaney’s work, For the Commander of the Eliza”. Sir Randolph Routh had complained to Sir Charles Trevelyan about D’Ombrain during the 1839 famine and this was the basis of Heaney’s poem, Ryan writes.

The Compass Rose at Kilmore Quay story is on page 20 of Joe Ryan's Bicentenary Booklet downloadable below

Ryan quotes from D’Ombrain’s correspondence with the British government on the issue – “I cannot but feel deeply mortified and grieved at the censure their Lordships have passed on me for an act which I considered at the time to be one of pressing emergency. “

After his retirement, D’Ombrain became a commissioner of the Lighthouse Authority of Ireland- at that time the Corporation for Preserving and Improving the Port of Dublin.

Ryan writes of the loss of the first White Star liner, Tayleur, which was wrecked off Dublin’s Lambay island on January 21st, 1854, with about 200 of the 670 passengers and crew on board surviving; the call up of Coast Guard ratings in Ireland to serve with Britain in the Crimean War from 1854; the transfer of Coast Guard control to the British Admiralty in 1856, with duties ranging from assisting vessels in distress, undertaking navigational duties, recording reports from fishing harbours and identifying wild birds and rare fish washed ashore.

“The Admiralty had an ulterior motive in taking over the Coast Guard. They had a reserve of trained men to call upon in times of war. We can also see how things like their benevolence and lifesaving skills were no longer priorities,” Ryan writes.

The Coast Guard Heli and Howth RNLI in 2007. This story is on page 64 on the bicentenary booklet downloadable below

The death of Captain John McNeill Boyd and five of his crew from the guardship Ajax during an attempted rescue of two ships seeking shelter in Kingstown (Dun Laoghaire) during storms in February 1861; the Fethard lifeboat disaster of February 1914; the establishment of the Coast Life Saving Service after independence in 1922; the initiation of a separate Coast Watch service during the second world war; and the last use of a breeches buoy are covered by Ryan.

He pays tribute to Joan O’Doherty (nee McGinley’s) West Coast Search and Rescue Action Committee of 1988, which highlighted the need for more helicopter rescue bases, and the role of Capt Liam Kirwan, first director of the new Irish Marine Emergency Service from 1993.

Kirwan had worked with Capt Peter Brown and Capt David Shiels on the Coast and Cliff Rescue Service from 1987, and Ryan also recalls the contribution of the late Agnes Walsh who worked for the Department of the Marine during implementation of the Government’s Doherty report on search and rescue.

MV Plassy was wrecked on Inisheer in 1960. The local CCLS team rescued the crew of 11 using breeches buoys.  See page 46 in the booklet downloadable below

Incidents such as the loss of all six crew without trace from the Donegal fishing vessel Carrickatine in November 1995; the death of volunteer diver Michael Heffernan during the Belderrig cave rescue in north Mayo in October 1997; the deaths of four Air Corps crew when Rescue 111 crashed off Waterford in July 1999; the extraordinary rescue of a young Spanish crewman wearing no lifejacket from the Skerd Rocks in outer Galway Bay by Rescue 115 from Shannon in 2000; and the rescue of 21 sailors from the Fastnet Yacht Race competitor Rambler in August 2011 are also recalled.

Ryan records the devastating impact of the death of the first Irish Coast Guard volunteer on duty – Caitriona Lucas of Doolin Coast Guard in September 2016 – and the loss of the Rescue 116 helicopter crew of Capt Dara Fitzpatrick, Capt Mark Duffy, and winch team Paul Ormsby and Ciarán Smith off Blackrock island, north Mayo on March 14, 2017.

Ryan spent 12 years at sea on all types of ships working initially for Marconi Marine, before going freelance and spending the final six years directly employed by a supertanker company. He worked as a computer engineer with McDonnell Douglas Information Systems Ltd in Dublin, and joined the Irish Marine Emergency Service in 1995 – renamed as the Irish Coast Guard in 2000.

He retired in 2014, and his booklet is based on research undertaken for a lecture for the Maritime Museum in Dun Laoghaire that same year. His commemorative publication is downloadable below, and copies are also available by contacting him at email [email protected]

The Coast Guard and RNLI are appealing to the public to exercise caution when participating in any activity on or near the water during the Christmas and New Year period, and to be mindful of the restrictions in place to deal with the COVID pandemic. With many traditional Christmas and New Year swims cancelled, anybody planning this activity should check on the up-to-date guidance and ensure that they have made the appropriate safety arrangements.

Both organisations have thanked the public for their cooperation during the past year and in particular to the positive response in adhering with severe weather warnings. 2021 proved to be a busy year with an almost 20% increase in callouts, placing extra demand on Search and Rescue providers, including Coast Guard and RNLI volunteer crews.

With the increased levels of open water swimming, both organisations are highlighting the risks of cold water shock, which is a danger for anyone entering water 15°C or below. Average sea temperature around Ireland at this time of year are between 6 and 10°C, which can pose a risk of hypothermia, even for the most experienced of open water swimmers.

Safety tips from the Coast Guard & the RNLI for open water swimming are:

• Always check the weather forecast and understand the local effects of wind, tides, and currents. (For weather and tides see safetyonthewater.gov.ie)
• Never swim alone and if possible, have somebody ashore who is familiar with your plans and can observe your progress.
• Only swim in sheltered areas with which you are familiar and swim parallel to the shore.
• Stay within your depth – know your limits including how long to stay in the water
• Ensure that you are visible from the shore. Wear a brightly coloured swim cap or use a tow float to increase your visibility in the water.
• Wearing a wetsuit is advisable to help stay warm.
• Acclimatise to cold water slowly to reduce the risk of cold-water shock.
• Get warmed up afterwards. Wrap up well in extra layers of clothing
• If in doubt, don’t go out.
• Tell someone else where you’re going and when you’ll be back.

Irish Coast Guard Operations Manager Micheál O’Toole said: ‘We wish to say a special thank everybody involved in SAR (Search and Rescue) for their commitment and service in these extraordinary times with a special thank you to the volunteer members of the rescue services. People love to get out and about over the Christmas and New Year period. For those who have an opportunity to go on coastal walks always remember to Stay Back Stay High Stay Dry – and this year please be especially mindful of Covid related restrictions.’

He added, ‘It is important to distinguish between the traditional Christmas quick dip and longer swims. Open water swimming at this time of the year is only for experienced participants and never ever swim alone.”

RNLI Regional Lifesaving Lead Owen Medland added: ‘Our wish for everyone planning a trip to the coast or a festive swim is that they do so safely. We urge everyone to be extra cautious and understand the risks and know how to stay safe before they enter the cold water. Follow the right advice for your activity and always carry a means of calling for help.’

He concluded, ’As we come to the end of the year, we would like to thank all those involved in search and rescue around the coast of Ireland and on inland waters. These dedicated men and women, many of whom are volunteers, will remain on call over the Christmas period and New Year.’

The Department of Transport has responsibility for delivery of an accessible, efficient, safe and sustainable transport system that supports communities, households and businesses.

Ireland’s marine footprint extends to more than 10 times our land mass and the marine sector plays a central role in our economic and social development.

We are now looking for an exceptional individual to lead Ireland’s Maritime Policy and Service Delivery at the Department of Transport, to drive and deliver Government policy. As a key member of our Management Board, the person we seek will have the skills necessary to make a real impact across the full range of issues relating to this sector.

This requires the ability to:

• lead the design of innovative, evidence-based policy to promote efficient, safe, secure and sustainable maritime transport;
• oversee a framework of port companies operating within the national transport chain of port services which are efficient, effective and adequate for the needs of our trading economy;
• lead and manage the Coast Guard function across a range of administrative, professional and technical grades;
• lead the delivery of an extensive legislative programme to support regulation of merchant shipping, maritime safety and ship source pollution, living and working conditions of all Irish ships and crew;
• represent the Department at the most senior levels in Government and in engaging with industry and the agencies under the remit of the Department;
• represent Ireland’s interests in the development of international maritime transport policy.

The successful candidate will;

• have a proven record of leadership and achievement at a senior level that demonstrates the necessary vision, leadership, governance and management skills;
• demonstrate the capacity to work collaboratively and contribute strategically to the overall leadership and future development of the Department;
• have a proven ability to deliver change initiatives including people management and performance improvement; and
• demonstrate excellent communication and people management skills, including the ability to network effectively, both internally and across the Sector.

If you feel you would benefit from a confidential discussion about this role, contact Eamonn Purcell at [email protected]

For more information and how to apply, visit: https://bit.ly/Afloat_Art_HdMaritime

The closing date for receipt of completed applications is 15:00 on Thursday 6th of January, 2022.

We are committed to a policy of equal opportunity and encourage applications under all nine grounds of the Employment Equality Act.

People Before Profit TD Bríd Smith has said the next contract for search and rescue aviation services should not be awarded to CHC Ireland.

Such services should be operated by the State, Ms Smith said.

She was speaking in the Dáil yesterday (November 17) during statements on the Air Accident Investigation Unit’s (AAIU) final report into the loss of four lives in the Irish Coast Guard Rescue 116 helicoper crash off Mayo in March 2017.

The final AAIU report published on November 5th made 71 findings and 42 recommendations in relation to the Sikorsky S-92 crash, which claimed the lives of Capt Dara Fitzpatrick, Capt Mark Duffy and winch crew Paul Ormsby and Ciarán Smith.

The bodies of the winch crew have still not been recovered.

Addressing Minister for Transport Eamon Ryan in the Dáil chamber, Ms Smith noted that he had referred to it as “a tragic, unforeseen accident”.

"I don’t believe this was a tragic, unforeseen accident"

“But I don’t believe this was a tragic, unforeseen accident, because when you prioritise costs in tendering out core services then you create very serious risk and cost of life,” Ms Smith said.

The Rescue 116 crew were employed by CHC Ireland which holds the current Irish Coast Guard contract to run four search and rescue aviation bases. A tender for the new contract is currently underway.

Referring to navigational issues, she questioned the “light-touch regulation” and the role of the Irish Aviation Authority (IAA).

“If we are to fully honour the crew of 116, and indeed to honour all of the Air Corps and sea rescue personnel, then we have to do more than simply accept the recommendations in this report,” Ms Smith said.

“We have to end the light-touch regulation in bodies like the IAA, and we have to end the tendering and obsession with cutting costs for vital public services and ensure the State operates such vital services itself,” she said.

“If you award that contract to CHC...then the dedicated staff and the personnel that are employed to look after our safety at sea and to rescue us will we be highly insulted,” she told the minister.

“ I think it would be an absolute irony and a tragedy for the State to do this,” she added.

Ms Smith expressed solidarity with the families of the four crew and said the State owed them an apology.

She also questioned why the final report had been sent for review, delaying its publication by over two years.

Opening the two hour debate, Minister Ryan said he accepted all of the recommendations relating to his department.

While it would take some time for his department to deal with each of the findings, he said he would formally respond to all of the safety recommendations ahead of a 90-day timeframe for him to do so.

The AAIU had concluded that the tragedy was an "organisational accident", he said, and he outlined a number of measures taken by his department to improve search and rescue operations, including publication of a national search and rescue plan.

A review of all training for Irish Coast Guard staff had taken place, and there had been a formal course on tasking of aviation assets.

New legislation would formalise the role of the IAA on oversight of search and rescue.

Mr Ryan explained that his department had asked that the IAA’s role as civil regulator be reviewed by external experts this year, and it found no gaps under the Irish Aviation Act 1993 in meeting obligations.

He paid tribute to the work of the AAIU and to the four Rescue 116 crew and expressed sympathies to their families.

Sympathies were also expressed by a number of deputies participating in the debate.

Independent TD for Galway West Catherine Connolly expressed frustration that such a short time frame had been allotted for considering such a lengthy and detailed report at 350 pages.

Sinn Féin’s transport spokesman Darren O’Rourke said that accepting the findings of the report alone was not enough.

He called on the minister to provide a timeline for when each of the 42 safety recommendations would be implemented.

Mr O’Rourke asked what mechanism would be used to ensure the different parties, to which recommendations were addressed, would comply with the report on a coordinated basis.

Mayo Sinn Féin TD Rose Conway Walsh welcomed the minister’s commitment, and said robust and thorough action was required to ensure crews had confidence in their working environment.

People living in her constituency in Erris had a special place in their hearts for the sacrifice made by the four crew on the morning of March 14th, 2017, she said.

Labour TD Aodhán Ó’Ríordáin read the statement on the AAIU report by the Irish Airline Pilots Association into the Dáil record, and noted that the pilots’ union had said that the loss of life was as "needless as it was preventable".

Fianna Fáil TD for Mayo Dara Calleary and Social Democrats co-leader Catherine Murphy also questioned why search and rescue aviation was not being run by the State.

Mr Calleary paid tribute to the communities in Erris and north Mayo who had rallied to provide support during the extended search effort.

Irish Coast Guard volunteers who were on call 24/7 deserved dignity and respect, which they were not getting at present, Mr Calleary said.

The loss of four Air Corps search and rescue helicopter crew in the Dauphin crash off Tramore, Co Waterford in 1999 was recalled by two Waterford deputies - Independent TD Matt Shanahan and Green Party TD Marc Ó Cathasaigh.

Mr Shanahan recalled that Capt Dave O'Flaherty, Capt Mick Baker, Sgt Paddy Mooney and Cpl Niall Byrne died shortly after midnight on July 2nd, 1999, while returning from a rescue mission off the Waterford coast.

He said the State needed to install a permanent fixed wing aircraft based in Dublin to provide top cover for search and rescue, assist in marine pollution, and with patient transfer capability.

He also queried the delay in rolling out night vision goggles for all search and rescue.

Members of the house observed a moment of silence in memory of the four Rescue 116 crew who died in the crash at the close of the debate.

The "probable cause" of the Rescue 116 Irish Coast Guard helicopter crash, which claimed the lives of four air crew off the north Mayo coast in March 2017, has been identified as a combination of poor weather, the helicopter's altitude and the crew being unaware of a 282ft obstacle on the flight path to an initial waypoint in a pre-programmed route guide.

The 350- page final report by the Air Accident Investigation Unit (AAIU) also identifies "serious and important weaknesses" in management of risk mitigation by helicopter operator, CHC Ireland, which holds the Irish Coast Guard search and rescue (SAR) contract.

Four crew Capt Dara Fitzpatrick, Capt Mark Duffy, winch team Paul Ormsby died in the crash at Blackrock island at 0046.08 hours on March 14th 2017.

The bodies of Capt Fitzpatrick and Capt Duffy were recovered, but both Paul Ormsby and Ciaran Smith are still missing despite extensive searches.

The report recalls how R116 was asked to provide top cover for Rescue 118 from Sligo, which had been tasked to airlift a casualty from a fishing vessel, situated approximately 140 nautical miles off the west coast of Ireland.

Black Rock off the Mullet Peninsula in Co Mayo, where the Sikorsky S-92 helicopter went down Credit: CIL

"At 00.46 hrs, on 14 March 2017, while positioning for an approach to Blacksod from the west, the helicopter, which was flying at 200 feet above the sea, collided with terrain at the western end of Black Rock, departed from controlled flight, and impacted with the sea," it says.

"During the immediate search and rescue response, the Commander was found in the sea to the south-east of Black Rock and was later pronounced dead. Subsequently, the main wreckage of the helicopter was found close to the south-eastern tip of Black Rock, on the seabed at a depth of approximately 40 metres," it says.

Capt Fitzpatrick's colleague Capt Duffy died instantly and was located within the cockpit section of the wreckage and was recovered by Naval service divers.

The report has 42 safety recommendations, which Minister for Transport Eamon Ryan says he accepts

The report has 42 safety recommendations, which Minister for Transport Eamon Ryan says he accepts.

The preliminary report published in April 2017 was critical of lack of navigational information for the crew. It highlighted how personal locator beacons in the pilots' lifejackets malfunctioned due to a conflict in fitting instructions.

The final report, which has been delayed in publication by two years after one of the parties sought a review, identifies "confusion at State level" regarding responsibility for oversight of search and rescue operations in Ireland.

It highlights how the Irish Aviation Authority believed Irish Coast Guard to be responsible for search and rescue oversight, when the Irish Coast Guard did not have this expertise.

Rescue helicopter R116

The report found that the initial route waypoint for the approach to Blacksod to refuel was almost "coincident" with the terrain at Blackrock island. Flight databases didn't indicate the presence of Blackrock, and neither did some of its imagery. Lighthouses were not clearly marked in the route guide with a small red dot and an elevation in numerical value.

Route guide hazards and obstacles listed on the route guide title page were identified by white numericals, within red circles, outlined in black.

The report has found that the helicopter operator didn't have "formalised, standardised, controlled or periodic" systems of testing flight routes.

Route guides had not been fully proven and updated, there was an error in the length of one of the route legs for Blacksod helipad which had gone undetected since 1999, and emails provided by CHC Ireland showed that one pilot advised in June 2013 that Blackrock lighthouse was not shown on the emergency ground proximity warning system (EGPWS).

It also found that the flight crew members' likely hours of wakefulness at the time of the accident were correlated with "increased error rates and judgement lapses."

A sleep study of some of the operator's SAR crew members found that they accrued less sleep than the US National Sleep Foundation recommended and that "this may not be enough sleep for optimal operational duty".

The Irish Coast Guard four helicopter bases operate a 24-hour shift – the only emergency service to do so –and it is understood that flight duty time was degraded over the years by the Irish Aviation Authority.

The Department of Transport has stated it fully accepts the recommendations contained within the report and will continue to evaluate the findings in the coming weeks.

"This was a tragic accident that claimed the lives of four individuals who were dedicated to saving the lives of others," Minister for Transport Eamon Ryan said.

He said he would "like to again convey my condolences to the families and loved ones of the R116's crew at this time".

"The completion of the Investigation and the publication of the report is a key step in ensuring that such accidents are prevented in the future. I wish to acknowledge the investigative work that has been done by the AAIU that has culminated in this report," he said.

"This is clearly reflected in the level of detail and wide-ranging nature of the report, with safety recommendations that cover all aspects of SAR aviation, both nationally and internationally," he said.

The AAIU, which states its role is not to apportion blame or liability, said it adopted a revised text after a review, and says the final report includes "substantially the same safety recommendations" as those issued in the draft final report in September 2019.

The report notes that the reasons for selecting a 282 ft obstacle as the starting point for what the Operator described as a 'Low Level' route, with no vertical profile, could not be determined because the origins of the route design itself were unknown to the operator.

"a number of factors militated against the flight crew detecting Black Rock"

It identifies a number of factors that militated against the flight crew detecting Black Rock in time to carry out an effective avoidance manoeuvre.

It says Black Rock was not in the emergency ground positioning warning system (EGPWS) databases.

"The BLKMO magenta waypoint symbol and track line likely obscured radar returns from Black Rock (which might have been detected on the 10 NM range)" and the 1:250,000 Aeronautical Chart, Euronav imagery did not extend as far as Black Rock."

"The 1:50,000 Ordnance Survey Ireland imagery in the Toughbook did not show Black Rock, but instead showed open water at Black Rock," it says.

"Furthermore, the operator did not have formal processes or procedures to approve mapping data/imagery for use in its helicopters," it says.

"The operating environment on the west coast would have been more challenging than east coast crews were familiar with, particularly regarding the availability of visual cues in the littoral environment. This meant that it would not have been possible for the Flight crew to accurately assess their horizontal visibility," it says.

"However, given that Black Rock was only detected on the FLIR camera when the Helicopter was approximately 600 m from it, it seems that the horizontal visibility to the naked eye was probably less than 600 m," it says.

"Furthermore, the Flight crew's night vision may have been compromised due to the helicopter's external lighting. Research indicates that if the Flight crew were awake for the length of time suggested by the Investigation's review (18 hours for the Commander and 17 hours for the Co-pilot), they would have been more prone to errors in judgement and decision-making," it says.

"The tempo of the mission was different to east coast missions, and furthermore, the SAR support nature of the mission was known to be monotonous, increasing the risk of the Crew succumbing to fatigue," it says.

"Routes were generally viewed as base-centric, and a level of local knowledge and familiarity may have been assumed, which was an invalid assumption when an east coast crew was utilising a west coast route, a situation compounded by darkness and poor weather," it says.

"The Operator said that the routes were merely there as a framework on which to build a plan for entry/exit to a number of known sites. However, there was no formal training in the use of routes; there was no formal procedure for how a route was to be designed; there was no formal procedure for how a crew should use a route guide; routes did not include a vertical profile or minimum altitudes generally, for route legs; and routes were not available for use in the simulator," it says.

"The Route Guide was prefaced with the statement that it was 'a work in progress and should be used with the necessary caution until all routes/waypoints are proven'. Therefore, the routes were unproven, and the Operator did not have a defined process for route proving. Consequently, in the absence of formal, standardised training, design procedure or procedure for how a crew should use a route guide, it is unclear what beliefs/expectations individual pilots may have had regarding routes and how they could be used operationally," it says.

"Problems with a number of routes had been identified in the SQID system (the Operator's Safety and Quality Integrated Database), however, the SQID report was closed after personnel were emailed to resolve the matter, but without checking that the routes had actually been updated correctly," it says.

"The closing of SQIDS without checking that effective action had been completed was one of a number of issues identified with the Operator's Safety Management System (SMS). The Investigation also found that safety meetings were not being held as often as called for; minutes were not being uploaded onto SQID; SQID closure was not following the protocols set out in the Safety Management and Compliance Monitoring Manual (SMCMM); the quality of Risk Assessments could be improved," it says.

The report recalls how the helicopter maintained a north-westerly track until it reached 200 ft, at which point the Commander announced that Approach One was complete and that she was '[…] just going to help it round the corner … coming to the left'.

"As the Helicopter commenced the left turn back towards BLKMO, the Winchman announced that the Helicopter was 'clear around to the left'. This was followed approximately 30 seconds later by a further announcement from the Co-pilot that they were 'ah clear ahead on E GYP WIZZ and radar'," it says.

"At 00.43 hrs, as the helicopter was turning back towards BLKMO at 200 ft, the 'Before Landing' checklist was commenced. During this time, the Co-pilot stated: 'starting to get ground coming in there at just over eight miles in the ten o'clock position'. Just as the Commander was completing the final item of the 'Before Landing' checklist, she commented that she was visual with the surface of the sea," it says.

"At 00.45 hrs, the Co-pilot announced 'okay so small targets at six miles at 11 o'clock… large out to the right there'. This was followed approximately 20 seconds later by an Auto Callout' Altitude, Altitude', which the Commander said was 'just a small little island that's B L M O itself'," it says.

"Just prior to 00.46 hrs the Winchman announced 'Looking at an island just eh directly ahead of us now guys…you wanna come right [Commander's name]'. The Commander asked for confirmation of the required turn, and the Winchman replied 'twenty degrees right yeh'," it says.

"The Commander instructed the Co-pilot to select heading (HDG) mode, which the Co-pilot acknowledged and actioned. Within one second of this acknowledgement, the Winchman announced 'come right now, come right, COME RIGHT'. Shortly after this, the helicopter pitched up rapidly and rolled to the right. At 00.46:08 hrs, the helicopter collided with terrain at the western end of Black Rock, departed from controlled flight, and impacted with the sea. The main wreckage of the helicopter came to rest on the seabed to the east of Black Rock, at a depth of 40 metres (m)," it says.

In its conclusions, the report states that there were gaps in the way tasking protocols were followed at MRSC Malin.

It says both flight crew members commented adversely about the quality of cockpit lighting, and neither had been to Blackrock recently.

It says the Commander reviewed the route waypoints with the co-pilot and took '*overfly*' off one waypoint, which the Investigation believes was BKSDC (Blacksod).

It says she did not verbalise the obstacle information from APBSS route into Blacksod, when she briefed the route but it appears that she did read at least some of the information because she was aware of an obstacle to the west of Blacksod when the Co-pilot asked about an escape heading.

It says the co-pilot self-briefed the route and he did not verbalise the obstacle information.

"Radar was operated on the 10 NM range throughout the descent and manoeuvring to commence APBSS," it says.

It says Black Rock was not identified on radar which was likely due to obscuration caused by the magenta BLKMO waypoint marker and the magenta track line to the waypoint marker.

"Black Rock was not in the EGPWS databases. The 1:250,000 Aeronautical Chart, Euronav imagery did not extend as far as Black Rock. The 1:50,000 OSI imagery available on the Toughbook did not show Black Rock Lighthouse or terrain, and appeared to show open water in the vicinity of Black Rock," it says.

"The AIS transponder installed on the helicopter was capable of receiving AIS Aids-to Navigation transmissions; however, the AIS add-on application for the Toughbook mapping software could not display AIS Aids-to-Navigation transmissions," it says.

"The winchman announced that he had detected an island ahead on the EO/IR camera system when the helicopter was about 0.3 NM from it, travelling at a ground speed of 90 kts. The winchman called for a change of heading and the flight crew were in the process of making the change when the urgency of the situation became clear to the winchman," it says.

"There is no indication on the cockpit voice recorder that the flight crew saw Black Rock, although in the final seconds of flight there was a significant, manual input on the Collective Lever, an associated 'droop' in main rotor RPM and a roll to the right," it says.

"the Department of Transport lacked the technical expertise to oversee the IAA"

"The helicopter collided with terrain at the western end of Black Rock, departed from controlled flight and impacted with the sea. At no stage did any member of the crew comment on seeing, or expecting to see, a light from Black Rock Lighthouse," it says.

It says the Department of Transport lacked the technical expertise to oversee the IAA and the Irish Coast Guard did not have a safety management system.

"Numerous areas, across several agencies, are explored in-depth in the Final Report, it says which demonstrate that the accident was, in effect, what expert Professor James Reason termed 'an organisational accident'," it says.

"The Final Report highlights the importance of robust processes in relation to the following areas: Route Guide design, waypoint positioning, and associated training; reporting and correcting of anomalies in EGPWS and charting systems; Fatigue Risk Management Systems; Toughbook usage; en route low altitude operation; and the functionality of emergency equipment," it says

"It is particularly important that an operator involved in Search and Rescue has an effective Safety Management System, which has the potential to improve flight safety by reacting appropriately to safety issues reported, and by proactively reducing risk with the aid of a rigorous risk assessment process, "it says.

The Final Report identifies the importance of the levels of expertise within organisations involved in contracting and tasking complex operations such as Search and Rescue, to ensure that associated risks are understood, that effective oversight of contracted services can be maintained and that helicopters only launch when absolutely necessary.

In a statement, Hermione Duffy, wife of the late Capt Mark Duffy, said her husband had been an excellent pilot and father and, together with his colleagues, shared a deep commitment to his search and rescue role, always taking pride and satisfaction from his work.

Ms Duffy asked people to remember that "four honourable souls lost their precious lives that night in the service of others, and in circumstances which are harrowing and traumatic to read of and which have left wives, children, parents and extended families bereft".

"the loss of four aircrew lives was "as needless as it was preventable"

The Irish Airline Pilots Association (IALPA) said the report shows that the loss of four aircrew lives was "as needless as it was preventable", it says.

The final publication of the Report corresponds with the AAIU Interim and Preliminary reports and "makes it clear that the crew of R116 were exemplary in the performance of their assigned task", IALPA says.

"Their planning, response, teamwork, and communication was exactly what would be expected from such a competent and seasoned crew, on a flight led by such professional pilots," it says.

"They were let down by a regulatory system which left them ill-equipped to do the vital work that same system tasked them with," it says.

"The report outlines a number of regulatory and systemic issues which conspired to put the crew in lethal danger. Prime amongst them was the provision of inaccurate and misleading chart and map data," IALPA says.

"All flight crew rely on the basic assumption that their maps and charts provide accurate data. Few flight crews could be more reliant on that assumption of accurate data than the crew of a rescue helicopter, operating offshore in challenging conditions outside their normal home base, scrambled at short notice to launch a rescue in the middle of the night (00:45 am). They relied on the data production standards of Irish regulation to guarantee them correct information" it says.

"They were let down," IALPA says.

IALPA President Evan Cullen described it as a fundamental betrayal, and said that "as an airline pilot, if I take a flight from Dublin to Rome, I must navigate the Alps, and I expect one of two things from the Swiss authorities; tell me the height of the alps, or tell me they don't know the heights, so I'd better avoid them. The one thing they can't do, under any circumstances, ever, is tell me the wrong height, or tell me the Alps are not there," he said.

"In essence that is what the Irish State did to Dara, Mark, Paul and Ciarán. They approved information which said, 'you are safe', when the absolute opposite was the truth."

IALPA said the report details failures in oversight, equipment requirements and maintenance, and in resourcing for SAR.

"But it is the regulatory failure by the now-defunct Irish Aviation Authority which is central to this accident. They set the standards for equipment, for mapping, and for oversight. They accepted standards which most, if not all, of their European peer authorities, would not," IALPA says.

"This tragic and unnecessary loss of life must not be allowed to happen again. IALPA is calling on the Government and Minister for Transport to institute an immediate review of the failures identified in this report, and to bring forward concrete proposals to address each and every identified failure immediately," it says.

CHC Ireland responds

CHC Ireland said it would like to express its deepest sympathy towards the family and friends of our colleagues; Ciarán, Dara, Mark and Paul", and welcomed the final report.

The company said it acknowledged the work of the AAIU "in producing such a comprehensive review", which is "extremely thorough and will make difficult reading for all those involved".

"These lessons will undoubtedly be applied across Search and Rescue operations in Ireland and throughout the world. We are also grateful for the work of the Chair of the Review Board," CHC Ireland said.

"CHC Ireland continues to advance aviation safety by investing in ongoing employee training and development, working to global standards and engaging with aviation stakeholders. Our commitment is to deliver essential Search and Rescue services to the people of Ireland in a safe and professional manner," it said.

"We are committed to implementing the appropriate Safety Recommendations that are directed towards CHC Ireland in the Final Report. The report is clear that the organisation of Search and Rescue in Ireland involves many stakeholders including the Irish Aviation Authority, the Irish Coast Guard and the European Aviation Safety Agency. CHC Ireland will ensure that it collaborates with all the relevant stakeholders to address the recommendations. The most important thing is that we collectively ensure that all areas identified for further strengthening are actioned," it said.

"We continue to honour the memories of Ciarán, Dara, Mark and Paul. They will never be forgotten"

CHC Ireland general operations manager Rob Tatten referred to the "unwavering commitment" of all those involved in search and rescue.

"Our crews continue to fly hundreds of search and rescue missions every year, saving many lives. Our team is justifiably proud of our global safety record and everyone in CHC Ireland is committed to the safe delivery of our service," he said.

"We continue to honour the memories of Ciarán, Dara, Mark and Paul. They will never be forgotten," Mr Tatten said.

Irish Aviation Authority statement

The Irish Aviation Authority (IAA) issued a statement this evening saying it wished to "take the opportunity to again express our greatest sympathy to the families and friends of the four crew members of the Irish Coast Guard R116, who tragically lost their lives while undertaking a rescue mission on 14 March 2017"

The authority said it welcomed the publication today of the Air Accident Investigation UUnit's (AAIU) comprehensive report into this accident, which we believe will contribute to the prevention of future aviation accidents both in Ireland and indeed globally.

We have reviewed and fully accept the recommendations addressed to the IAA, which have already been implemented or are proceeding to full implementation. We will verify our progress in this regard to the AAIU.

At the time of the R116 accident, the IAA exercised safety oversight of the operator through their Air Operator Certificate and a national Search & Rescue approval. As indicated in the AAIU report, Search & Rescue regulation is not covered by ICAO or EU safety rules. The AAIU has recommended that the EU Commission review Search & Rescue safety standards at European level with a view to developing guidance material, and the IAA supports this recommendation. The IAA continues to work on an on-going basis with the European Commission and EASA in the development of safety rules.

As the aviation regulator for Ireland, the safety of air crew and passengers is our number one priority. We want to restate our commitment to working with all stakeholders to achieve this aim, including the implementation of all safety recommendations in the AAIU report.

The IAA is currently undergoing a programme of institutional restructuring, which will establish a new, single, independent aviation regulator for civil aviation in Ireland. This conforms with best practice for institutional structure and governance for regulators in Europe and globally.

Pilot Dara Fitzpatrick

In a statement the family of pilot Dara Fitzpatrick said they believed that Dara and her fellow crew members were ""adly let down" "by operator CHC Ireland for ""ot providing them with the safe operating procedures and training that they were entitled to expect'"

Family response

The Fitzpatrick family said there was an expectation on the operator of the search and rescue service to minimise the risk to the crew by aiming to remove risk and providing crews with safety procedures on which they can rely.

"Unfortunately, this was not done on this occasion," "the Fitzpatrick family said.

"We hope that the AAIU final report and the review board report will ensure that those responsible for this operation, both directly and at a supervisory level, urgently implement the necessary changes, and that in future they pay attention to the feedback that they get from flight crew as to any inadequacies and hazards in the operation, so that such an accident will never happen again, that no one else will needlessly lose their lives, and that no other families will have to endure the devastating loss that we endure with the untimely death of our beautiful Dara," "the family stated.

An independent Association has been established to represent the concerns of Irish Coast Guard (“IRCG”) Volunteers.

As Afloat reported previously, the Irish Coast Guard Volunteers Representative Association (“ICGVRA”), consisting of existing and former IRCG volunteers, was launched in Kilkee over the bank holiday weekend following a moving commemoration for IRCG volunteer Caitriona Lucas who lost her life at Kilkee on 12th September 2016.

During the ceremony, Emma Lucas, daughter of Caitriona Lucas, placed a wreath for her mother, together with John O Mahony, Chairman ICGVRA, on the clifftop beside where Caitriona died when Kilkee’s Irish Coast Guard Delta Rib capsized. ICGVRA’s launch was attended by several politicians, including Clare Oireachtas members Joe Carey T.D and Senator Roisin Garvey, Senator Gerard Craughwell (Galway), and Maurice Quinlivan T.D (Limerick), as well as international maritime lawyer, Michael Kingston. 

Many Irish Coast Guard Volunteers both past and present spoke movingly about the importance of having an independent association to represent their interests. Bernard Lucas, Vice Chairperson of ICGVRA said "Volunteers are central to the strength and capability of the Coast Guard Units and their value must be prioritised. For far too long volunteers have had no voice. The time is now to stand together for the betterment of the Coast Guard as a whole and its volunteers."

Inaugural Members of ICGVRA at launch, Kilkee, Co Clare, with (left to right) Joe Carey T.D, Senator Roisin Garvey, Maurice Quinlivan T.D, Senator Gerard Craughwell, and Michael Kingston (far right)

ICGVRA Chairman, John O Mahony stated “In the history of the Irish Coast Guard there has never been an independent voice to speak on behalf of the Volunteers as a collective, to ensure that the well-being of volunteers from their perspective is at the heart of best practice policies within Units and in Units and volunteers’ interaction with IRCG Management. We need to be here to offer support and help to all IRCG members both past and present, to assist in resolving any issues that they may have struggled with, and to work with IRCG Management to ensure best practice prevails so that issues do not arise, if possible, in the first place. And if they do, we are here to ensure that when conflicts arise, they can be resolved objectively and transparently whilst exercising fairness and common sense. We are here to establish positive dialogue with I.R.G.C management”

A wreath laid for Caitriona Lucas, at clifftop close to where Kilkee's IRCG Delta Rib capsized on 12th September 2016, Kilkee, Co Clare

ICGVRA Secretary, Jim Griffin, who relayed to those present the aims of ICGVRA said “The formation of the Irish Coast Guard Volunteers Representative Association is long overdue given the events and treatment of IRCG Volunteers in recent years by H.Q. It has become apparent that IRCG management have adopted a ‘Divide and Conquer’ mentality towards the Volunteers” 

ICGVRA says it is now seeking an urgent meeting with Transport Minister, Eamonn Rayan, and has already, through Darren O Rourke T.D (Sinn Fein), raised their concerns with the Transport Minister. Joe Carey T.D (Fine Gael) and Senator Gerard Craughwell (Independent), as members of the Transport and Communications Committee (together with Darren O Rourke) confirmed they would also be raising ICGVRA’s concerns at the next Committee meeting.

As schools in Northern Ireland prepare for the half-term break, the RNLI and the Coastguard are reminding everyone to stay safe if they are heading to the coast or are visiting the local inland waterways as the autumn sets in.

During last year’s half-term holidays, RNLI lifeboats across Ireland and the UK launched 143 times and aided 78 people as its volunteer crews dealt with everything from tidal cut-offs and struggling paddleboarders to slips and trips on coastal paths, as well as vessels in distress.

Lisa Hollingum, RNLI Water Safety Delivery Support said: ‘With the best of the weather behind us for the year, we’re asking those visiting the coast and inland waterways this half-term to consider the dangers.

‘Our lifeboats often rescue those cut off by the tide on coastal walks, so we encourage you to check the tide times and ensure you have planned to get back safely before the water level rises.

‘For those planning a coastal walk, also consider the terrain as what may seem like firm ground can, in fact, be very soft sand or mud meaning that people might get stuck.

‘If you are cruising on the inland waterways, plan your journey, and be aware of the shorter evenings so that you leave enough time to reach your overnight mooring.

‘Over the coming months, sea and lake conditions will become rougher and more unpredictable which brings many additional dangers. Large waves will break on the shoreline which increases the risk of people being swept off their feet, along with coastal erosion causing cliff falls making some areas more dangerous.

‘Around 140 people lose their lives around Irish and UK coasts, including on inland waterways each year, and over half never even planned to enter the water. If you do find yourself in the water unexpectedly, FLOAT to live by fighting your instinct to thrash around, lean back, extend your arms and legs, and float until you gain control of your breathing, before deciding whether to call for help or swim to safety.’

Claire Hughes, Director of HM Coastguard, said: ‘Autumn is a perfect time to explore the coastal areas and inland waterways around the UK, the summer crowds have gone and the weather is ideal for a walk. However, the sunshine can quickly vanish making the temperature much colder and the lifeguards who were present in peak season are no longer on most beaches. It is vital at this time of year to be prepared before you head to the coast.

‘As always, we are ready to deal with emergency situations but please take note of safety advice and don’t take risks. If you see anybody in trouble, don’t enter the water yourself to try and rescue them, call 999 and ask for the Coastguard.’

The RNLI’s key coastal safety advice is:

• Have a plan - check the weather forecast, tide times, read local hazard signage and let someone know where you are going and when you intend to be back
• Keep a close eye on your family and keep dogs on a lead near the edge of cliffs
• If walking or running be aware that coastal paths, promenades and piers may be slippery or prone to waves breaking over them
• If you fall into the water unexpectedly, FLOAT to Live. Fight your instinct to thrash around, lean back and relax, extending your arms and legs
• In an emergency dial 999, and ask for the Coastguard

Minister for Transport Eamon Ryan has said his department will cover “reasonable legal expenses” incurred by the families of the four Rescue 116 air crew who died off North Mayo in relation to a review of the draft final Air Accident Investigation Unit (AAIU) report.

In a statement issued this Thursday evening, Mr Ryan said he had written to the families of the crew of R116 that afternoon.

He said he had “ let them know that the Department of Transport will cover their reasonable legal expenses incurred as a result of the Review into the accident in which their loved ones lost their lives”.

Pilots Dara Fitzpatrick and Mark Duffy and winch team Paul Ormsby and Ciarán Smith died when their Sikorsky S-92 crashed at Blackrock island off north Mayo in the early hours of March 14th, 2017.

The four crew were employed by CHC Ireland which holds the Irish Coast Guard search and rescue contract.

The AAIU issued a preliminary and interim reports, and sent its draft final report to “interested parties” in September 2019 with a 60-day window for submissions and comments.

However, in March 2020, former transport minister permitted the establishment of a review board to examine certain findings in the draft final report before publication, following a request from one of the parties.

A review board, chaired by senior counsel Patrick McCann, was established under Regulation 16 of Air Navigation Regulations 2009.

The Irish Airline Pilots Association and European Cockpit Association were critical of this decision as being against the international norm, which seeks to ensure investigations are published within a timeframe to improve safety.

The AAIU does not apportion blame, and this was the first time its draft final report had been subject to such a review.

Earlier this week, RTÉ Investigates reported that three of the four families were obliged to pay for their own legal representation in the review which had been sought by the air crews’ employer, CHC Ireland, and had incurred substantial costs.

Ryan said that “the chairman of the Review board wrote to me with a recommendation that the reasonable legal costs of the families be covered”.

“I was happy to accept this recommendation and asked my officials to work on a mechanism to resolve the issue,” he said.

“The families of the crew did not ask for the review and were placed in a position of having to contribute to a complex process to ensure their loved ones’ interests were fully represented,”Ryan said.

“While the Department of Transport argued before the review board that it did not have authority to make an order on costs, this was done because of the broader implications that such a ruling might have in future,” he said.

“ This was never intended to imply a reluctance to pay these costs, and the additional stress this may have caused is regretted,” he said.

“In writing to the families, I am also conscious that they will shortly receive the final report of the investigation into the accident, a moment which is bound to be difficult for all concerned,” he said.

“Today we remember the service of pilot Dara Fitzpatrick, co-pilot Mark Duffy, winchman Ciarn Smith and winch operator Paul Ormsby who gave their lives in the courageous pursuit of protecting others,” Ryan said.

The new Irish Coast Guard Volunteers Representative Association will be announced on Saturday at a meeting in Kilkee, Co.Clare.

It is the first association established to represent Coast Guard volunteers and its organisers say it consists of existing and former volunteers from around the coast.

There has been controversy over allegations by Coast Guard volunteers at several locations of "poor treatment" and of disciplinary action following any disagreement with management over operational issues.

Management has denied the allegations and pointed to the introduction of new systems and reforms.

The new Association will be asking for the issues to be addressed by the Minister for Transport, Eamon Ryan, under whose Department the Coast Guard operates.

It says it will work with Coast Guard Management to "provide a high-quality emergency service which always provides the best response for those who are in need of assistance" and that it wants to "promote the health, safety and well-being of volunteers within Irish Coast Guard Units, to promote openness, fairness and transparency within IRCG Units in the interaction between volunteers and Management"

In the early evening of Saturday, 2nd October, Belfast Coastguard put out a MAYDAY in response to a 20ft yacht with four people on board reportedly taking on water and without power, a mile north of Corsewall Point, at the mouth of Loch Ryan on the southwest coast of Scotland.

The Stena Superfast VIII, the ro-ro/passenger ferry between Belfast and Cairnryan on Loch Ryan, passed and responded. They launched their fast rescue craft and stood by the vessel until the arrival of Portpatrick and Stranraer RNLI lifeboats. The craft was assisted to Stranraer marina by the lifeboats.

Belfast Coastguard, with Headquarters in Bangor on Belfast Lough, coordinates Search and Rescue for Northern Ireland, Southwest Scotland and North West England. They commented, "We are very grateful for the swift and professional response from Superfast VIII and at no time was the ferry or its passengers or crew in any danger".