I thank the Ceann Comhairle. I am grateful to the House for affording me this occasion to make a statement on the Air Accident Investigation Unit’s final report of its investigation into the Rescue 116 accident, published on 5 November.
The R116 accident on 14 March 2017 was an appalling tragedy. It claimed the lives of four people who, with consummate professionalism and total dedication, gave themselves to the task of saving others. I would like to take this opportunity to extend again my heartfelt sympathy to the families and loved ones of pilot Ms Dara Fitzpatrick, co-pilot Mr. Mark Duffy, Mr. Ciarán Smith and Mr. Paul Ormsby. I am sure the Ceann Comhairle and every other Member of this House extend their deepest sympathy to the families for their loss and for the brave work their family members did.
I recognise also the tremendous recovery effort in the days and weeks after the accident, often by people who knew them well, both professionals and volunteers, and they deserve our deep gratitude.
The Government acknowledges and appreciates the completion and publication of the Air Accident Investigation Unit, AAIU, report. The completion of the investigation and the publication of the report is a key step in ensuring such accidents are prevented in the future. I wish to commend the Chief Inspector of Air Accidents and his team on compiling such a comprehensive and detailed report. Search and rescue, SAR, aviation operations will benefit greatly from its findings and the implementation of its safety recommendations both in Ireland and internationally.
I wish to focus my comments, a Cheann Comhairle, on the safety aspects and on the lessons that need to be learned because it is very important that we do that in marking the lost lives of those heroes tonight. The Air Accident Investigation Unit is an operationally independent unit in the Department of Transport and is responsible for the investigation of aircraft accidents, serious incidents, and incidents that occur within Ireland. The AAIU conducts investigations in accordance with global and European legislation and under the provisions of the 2009 Air Navigation (Notification and Investigation of Accidents, Serious Incidents and Incidents) Regulations of 2009.
The fundamental purpose of an AAIU investigation is to determine the circumstances and causes of air incidents and accidents, with a view to the preservation of life and the avoidance of similar occurrences in the future. It is not the purpose of such investigations to apportion blame or liability.
The report of the investigation into the R116 accident is wide ranging in scope with findings and safety recommendations that cover all aspects of search and rescue aviation, both nationally and internationally. The report sets out the factual information of the flight, followed by an analysis of that information which informs the conclusions and findings, including probable cause and contributory causes. Subsequent to the conclusions, a number of safety recommendations are made.
The main conclusion by the AAIU is that the accident was what is known as an “an organisational accident”. Organisational accidents have multiple causes involving many people operating at different levels of their respective organisation.
In total, there are 71 findings and 42 safety recommendations, of which ten findings and 14 safety recommendations are directly relevant to the Minister for Transport. I fully accept the recommendations addressed to me contained within the report. Given the size and complexity of the report, my Department will require some time to examine it in detail and consider its findings and recommendations. I propose, however, to formally respond to the Chief Inspector of Air Accidents in respect of each safety recommendation addressed to me, in advance of the 90-day timeframe required under the relevant EU legislation governing the investigation and prevention of accidents and incidents in civil aviation.
The Department did not wait for the publication of the final report to implement changes on foot of the lessons learned following the accident. Since March 2017, and specifically following receipt of the draft final report in September 2019, the Department and, in particular, the Irish Coast Guard, have undertaken a significant programme of change across key areas to take account of issues raised and recommendations addressed to the Minister of Transport.
On foot of the interim report of the air accident investigation unit, the then Minister for Transport, Tourism and Sport commissioned an independent review of oversight arrangements for search and rescue aviation operations in Ireland. Following publication of the independent review, known as the AQE report, in September 2018, the then Minister committed to implementing its 12 recommendations. The measures that have been taken fall under six broad categories: the development of a new national search and rescue framework, the national SAR plan, NSP; enhancing safety and oversight across the search and rescue system; addressing oversight of search and rescue aviation elements nationally and internationally; the review and revision of all relevant standard operating procedures and training for Coast Guard personnel, in particular rescue co-ordination centre staff training, with a focus on aviation tasking including the introduction of a formal course on tasking of aviation assets delivered by an IAA authorised training organisation; the development of an externally accredited safety management system in the Coast Guard; and a review of governance arrangements in regard to the aviation contractor, enhancing aviation expertise in critical areas and legislative reform of the IAA.
A new search and rescue framework, the NSP, which provides for more explicit governance, assurance and oversight roles across the SAR system, was noted by Government and published in July 2019. The key objectives of the NSP are to achieve a rebalancing of the previous maritime-centric SAR framework to encompass air and land SAR more comprehensively; establish effective governance, oversight and assurance across the SAR system to take account of national and international obligations; achieve clarity on roles, inter-relationships and responsibilities from the strategic through to tactical and operational levels; develop a common approach to managing SAR incidents across the three domains; to set priorities, objectives and performance expectations, measure performance at system level; and provide a sound and clear basis for continuous improvement.
The NSP sets out more explicit governance, assurance and oversight roles across the SAR system. The plan resets a more strategic and focused national search and rescue committee with a leaner and more coherent set of sub-committees, including an SAR consultative committee, a regulators forum, a health and safety forum and an aviation forum. The plan also sets out a clear description of the national SAR system, including roles, inter-relationships and responsibilities from the strategic through to tactical and operational levels.
The national SAR committee, NSARC, set up under the NSP, is a strategic level committee with oversight of the national SAR plan as a whole and covers all three SAR domains, that is maritime, aeronautical and land-based. Its membership includes senior managers from the three SAR co-ordinators, namely the Coast Guard, the IAA and An Garda Síochána, and their respective Departments, as well as senior representatives from supporting Departments and agencies. It meets at least three times a year and has an independent external chair. It gives strategic direction to the SAR system, and has a forward-looking remit to ensure investments in SAR are strategically sound and a review remit to examine performance, disseminate best practice and learn from experience.
A second deliverable was an implementation plan for the recommended model for a joint rescue co-ordination centre, JRCC. It is a special type of rescue co-ordination centre that is operated by personnel from the maritime rescue co-ordination centre and the aviation rescue co-ordination centre. This virtual JRCC is intended to capitalise on the strengths of the current model, minimising disruption and exploiting opportunities for enhanced technology, closer co-operation and revised operating procedures, notably to address the vulnerabilities identified in the existing model and to provide for stronger oversight arrangements.
Significant progress has been made on the implementation of the new joint model. The Coast Guard and IAA have agreed a concept of operations and procedures manual and this work has resulted in increased collaboration and professional interaction between the Coast Guard and the aeronautical rescue co-ordination centre. Formal establishment is subject to the filling of newly established positions in the Coast Guard rescue co-ordination centre following a public appointments service process.
As an appendix to the NSP, guidance is provided on the development of a common approach to managing SAR incidents across all three domains of land, maritime and aeronautical SAR, including the transition from search and rescue to search and recovery. It was agreed that the NSP would be delivered on a phased basis to enable a managed and integrated approach to the development of the new SAR structures, along with the coherent development of memoranda of understanding and service level agreements between all relevant stakeholders to underpin the new assurance mechanism.
Since then, progress in delivering key aspects of the implementation plan has been good, with the majority of actions completed and the remainder on track for delivery in 2022. The actions include the first annual report of the NSARC on the NSP, which was approved in July of last year and subsequently published by the Government on gov.ie. The second annual report will be presented shortly.
The new or reformed structures envisaged by the NSP are fully up and running. The NSARC meets at least three times a year and has an ambitious work programme involving each of the three SAR co-ordinators. The national SAR consultative committee is an amalgam of previous existing SAR consultation groups and has a wide membership across all SAR providers. It meets twice a year. A national SAR stakeholders forum takes place annually. It brings all SAR actors and a selection of SAR beneficiaries together. The Minister of State, Deputy Hildegarde Naughton, addressed this year’s forum in July where the invaluable contribution of volunteers to the service was recognised.
The aviation forum meets on a quarterly basis. One of the key innovations in the new NSP is the SAR assurance mechanism. Adapted from the New Zealand SAR model of system assurance, it places an onus on all participants to provide annual assurance statements across key areas of performance and safety and risk management. The SAR regulators forum and health and safety forum, which form part of this mechanism, meet regularly and are working to a programme.
Significant progress has been made on the implementation of the new virtual JRCC. Clarity has been provided on the roles and responsibilities and has been promulgated across the system, and formal agreements are being finalised with all key stakeholders. A mechanism has been formalised and tested for reviewing international SAR agreements. The Coast Guard’s standard operating procedures have undergone a major review and refresh.
Key performance indicators for the NSP have been developed by a dedicated working group. The development of a new SAR assets register is under way. A new aviation training programme for Irish Coast Guard staff provided by an IAA approved training provider is ongoing and the ninth such course is currently taking place. In addition to the Irish Coast Guard staff, course participants include aeronautical rescue co-ordination centre staff and members of An Garda Síochána from the Garda air support unit, which is indicative of the increased collaboration between the three SAR co-ordinators.
The provision of an effective maritime search and rescue service is critical to Ireland as an island nation with a strong maritime sector. The sector depends on the reliability and professionalism of the Irish Coast Guard and all its component parts, including the Coast Guard aviation service, to offer a service which can deploy at a moment’s notice to rescue people in distress and bring them to a place of safety.
As mentioned earlier, in light of safety recommendations, the Coast Guard is building on its safety management system, which encompasses all aspects of its operations. The safety management system will be externally accredited to ISO 45001. A review and revision of all relevant standard operating procedures and training of Coast Guard personnel was completed and updated on foot of incident reviews under the Coast Guard continuous improvement regime.
Training for personnel involved in decisions to launch Coast Guard helicopters is being provided to the Coast Guard by an authorised training organisation approved by the IAA. Eight such courses have been held so far, encompassing 70 staff, and courses are ongoing.
In regard to implementing a safety management system to ISO 45001, the Coast Guard is currently undergoing pre-certification audit which will be completed in the first quarter of 2022. The Coast Guard is also implementing a range of measures which represent a SAR assurance system. This includes updating and renewing its memorandums of understanding, MOUs, with SAR co-ordinators and SAR facility providers. MOUs are based on an agreed template setting out respective roles and responsibilities, services provided, availability and oversight arrangements. This includes continuous system improvement, risk assessment and safety management. The vast majority of these MOUs are completed with first-line SAR facility providers and SAR co-ordinators. Work is ongoing with the remaining support organisations with which the Coast Guard has links.
The AAIU report found there was a lack of clarity concerning oversight of search and rescue aviation operations. As I mentioned recently, the national search and rescue plan sets out more clearly the roles and responsibilities in respect of oversight. The SAR review report published in July 2019 also describes the measures undertaken by the Irish Aviation Authority, IAA, as the national aviation regulator to address recommendations arising from the AQE independent review of SAR aviation oversight that are clearly relevant to those aspects of the AAIU’s report. The implementation of these specific recommendations is also addressed in the AQE 2019 report on implementation. The role of the IAA concerning search and rescue covers both the aviation safety regulation and oversight of search and rescue operations performed by air, the operator, and the aircraft, as well as oversight and operational responsibility for search and rescue aviation co-ordination centres and sub-centres. At the time of the R116 accident, as is the case today, the IAA exercised safety oversight of the SAR operator through its air operator certificate and a national search and rescue approval. The air operator certificate allows an operator to perform specific operations of commercial air transport and the national search and rescue approval provides for alleviation or exemptions that are necessary to operate outside of the requirements used to conduct commercial air transport, without which some of the search and rescue operations would not be possible. There are safety cases for all alleviation or exemptions, and these are reviewed by the IAA each year.
We continue to enhance the legislative framework for the regulation of Coast Guard aviation activities. The IAA has developed a revised set of regulations and detailed rules specific to search and rescue that are currently being considered by the Department and the Coast Guard. The Air Navigation and Transport Bill 2020 provides for further enhancement and strengthening of this framework. It underpins the IAA role in terms of oversight of Coast Guard aviation activities generally but also aligns this regulatory oversight activity by the IAA with European aviation safety regulations. Further alignment with European aviation safety regulations is planned by exercising the option in Regulation 2018/1139 on common rules in the field of civil aviation, the European Aviation Safety Agency, EASA, regulation, to apply certain elements of that regulation to the Coast Guard and search and rescue aviation activities, which are currently outside the EU regulations. The opting into the European regulatory framework for search and rescue is a one of the recommendations in the report. National primary legislation is required for this, and the necessary provisions are in the Air Navigation and Transport Bill. In practice, the IAA already applies commercial air transport standards and procedures to the majority of Coast Guard aviation activities. Exercising the option in Regulation 2018/1139 will formalise this and provide European oversight by EASA of the regulatory role of the IAA with regard to search and rescue.
Finally, with regard to regulatory oversight and responsibilities, it should be noted that wholesale reform of aviation regulation in Ireland, which will separate the regulatory and commercial functions of the IAA, is being advanced through the Air Navigation and Transport Bill 2020. The separation will provide clearer lines of responsibility and accountability in respect of aviation regulatory oversight and the opportunity to invest in strengthening regulatory capacity. The Bill has been passed by the Dáil and is currently before the Seanad. In the meantime, all the necessary administrative arrangements are being made in preparation for the new arrangements.
As regards oversight of the IAA’s role in regulating search and rescue and other aviation activities, the Department does not retain specialist aviation expertise, either pilot or engineering, but contracts expertise when necessary. Periodic review of the IAA by the Department is built into the Irish Aviation Authority Act 1993. Section 32 of the 1993 Act requires periodic examination of the performance by the IAA of its functions insofar as they relate to the application and enforcement of technical and safety standards in aircraft and air navigation. The examination is a safeguard to ensure safety standards are upheld. The most recent section 32 examination was carried out in 2019 by independent consultants Helios/Egis Avia. The examination work carried out by the consultants included a focused review of search and rescue oversight by the IAA. The examination work provides us with an external view on the oversight role of the IAA with regard to matters raised in the AQE 2018 report on search and rescue aviation oversight in Ireland. Helios/Egis Avia specifically reviewed the regulation of the national search and rescue approval and safety cases to alleviate or exempt search and rescue operations from the standard rules of the air, which is necessary to safely plan and carry out search and rescue operations and flight training. The findings of the examination gave assurance regarding the performance of the IAA of its oversight function.
I am sorry to run over my time, but I will take an extra minute to conclude because the detail of this is important in response to the safety report.
Also this year, at the request of my Department and following a public tender process, the IAA engaged consultants, Bureau Veritas, to complete an independent review of the IAA role as national civil aviation regulator, addressing areas of regulation that are outside of the EU regulatory framework. The scope of the review, agreed with the Department in advance, covered the full range of activities in respect of aircraft operations, airworthiness, licensing, aerodromes and air navigation services. I can report that the review found no gaps in the areas examined in respect of the provisions of the Irish Aviation Act 1993 and associated statutory instruments in meeting obligations in the International Civil Aviation Organisation, ICAO, annexes. In addition to the periodic section 32 examination, the IAA is regularly audited by the European Aviation Safety Agency and the International Civil Aviation Organisation. The outcomes of standardisation audits by EASA and audits under the ICAO universal oversight audit programme, USOAP, are a standing item on the agenda of the quarterly meetings of the national State safety programme co-ordination committee. In terms of safety regulation, the IAA performs strongly within the European and global regulatory framework.
I wish to record my thanks to the AAIU for its report, which follows a long period of investigation and deliberation. I accept its recommendations addressed to me, and I and my Department will accord the report the time and consideration it deserves in the coming weeks. As noted earlier, since receiving the draft final report in September 2019, my Department has undertaken a significant programme of change across key sectors to take account of the issues raised and the recommendations made at that time. I am confident these measures will strengthen the safe conduct of search and rescue operations.
Uppermost in our thoughts right now are the crew of R116 and their families and loved ones. We must all ensure the findings and recommendations set out in the report of the investigation are fully implemented to prevent similar accidents occurring in the future. I only wish we could turn back the clock. What we can do is learn the lessons so that such an accident will never occur again.