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Verdicts of Accidental Death for Rescue 116 Air Crew Delivered at Inquest

2nd June 2022
The inquest was formally opened in April 2018 but was adjourned to allow for the completion of separate investigations into the tragedy which cost the lives of All four crew of R116 (above) - Capt Dara Fitzpatrick, Capt Mark Duffy, winch crew Paul Ormsby and Ciarán Smith
The inquest was formally opened in April 2018 but was adjourned to allow for the completion of separate investigations into the tragedy which cost the lives of All four crew of R116 (above) - Capt Dara Fitzpatrick, Capt Mark Duffy, winch crew Paul Ormsby and Ciarán Smith

A jury at the Rescue 116 helicopter crash inquest has returned verdicts of accidental death for all four air crew – Capt Dara Fitzpatrick, Capt Mark Duffy and winch crew Paul Ormsby and Ciarán Smith.

As RTÉ news reports, the jury at the coroner’s court in Belmullet, Co Mayo, delivered verdicts on Thursday morning after considering evidence for over an hour and a half.

Evidence from a number of witnesses had been heard by coroner Dr Eleanor Fitzgerald at a resumed hearing on Wednesday, June 1st.

The inquest had opened in April 2018, a year after the crash in which all four air crew lost their lives when their Sikorsky S-92 crashed at Blackrock island, west of the Blacksod lighthouse refuelling point in north Mayo. It was adjourned pending completion of investigations by the Garda and Air Accident Investigation Unit (AAIU).

The bodies of the two winch crew have not been found.

The initial hearing had also heard that Capt Fitzpatrick died as a result of drowning, and Capt Duffy sustained fatal injuries as a result of the crash.

The decision by a Malin Coast Guard radio officer to task the Sligo based Rescue 118 helicopter, to evacuate an injured fisherman from the Scottish vessel Kings Cross 140 km west of Eagle Island, Co Mayo.

Crewman John James Strachan had severed his thumb when hauling nets on the night of March 13th 2017.

Mr Scott outlined how he had tried to secure top cover by the Air Corps and that he also "tried to get a Nimrod from the UK" but this was not available.

Rescue 116 was then asked to provide top cover and flew from Dublin. It was approaching Blacksod to refuel when it crashed at Blackrock island, west of Blacksod.

Mr Scott told the inquest that a doctor he had consulted did not object to his decision to take the injured crewman ashore.

He said he used his judgement, accrued over 42 years, and said “in my opinion the man needed off the vessel".

Mr Scott told the inquest he would make the same decision today.

Garda Supt Gary Walsh read a deposition from the captain of the Kings Cross fishing vessel, William Buchan, describing how crewman John James Strachan sustained a severed thumb when he was hauling in nets on the night of March 13th, 2017 when the vessel was 140 nautical miles west of Eagle Island.

Mr Buchan recalled hauling at about 9.15pm on March 13th, 2017 after five or six hours on blue whiting. Mr Strachan’s hand got caught, and he managed to get his hand ot of his glove but half of his thumb had been crushed and was inside the glove. He said they put the thumb top in the ship’s freezer.

Cork University emergency registrar Dr Mai Nguyen, who was consulted about the injury on the night of the call-out, told the inquest she felt the decision to task had been made before she was called. She described the injury as “minor”, and said she would not have sent the Irish Cost Guard as there was no hope of re-attaching the severed thumb and they were far from the coast.

A recording of calls between the Kings Cross vessel, Malin Coast Guard and Dr Nguyen confirmed this at the inquest.

After Dr Nguyen advised skipper, William Buchan on how to handle the casualty, she asked the radio officer if a “medevac” was being carried out and he said it was.

The inquest also heard that in the minutes before the Rescue 116 helicopter was due to land at Blacksod lighthouse helipad to refuel, visibility "dropped fast".

Lightkeeper Vincent Sweeney described how in the minutes before Rescue 116 was due to land to refuel, visibility "dropped fast", to the point that "you'd hardly see your arm in front of you".

There were 42 recommendations in the 350-page final AAIU report published last November - 19 applying to the air crew’s employer, CHC Ireland, which holds the Irish Coast Guard contract for four helicopter search and rescue bases.

The AAIU report found the “probable” cause of the crash was a combination of poor weather, the helicopter’s altitude and the crew being unaware of a 282 ft obstacle – as in Blackrock island – on a pre-programmed route guide to Blacksod.

Series of recommendations

The jury made a series of recommendations at the resumed inquest.

The jury foreman called for “definitive medical criteria informing any decision to dispatch an emergency helicopter.”

“There should be no ambiguity as to who the decision-maker is.

“There should be reliable top cover available at all times ideally not using another SARs aircraft. Based on clear evidence, errors in mapping and navigation aids contributed significantly to this accident,”he said.

“There needs to be cohesive oversight in relation to the various bodies and agencies who bear collective responsibility for the provision of these services,” he said.

“In making this statement, we wish to acknowledge the painstaking work undertaken by An Garda Síochána, the Air Accident Investigation Unit, the judicial and the many other agencies,”he said.

“We further wish to acknowledge the strength of those individuals who gave evidence and to the families and friends of the victims who have, for these past five years, been forced to relieve these harrowing experiences for the purposes of seeking the truth of these events,”he said.

“The burden of responsibility we collectively feel as a jury towards those who continue to operate on the front line of the rescue services, their families and to those lost in service cannot be overstated,” he said.

“We wish to take this opportunity to acknowledge the heroic efforts of the rescue services in the protection of the public on a daily basis,”he said.

“We offer our sincere sympathies to the family and loved ones of Dara Fitzpatrick, Mark Duffy, Paul Ormsby and Ciaran Smith,” he said.

“Ar dheis Dé go raibh a h-anam dilís.”

Coroner Dr Eleanor Fitzgerald thanked the jury for their service and diligence and said “this tragic accident and the loss of four people occurred from a multiplicity of factors and in normal conditions, this accident would not have happened”.

“But in their line of duty, is there such a thing as normal? In undertaking search-and-rescue missions there is always some risk involved,”she said.

“However, in this particular tragedy there were a few contributing factors,” Dr Fitzgerald.

Dr Fitzgerald described the conditions that night as “treacherous”.

Barrister Derek Ryan, representing  Ciaran Smith’s widow Martina, their children Caitlin, Shannon and Finlay, his parents Michael and Teresa and his brother and sister,thanked the coroner, the jury and the Garda for their work.

“A very difficult matter has been dealt with efficiently and very sensitively by everyone involved and for that, thank you,”  Mr Ryan said.

He paid tribute to the witnesses who gave “sometimes very difficult statements to this coroners court”.

“Ciaran’s family wish to thank all those involved in the original searches back in 2017, An Garda Síochána, the RNLI, the Coast Guard, Ciaran’s friends and colleagues, the military services, local boat owners and local fisherman.”

Mr Ryan also extended the Smith family’s thanks to the local people of the Belmullet area “who extended such kindness to Ciaran’s family at a very difficult time”.

Capt Dara Fitzpatrick’s father, John Fitzpatrick, concurred with the comments of the Smith family.

Read the RTÉ News report here

Published in Coastguard
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The Irish Coast Guard

The Irish Coast Guard is Ireland's fourth 'Blue Light' service (along with An Garda Síochána, the Ambulance Service and the Fire Service). It provides a nationwide maritime emergency organisation as well as a variety of services to shipping and other government agencies.

The purpose of the Irish Coast Guard is to promote safety and security standards, and by doing so, prevent as far as possible, the loss of life at sea, and on inland waters, mountains and caves, and to provide effective emergency response services and to safeguard the quality of the marine environment.

The Irish Coast Guard has responsibility for Ireland's system of marine communications, surveillance and emergency management in Ireland's Exclusive Economic Zone (EEZ) and certain inland waterways.

It is responsible for the response to, and co-ordination of, maritime accidents which require search and rescue and counter-pollution and ship casualty operations. It also has responsibility for vessel traffic monitoring.

Operations in respect of maritime security, illegal drug trafficking, illegal migration and fisheries enforcement are co-ordinated by other bodies within the Irish Government.

On average, each year, the Irish Coast Guard is expected to:

  • handle 3,000 marine emergencies
  • assist 4,500 people and save about 200 lives
  • task Coast Guard helicopters on missions

The Coast Guard has been around in some form in Ireland since 1908.

Coast Guard helicopters

The Irish Coast Guard has contracted five medium-lift Sikorsky Search and Rescue helicopters deployed at bases in Dublin, Waterford, Shannon and Sligo.

The helicopters are designated wheels up from initial notification in 15 minutes during daylight hours and 45 minutes at night. One aircraft is fitted and its crew trained for under slung cargo operations up to 3000kgs and is available on short notice based at Waterford.

These aircraft respond to emergencies at sea, inland waterways, offshore islands and mountains of Ireland (32 counties).

They can also be used for assistance in flooding, major inland emergencies, intra-hospital transfers, pollution, and aerial surveillance during daylight hours, lifting and passenger operations and other operations as authorised by the Coast Guard within appropriate regulations.

Irish Coastguard FAQs

The Irish Coast Guard provides nationwide maritime emergency response, while also promoting safety and security standards. It aims to prevent the loss of life at sea, on inland waters, on mountains and in caves; and to safeguard the quality of the marine environment.

The main role of the Irish Coast Guard is to rescue people from danger at sea or on land, to organise immediate medical transport and to assist boats and ships within the country's jurisdiction. It has three marine rescue centres in Dublin, Malin Head, Co Donegal, and Valentia Island, Co Kerry. The Dublin National Maritime Operations centre provides marine search and rescue responses and coordinates the response to marine casualty incidents with the Irish exclusive economic zone (EEZ).

Yes, effectively, it is the fourth "blue light" service. The Marine Rescue Sub-Centre (MRSC) Valentia is the contact point for the coastal area between Ballycotton, Co Cork and Clifden, Co Galway. At the same time, the MRSC Malin Head covers the area between Clifden and Lough Foyle. Marine Rescue Co-ordination Centre (MRCC) Dublin covers Carlingford Lough, Co Louth to Ballycotton, Co Cork. Each MRCC/MRSC also broadcasts maritime safety information on VHF and MF radio, including navigational and gale warnings, shipping forecasts, local inshore forecasts, strong wind warnings and small craft warnings.

The Irish Coast Guard handles about 3,000 marine emergencies annually, and assists 4,500 people - saving an estimated 200 lives, according to the Department of Transport. In 2016, Irish Coast Guard helicopters completed 1,000 missions in a single year for the first time.

Yes, Irish Coast Guard helicopters evacuate medical patients from offshore islands to hospital on average about 100 times a year. In September 2017, the Department of Health announced that search and rescue pilots who work 24-hour duties would not be expected to perform any inter-hospital patient transfers. The Air Corps flies the Emergency Aeromedical Service, established in 2012 and using an AW139 twin-engine helicopter. Known by its call sign "Air Corps 112", it airlifted its 3,000th patient in autumn 2020.

The Irish Coast Guard works closely with the British Maritime and Coastguard Agency, which is responsible for the Northern Irish coast.

The Irish Coast Guard is a State-funded service, with both paid management personnel and volunteers, and is under the auspices of the Department of Transport, Tourism and Sport. It is allocated approximately 74 million euro annually in funding, some 85 per cent of which pays for a helicopter contract that costs 60 million euro annually. The overall funding figure is "variable", an Oireachtas committee was told in 2019. Other significant expenditure items include volunteer training exercises, equipment, maintenance, renewal, and information technology.

The Irish Coast Guard has four search and rescue helicopter bases at Dublin, Waterford, Shannon and Sligo, run on a contract worth 50 million euro annually with an additional 10 million euro in costs by CHC Ireland. It provides five medium-lift Sikorsky S-92 helicopters and trained crew. The 44 Irish Coast Guard coastal units with 1,000 volunteers are classed as onshore search units, with 23 of the 44 units having rigid inflatable boats (RIBs) and 17 units having cliff rescue capability. The Irish Coast Guard has 60 buildings in total around the coast, and units have search vehicles fitted with blue lights, all-terrain vehicles or quads, first aid equipment, generators and area lighting, search equipment, marine radios, pyrotechnics and appropriate personal protective equipment (PPE). The Royal National Lifeboat Institution (RNLI) and Community Rescue Boats Ireland also provide lifeboats and crews to assist in search and rescue. The Irish Coast Guard works closely with the Garda Siochána, National Ambulance Service, Naval Service and Air Corps, Civil Defence, while fishing vessels, ships and other craft at sea offer assistance in search operations.

The helicopters are designated as airborne from initial notification in 15 minutes during daylight hours, and 45 minutes at night. The aircraft respond to emergencies at sea, on inland waterways, offshore islands and mountains and cover the 32 counties. They can also assist in flooding, major inland emergencies, intra-hospital transfers, pollution, and can transport offshore firefighters and ambulance teams. The Irish Coast Guard volunteers units are expected to achieve a 90 per cent response time of departing from the station house in ten minutes from notification during daylight and 20 minutes at night. They are also expected to achieve a 90 per cent response time to the scene of the incident in less than 60 minutes from notification by day and 75 minutes at night, subject to geographical limitations.

Units are managed by an officer-in-charge (three stripes on the uniform) and a deputy officer in charge (two stripes). Each team is trained in search skills, first aid, setting up helicopter landing sites and a range of maritime skills, while certain units are also trained in cliff rescue.

Volunteers receive an allowance for time spent on exercises and call-outs. What is the difference between the Irish Coast Guard and the RNLI? The RNLI is a registered charity which has been saving lives at sea since 1824, and runs a 24/7 volunteer lifeboat service around the British and Irish coasts. It is a declared asset of the British Maritime and Coast Guard Agency and the Irish Coast Guard. Community Rescue Boats Ireland is a community rescue network of volunteers under the auspices of Water Safety Ireland.

No, it does not charge for rescue and nor do the RNLI or Community Rescue Boats Ireland.

The marine rescue centres maintain 19 VHF voice and DSC radio sites around the Irish coastline and a digital paging system. There are two VHF repeater test sites, four MF radio sites and two NAVTEX transmitter sites. Does Ireland have a national search and rescue plan? The first national search and rescue plan was published in July, 2019. It establishes the national framework for the overall development, deployment and improvement of search and rescue services within the Irish Search and Rescue Region and to meet domestic and international commitments. The purpose of the national search and rescue plan is to promote a planned and nationally coordinated search and rescue response to persons in distress at sea, in the air or on land.

Yes, the Irish Coast Guard is responsible for responding to spills of oil and other hazardous substances with the Irish pollution responsibility zone, along with providing an effective response to marine casualties and monitoring or intervening in marine salvage operations. It provides and maintains a 24-hour marine pollution notification at the three marine rescue centres. It coordinates exercises and tests of national and local pollution response plans.

The first Irish Coast Guard volunteer to die on duty was Caitriona Lucas, a highly trained member of the Doolin Coast Guard unit, while assisting in a search for a missing man by the Kilkee unit in September 2016. Six months later, four Irish Coast Guard helicopter crew – Dara Fitzpatrick, Mark Duffy, Paul Ormsby and Ciarán Smith -died when their Sikorsky S-92 struck Blackrock island off the Mayo coast on March 14, 2017. The Dublin-based Rescue 116 crew were providing "top cover" or communications for a medical emergency off the west coast and had been approaching Blacksod to refuel. Up until the five fatalities, the Irish Coast Guard recorded that more than a million "man hours" had been spent on more than 30,000 rescue missions since 1991.

Several investigations were initiated into each incident. The Marine Casualty Investigation Board was critical of the Irish Coast Guard in its final report into the death of Caitriona Lucas, while a separate Health and Safety Authority investigation has been completed, but not published. The Air Accident Investigation Unit final report into the Rescue 116 helicopter crash has not yet been published.

The Irish Coast Guard in its present form dates back to 1991, when the Irish Marine Emergency Service was formed after a campaign initiated by Dr Joan McGinley to improve air/sea rescue services on the west Irish coast. Before Irish independence, the British Admiralty was responsible for a Coast Guard (formerly the Water Guard or Preventative Boat Service) dating back to 1809. The West Coast Search and Rescue Action Committee was initiated with a public meeting in Killybegs, Co Donegal, in 1988 and the group was so effective that a Government report was commissioned, which recommended setting up a new division of the Department of the Marine to run the Marine Rescue Co-Ordination Centre (MRCC), then based at Shannon, along with the existing coast radio service, and coast and cliff rescue. A medium-range helicopter base was established at Shannon within two years. Initially, the base was served by the Air Corps.

The first director of what was then IMES was Capt Liam Kirwan, who had spent 20 years at sea and latterly worked with the Marine Survey Office. Capt Kirwan transformed a poorly funded voluntary coast and cliff rescue service into a trained network of cliff and sea rescue units – largely voluntary, but with paid management. The MRCC was relocated from Shannon to an IMES headquarters at the then Department of the Marine (now Department of Transport) in Leeson Lane, Dublin. The coast radio stations at Valentia, Co Kerry, and Malin Head, Co Donegal, became marine rescue-sub-centres.

The current director is Chris Reynolds, who has been in place since August 2007 and was formerly with the Naval Service. He has been seconded to the head of mission with the EUCAP Somalia - which has a mandate to enhance Somalia's maritime civilian law enforcement capacity – since January 2019.

  • Achill, Co. Mayo
  • Ardmore, Co. Waterford
  • Arklow, Co. Wicklow
  • Ballybunion, Co. Kerry
  • Ballycotton, Co. Cork
  • Ballyglass, Co. Mayo
  • Bonmahon, Co. Waterford
  • Bunbeg, Co. Donegal
  • Carnsore, Co. Wexford
  • Castlefreake, Co. Cork
  • Castletownbere, Co. Cork
  • Cleggan, Co. Galway
  • Clogherhead, Co. Louth
  • Costelloe Bay, Co. Galway
  • Courtown, Co. Wexford
  • Crosshaven, Co. Cork
  • Curracloe, Co. Wexford
  • Dingle, Co. Kerry
  • Doolin, Co. Clare
  • Drogheda, Co. Louth
  • Dun Laoghaire, Co. Dublin
  • Dunmore East, Co. Waterford
  • Fethard, Co. Wexford
  • Glandore, Co. Cork
  • Glenderry, Co. Kerry
  • Goleen, Co. Cork
  • Greencastle, Co. Donegal
  • Greenore, Co. Louth
  • Greystones, Co. Wicklow
  • Guileen, Co. Cork
  • Howth, Co. Dublin
  • Kilkee, Co. Clare
  • Killala, Co. Mayo
  • Killybegs, Co. Donegal
  • Kilmore Quay, Co. Wexford
  • Knightstown, Co. Kerry
  • Mulroy, Co. Donegal
  • North Aran, Co. Galway
  • Old Head Of Kinsale, Co. Cork
  • Oysterhaven, Co. Cork
  • Rosslare, Co. Wexford
  • Seven Heads, Co. Cork
  • Skerries, Co. Dublin Summercove, Co. Cork
  • Toe Head, Co. Cork
  • Tory Island, Co. Donegal
  • Tramore, Co. Waterford
  • Waterville, Co. Kerry
  • Westport, Co. Mayo
  • Wicklow
  • Youghal, Co. Cork

Sources: Department of Transport © Afloat 2020

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