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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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A Coast Guard radio officer has defended his decision to request a medical evacuation for an injured fisherman off the west coast on the night that the Irish Coast Guard Rescue 116 helicopter crashed with the loss of four lives.

All four crew- Capt Dara Fitzpatrick, Capt Mark Duffy, winch crew Paul Ormsby and Ciarán Smith – died when their Sikorsky S-92 helicopter crashed at Blackrock island in the early hours of March 14th, 2017.

The Dublin-based helicopter had been asked to provide “top cover” or communications for the Sligo-based Rescue 118 helicopter which was tasked to airlift a fisherman with an injured thumb from a vessel 140 km off the Mayo coast.

At a resumed inquest in Belmullet, Co Mayo, coroner Dr Eleanor Fitzgerald was told by Malin Head Coast Guard radio office Ian Scott that the casualty was bleeding out, in severe pain and had a section of his thumb amputated.

As RTÉ News reports, 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, when the vessel was 140 nautical miles west of Eagle Island.

Mr Buchan recalled hauling at about 9.15 pm on March 13th, 2017 after five or six hours on blue whiting. Mr Strachan’s hand got caught, and Mr Buchan managed to get his hand out 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".

The bodies of Captain Dara Fitzpatrick and Captain Mark Duffy were recovered after the crash, but winch operator Paul Ormsby and winchman Ciarán Smith are still missing in spite of extensive searches.

The inquest was formally opened in April 2018 but was adjourned - after a brief sitting and issue of death certificates - to allow for completion of the Air Accident Investigation Unit report and Garda investigations.

The Garda investigation was completed in April 2019 and a file was sent to the Director of Public Prosecutions, but no prosecutions were recommended.

There were 42 recommendations in the 350-page Air Accident Investigation Unit (AAIU) report - 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.

Read the RTÉ News report here

Published in Coastguard
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Over five years after the fatal Rescue 116 helicopter crash off the north Mayo coast, the inquest is due to resume into the deaths of the four Irish Coast Guard air crew.

Dates of June 1st to 3rd have been set by the North Mayo coroner Dr Eleanor Fitzgerald for the inquest which will be held in Belmullet civic centre.

Families of the four crew - Capt Dara Fitzpatrick, Capt Mark Duffy and winch crew Paul Ormsby and Ciarán Smith – are expected to attend or be represented at the three-day hearing.

The crash occurred in the early hours of March 14th, 2017 when the Sikorsky S-92 helicopter collided with Blackrock island, 13 km west of the Mullet peninsula, while approaching Blacksod lighthouse to refuel.

The Dublin-based crew had been asked to provide top cover for the Sligo-based Rescue 118 helicopter which had been tasked for a medical evacuation 141 nautical miles west of Eagle Island. The bodies of the two winch crew have not been found.

It is expected that CHC Ireland, employer of the four air crew, will be represented at the resumed inquest, along with officials from the Air Accident Investigation Unit (AAIU), the Garda and Irish Coast Guard.

The 350- page final report by AAIU identified "serious and important weaknesses" in management of risk mitigation by CHC Ireland, which holds the Irish Coast Guard search and rescue contract.

It also identified "confusion at State level" regarding responsibility for oversight of search and rescue operations in Ireland.

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

The coroner’s office confirmed that the recent publication of the AAIU’s final report – delayed by a year due to a request by CHC Ireland for a review - had allowed the inquest to reconvene.

A preliminary inquest was held on April 12th, 2018 to issue death certificates for all four crew, and was then adjourned.

At the preliminary hearing, AAIU chief inspector Jurgen Whyte said that “everything that could be done was done” to find the two missing crew.

He said the search was “very challenging”, and the helicopter could not have come down in a more difficult location.

Speaking on RTÉ Radio 1’s Katie Hannon show last year, Ms Fitzpatrick’s father John said the inquest into the deaths of the crew members would give “finality” and would “mean an awful lot” to the families.

Published in Coastguard
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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 island 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 R116Rescue 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 FitzpatrickPilot 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.

Published in Coastguard
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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.

Published in Coastguard
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Skerries RNLI’s volunteers launched their inshore lifeboat on Wednesday evening (21 April) as part of a multi-agency response to reports of a swimmer in difficulty near the Martello tower in Balbriggan.

The Atlantic 85 lifeboat Louis Simson was launched within minutes of the crew being paged just before 7pm and proceeded directly to the area indicated.

On arrival the crew found the Dublin-based Irish Coast Guard helicopter Rescue 116 already on scene and winching a man from the water.

The casualty was the lowered onto the beach and into the care of an ambulance crew and members of Dublin Fire Brigade who administered first aid before he was transferred to hospital.

Meanwhile, further reports came in that other swimmers had entered the water to assist the casualty and a subsequent emergency call raised concerns that there may still be someone in the water.

Rescue 116, Skerries RNLI and the Skerries Coast Guard unit coordinated to carry out a search of the immediate area covering the water and the shoreline.

The lifeboat investigated a number of objects at the request of Rescue 116, including a lifebuoy which they recovered into the lifeboat.

When Dublin Coast Guard was satisfied that the area had been thoroughly searched and there were no further swimmers in danger, the lifeboat was stood down and returned to station.

Speaking about the callout, press officer Gerry Canning said: “When a person is in trouble in the water, every second counts. Rescue 116 were on scene very quickly and it was an excellent response from all of the emergency services who worked brilliantly together.

“Our thoughts are with the friends and family of the man taken from the water and we hope he makes a full recovery.”

Published in RNLI Lifeboats

A European pilots’ organisation has expressed alarm at the delay in publishing the final report into the loss of four air crew in the Rescue 116 helicopter crash off the Mayo coast four years ago.

As The Times Ireland edition reports, European Cockpit Association (ECA) president Captain Otjan de Bruijn has also questioned why Ireland had adopted a “rare procedure” where an aviation accident investigation can be re-examined before publication.

An air accident investigation must be published to ensure key safety lessons can be learned “swiftly”, Capt de Bruijn said, and he has urged release of the report “without delay”.

Capt Dara Fitzpatrick, Capt Mark Duffy and winch team Paul Ormsby and Ciarán Smith died after their Irish Coast Guard Sikorsky S-92 helicopter crashed at Blackrock island off the north Mayo coast on March 14th, 2017.

The four Dublin-based helicopter crew were providing “top cover” communication for the medical evacuation of a crewman from a British-registered fishing vessel off the west coast.

The Air Accident Investigation Unit (AAIU) issued a preliminary report and a series of interim reports, and a final draft report was given to families and stakeholders in late 2019, with a 60-day period for submissions.

However, its publication was put on hold by a request in January 2020 by an unidentified stakeholder for a review, which was granted by Ryan’s predecessor, Shane Ross.

The ECA president said that the final report was due in January 2020, and it “is an extremely long delay for publishing a report”

Capt de Bruijn said that during these four years, “possible safety-critical flaws have remained unaddressed – something we are quite alarmed about”.

“Any deficiencies that have been identified in the accident investigation must be made public, out in the open so they can be fixed swiftly. In the interests of passenger safety, we urge the Irish AAIU to release the report without delay,” he said.

“We are not aware of any other similar cases across Europe of a re-examination of the technical work of an independent technically qualified organisation by a body with limited expertise in aviation accident investigations,” Capt de Bruijn said of the review board option.

“This rare procedure could be a slippery slope allowing for undue influence over the investigation process and its findings, and clearly has resulted in an unhelpful delay in the publication of the report,” he said.

“Let us not forget that the final report contains safety-critical recommendations that are valuable – and potentially life-saving – lessons for the aviation system in and beyond Ireland,” he said.

The Irish Airline Pilots Association (IALPA) has already questioned the decision to include a review in the Irish legislation, and said the review “does not comply with the standards and recommended practices laid down by the International Civil Aviation Organisation (ICAO)”.

The Department of Transport said, “the review board is independent in its work in accordance with the 2009 Regulations and the timeframe for the board to carry out the re-examination is a matter for the chairperson to determine”.

Read more in The Times here

Published in Coastguard
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Minister for Transport Eamon Ryan has appointed a new review board into the Air Accident Investigation Unit’s (AAIU) final report on the Rescue 116 helicopter crash.

As The Irish Independent reports today, the review experienced a setback last month when the technical advisor Philip Hanson, an aviation expert with the British Maritime and Coastguard Agency, stood down over a potential conflict of interest.

However, Mr Ryan has established a new board to review aspects of the unpublished AAIU final report into the crash, which claimed the lives of Capt Dara Fitzpatrick, Capt Mark Duffy and winch team Paul Ormsby and Ciarán Smith off the north Mayo coast in March 2017.

The minister has opted to re-appoint senior counsel Patrick McCann as chairman and sole member of the review, following legal advice from the Attorney-General.

Mr McCann was chair of the previous review which was established by former transport minister Shane Ross earlier this year, and Mr Hanson was appointed as technical expert.

In a parliamentary response to Galway West Independent TD Catherine Connolly, the transport minister says the new timeframe for the re-examination of the final report is “ a matter for the chairperson to determine” as the board is “entirely independent in its work”.

Relatives of the four air crew are now waiting over three-and-a-half years for the final report into the Sikorsky S-92 collision, which occurred at Blackrock island, Co Mayo, while the helicopter was approaching Blacksod lighthouse to refuel.

The four Dublin-based crew were providing “top” cover” or support to a medical evacuation off the west coast by the Sligo-based Rescue 118 helicopter.

The bodies of the two winch crew have not been found in spite of extensive searches.

A draft of the final report was given last November to the families of the four crew and stakeholders including their employer, CHC Ireland, with a 60-day period for submissions or comments.

However, its publication had to be put on hold when Mr Ross acceded to a request for a “notice of re-examination” by an unidentified stakeholder.

Under Ireland’s Air Navigation (Notification and Investigation of Accidents, Serious Incidents and Incidents) Regulations 2009, a review can be applied for by an “interested party” in relation to “findings and conclusions that appear to reflect adversely on the person’s reputation”.

A Department of Transport spokeswoman said the minister was notified of Mr Hanson’s alleged conflict of interest on September 22nd. She said Mr Hanson did not receive any payment for his work on the review board over the past six months.

CHC Ireland has declined to say whether it sought the review. It was the first request of its type in the AAIU’s history of undertaking air crash investigations.

The AAIU had ruled out mechanical fault early on, and made recommendations in a preliminary report published a month after the helicopter crash, relating to anomalies in chart information software and a flaw in installation of locator beacons on crew life-jackets.

In its first interim report, the AAIU highlighted failures of oversight for search and rescue by the State.

It also recommended a review of safety management systems by CHC Ireland; and it identified a software issue with data recorded, which was not directly relevant to the cause of the crash.

It recommended a thorough review of search and rescue aviation operations in Ireland, which former minister Mr Ross commissioned.

Read more here

Published in Rescue
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In the absence of this year’s Bray Air Display due to the coronavirus pandemic, the Irish Coast Guard’s Dublin-based helicopter Rescue 116 conducted a special fly-past to pay tribute to Ireland’s frontline healthcare workers.

The Sikorsky S92 helicopter took to the skies over the Co Wicklow town at 3pm yesterday, Saturday 25 July, on the same afternoon it flew to the rescue of a family of four stranded by the tide at Sandymount.

Rob Tatten, general operations manager of CHC Ireland, which operates the coastguard’s SAR helicopter service, was in attendance to make small presentation to Mr Paul Reid, chief executive of the HSE, and spoke before the event.

He said: “CHC, who operates the helicopter search and rescue contract on behalf of the Irish Coast Guard, has been taking part in the Bray Air Display every year. However due to the pandemic that wasn’t possible this year.

“But with the organisers of the show we said could we do something to recognise the phenomenal work of our fellow frontline healthcare workers, who like us continue to work 24/7, 365 days a year.

“So today, Rescue 116, while out training, will do a fly-past to thank those workers while we also make a short presentation to Paul Reid and other frontline workers to say thank you on behalf of CHC, the Irish Coast Guard, the aviation community and Bray Air Display.”

Published in Coastguard

The Irish Coast Guard’s Dun Laoghaire unit launched to the rescue of a family of four cut off by the tide on Sandymount yesterday afternoon, Saturday 25 July.

Dun Laoghaire Coast Guard were tasked to incident along with the local RNLI’s inshore lifeboat and the Dublin-based coastguard helicopter Rescue 116.

The two adults and two children were retrieved from their sandbank by the helicopter crew, who landed them at a safe spot on land where they wiremen by a coastguard team. All were found to be in good spirts.

Emergency services remind the public if you see anyone in difficulty in or near the water to dial 112/999 immediately and ask for the coastguard.

Published in Rescue
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