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Dáil Éireann debate -
Wednesday, 17 Nov 2021

Vol. 1014 No. 2

Air Accident Investigation Unit Final Report into R116 air accident: Statements

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 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.

On a point of order, can we get a copy of the Minister's speech? It is a very detailed speech on a very serious issue, but we are left trying to scribble notes.

It will be circulated.

At the outset I join the Minister and colleagues across the House in expressing my deepest sympathies and those of my party to the families, friends and colleagues of Captain Dara Fitzpatrick, Captain Mark Duffy, winchman Ciarán Smith and winch operator Paul Ormsby. The crew of R116 epitomised the courage, bravery, selflessness and dedication to the welfare of others that are the hallmark of members and volunteers of the Irish Coast Guard and our emergency services. Today we remember them. Ar dheis Dé go raibh a n-anamacha dílse.

The extensive final report on the crash of the R116 helicopter in March 2017 was published by the AAIU earlier this month.

It included detailed findings and recommendations. I thank the members of the AAIU for their vital work in investigating this incident and preparing this report. I welcome the comments from the Minister for Transport that he fully accepts the recommendations contained in the report. However, accepting these recommendations is not enough and I would like the Minister to outline a timeline for when each of the 42 safety recommendations will be fully addressed and implemented.

As colleagues have said, the Minister's statement was a very detailed one and will take time to consider. Noting that the safety recommendations relate to several parties such as the IAA, CHC Ireland, the Department itself, the Sikorsky Aircraft corporation, the European Commission and EASA, how does the Minister intend to ensure each party responds and acts appropriately to the recommendations that apply to it? What mechanism will be put in place to ensure that happens on a co-ordinated basis? Some people have suggested a co-chaired working group model or a stakeholder forum. I would be interested to hear the Minister's perspective.

It is essential that each of the recommendations is acted on with haste to ensure everything is done to try to prevent another such tragedy. A deadline should be set for departmental officials or the Minister to appear before the Oireachtas Joint Committee on Transport and Communications to report on the full implementation of the 42 safety recommendations. I know significant detail was given to the House tonight, but it would be appropriate to submit that information to the committee and to have it line up against the 42 recommendations. I would welcome the Minister's opinion on this approach.

The AAIU detailed 71 findings in the conclusion of its report. These findings raise serious questions for the State, its agencies and the operator. For example, contributory cause No. 12 identified that there was confusion at State level regarding responsibility for oversight of SAR operations in Ireland. The Minister referred to this in his contribution.

The Air Navigation and Transport Bill, which seeks to significantly redesign air navigation services in the State, is currently on Committee Stage in the Seanad. Is the Minister satisfied the confusion regarding responsibility for oversight of SAR operations in Ireland has now been fully resolved? Are any changes needed to the Bill to make this key responsibility more explicit?

Regarding the maps, charts and imagery available to the crew on the night, the report found that Black Rock was not in the enhanced ground proximity warning system, EGPWS, databases; the 1:250,000 aeronautical chart, Euronav, imagery did not extend as far as Black Rock; and the 1:50,000 Ordnance Survey of Ireland, 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. Even to an ordinary person reading this report, these findings are striking and pose sobering questions about the aeronautical data available to the crew of R116 on the night.

The Irish Air Line Pilots Association, IALPA, has been in contact with the Minister about the role of the IAA in overseeing the provision of accurate charts and aeronautical data as set out by ICAO obligations. IALPA has stated that the crew “relied on the data production standards of Irish regulation to guarantee them correct information. They were let down.” It is hard to disagree with that assessment on reading the report.

Raising concerns some time beforehand on 26 June 2013, one of the operator’s pilots emailed several other personnel, advising that the Blacksod south route had been flown the previous night and it was noticed that Black Rock Lighthouse was not shown on the EGPWS. The pilot stated that at 310 ft. high, the lighthouse was an obvious hazard and suggested that although it was mentioned in the route notes, the EGPWS issue should be highlighted as well. The following day, on 27 June, a different pilot emailed several of the same personnel, advising that Inishmurray and Black Rock were not contained in the EGPWS databases.

The next day, on 28 June, one of the operator’s pilots emailed the EGPWS manufacturer advising that: "a few Islands and lighthouses locally... do not appear on the database. Is it possible to get these obstructions added to the database? If so, how do we go about it?" The manufacturer replied stating it would examine the matter. The manufacturer later told investigators that it could not find any evidence it had been provided with “specific actionable data on what islands and lighthouses to add”, and the matter was regrettably closed in March 2015 with no action taken. It is devastating to read that concern about this critical information was raised four years before the R116 crash, but no action was taken to address it. I hope new processes have been put in place to ensure critical pieces of information about mapping errors are acted upon and addressed with appropriate urgency when they are identified.

The crew were provided with a low-level approach chart that started right above a fatal hazard. That hazard, Black Rock Island, was not adequately highlighted on charts and the charts had no vertical profile to provide crew with safe crossing heights. The crew had not been trained on all specific approaches on simulators and did not have "prescribed recent experience" of different landing sites.

In response to the AAIU report, the family of Captain Dara Fitzpatrick said that while there is a weighty responsibility on the operator to minimise the risk to the crew, this was not done on this occasion. They said they believed the crew members of R116 were badly let down by the operator not providing them with the safe operating procedures and training that they were entitled to expect.

It is impossible to read the report without thinking that many opportunities to mitigate risk were missed and wondering if the tragedy on the morning of 14 March 2017 would have been avoided if instead of being missed, corrective and preventative actions had been realised. What might have happened if the systems of operation, training, support and oversight were to the standard required?

Captain Dara Fitzpatrick, Captain Mark Duffy, winchman Ciarán Smith and winch operator Paul Ormsby gave their lives in the courageous pursuit of protecting others. Nothing we say here will turn back time or ease the pain for their loved ones. The report from the AAIU provides the basis for ensuring that lessons are learned and acted on. It is an opportunity that should not be missed.

Like others I welcome the publication of the air accident report into the R116 tragedy, which will now enable the long-awaited inquest to go ahead. My thoughts are with the families of Dara Fitzpatrick, Mark Duffy, Paul Ormsby and Ciarán Smith.

Those of us who live on the Mullet Peninsula and the wider Mayo area share a special affinity with these families and with the crew. The whole community took them into their hearts as the tragedy unfolded in the early hours of 14 March 2017. Their courage and dedication are forever remembered when we look out on Black Rock and Blacksod Bay. I take this opportunity to thank all those in the community who were involved, all the agencies that were involved on the ground, the local gardaí, the people from the Royal National Lifeboat Institution, RNLI, the fishermen and so many others who pulled together in that awful time following that terrible accident. We are constantly mindful that the bodies of winchmen Paul Ormsby and Ciarán Smith have not yet been recovered.

As I talk about this, I am very conscious not to jeopardise any future legal actions.

That curtails what I will say. The Minister has detailed many actions in his contribution, but the question is why it has taken so long. We automatically trusted what was in this report and that the system worked. We trusted that the system worked to keep crews and volunteers safe so we are shocked to find out this was not the case. We ask why issues have been identified and not rectified. It is very plain that they were identified but nobody was listening.

We can consider Black Rock and why a natural structure the size and height of the island did not appear in the mapping. It is absolutely unbelievable. Why do agencies have a common purpose but do not act more holistically? Why did we have so much confusion? We ask what lessons can be learned and how we can procure cutting-edge equipment that we need while safeguarding against glitches in the new technology. How do we ensure consistency in equipment with training and standards? Are the regulatory and legislative structures appropriate and consistent across the entire SAR framework, including aviation, working at height, cliff, land and boat rescue? Do we need to look more globally to benchmark best practices in regulation, training and operation?

Unfortunately, all this is too late for Dara, Mark, Paul and Ciarán but we must not let their lives and deaths be in vain. The 42 recommendations must be implemented and I am glad to hear the Minister detail how that will happen. Those accountable for overseeing the implementation of these recommendations must be known because we must have accountability within the system. It is vital that lessons are learned from what has occurred here to ensure all crews and volunteers can work safely and have confidence that they are protected while they go about the important work they do. There must be robust and thorough action from the Minister, the Department of Transport, the Irish Coast Guard and those involved with SAR operations to ensure the measures are put in place. Crews must have confidence in their working environment and the public must have confidence in that environment too.

As my colleague, Deputy Darren O'Rourke, has said, we need a timeline and continuous reviews and updates. We owe that to those who lost their lives and gave their lives in service. This must never happen again. We will always ask why and always ask if this could have been avoided. People need to answer those questions. My thoughts this evening are with the families, who as I say will always be in the hearts of the people of Mayo and Erris.

I thank the Minister for his comprehensive statement to the House. As others have said, it will take some time for us to go through. As Deputy Conway-Walsh has said, we are all united as an Oireachtas in our grief for the loss of these brave public servants. I know for the families it is not a case of ever getting over such a loss but I suppose it is pain that they must, in some way, try to get used to.

I am minded to read into the record the statement by IALPA in response to the report, as the Minister should take cognisance of its views. It states:

Captain Dara Fitzpatrick, Captain Mark Duffy, Winch Operator Paul Ormsby, and Winchman Ciaran Smith lost their lives while participating in a rescue off the Mayo coast. This report shows that the loss of their lives was as needless as it was preventable. It is evident from media reporting that 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. 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. They were let down by a regulatory system which left them ill-equipped to do the vital work that same system tasked them with.

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. 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. They were let down.

IALPA President Evan Cullen described it as a fundamental betrayal: "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 had better avoid them. The one thing they cannot do, under any circumstances, ever, is tell me the wrong height or tell me the Alps are not there. In essence that is what the Irish State did to Dara, Mark, Paul and Ciaran. They approved information which said, 'you are safe', when the absolute opposite was the truth."

The report details failures in oversight, equipment requirements and maintenance and in resourcing for search and rescue. 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.

This tragic and unnecessary loss of life must not be allowed to happen again.

All of us in the House can agree with that same very basic sentiment. It is the point of this debate and the report we are discussing this evening. I know the Minister shares that view. The statement finishes with a call supported by the Labour Party:

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 is to the Minister's credit that he gave this House a very detailed statement that will take time for us to dissect and understand better. I was determined this evening to put the voice of airline pilots on the record of the House to ensure we never have to debate another tragedy of the nature and magnitude of what happened to the four brave people who lost their lives aboard R116.

I greatly appreciate the opportunity to contribute to this very sombre exchange this evening. I thank the Minister for bringing this important report to the House. Like others, I pass my sincere condolences after many years on to the family members and friends of all those who lost their lives in the ill-fated R116 tragedy of March 2017.

Quite frankly, what happened that night was avoidable and should not have occurred. When we speak of this incident we must bear in mind that these crew members made the ultimate sacrifice to protect others, they did so thoroughly and this occurred through absolutely no fault of their own. We must remember that all four crew members on board did absolutely everything correctly and by the book. They were not at fault for what happened that evening.

We have all seen the very concerning report on the flight compiled by the AAIU, which outlines 12 factors that contributed to the crash. I will deal with some of those this evening. The main finding of the report is that the crew on board the helicopter were not aware of the location of Black Rock Island because it was not on their maps or navigational system. They had absolutely no way of knowing the rock was there and so had no way of avoiding the crash, given the poor weather conditions they experienced.

I will not repeat the comments others have made this evening but it is worth focusing again on a point raised by Deputy Darren O'Rourke. Although the crash took place in 2017, in 2013 a pilot emailed CHC Ireland, the company which the State contracted to operate these helicopter flights, stating that neither Black Rock Lighthouse nor Black Rock itself was visible on its flight database or navigational equipment.

Again, this was flagged four years prior to the R116 flight. We can all agree that while hindsight is 20-20, clearly a major error was made here that cost four people their lives. This is hugely worrying and disappointing both for the families affected by the R116 flight, and for the crew members who currently operate SAR missions for the State and their families. We all deserve to be safe and protected at work, and this line of work is absolutely no different.

The report further found that there was no formalised, standardised, controlled or periodic testing of flight routes. Even if there were issues that were not flagged, they would not have been discovered. The crew was flying at night under cloud cover at 200 ft above the Atlantic Ocean. They had no chance of seeing Black Rock without their navigational equipment flagging it for them. I cannot stress enough how disappointing this is. When we ask people to put themselves in harm's way to save another person, it goes without saying that everyone involved will do all he or she can to ensure everyone is safe. Frankly, was not the case for those involved in SAR missions.

The report states that there should be no presumption of blame or liability in this accident. I respect that and, like Deputy Conway-Walsh, I do not want to say anything that would jeopardise this. However, we have to be capable of asking the hard questions in this House to ensure that when we finally study this report, and if the Minister brings conclusions, it is assessed in a comprehensive manner.

A second concern I want to raise is that of oversight, including the oversight of CHC Ireland and, indeed, everyone involved in the contracts. The Department negotiated the contract to provide this vital work, but there is major confusion about who was overseeing this. Put simply, who governs CHC Ireland? Who was there to ensure regulations were being followed, security protocols were in place and personnel were safe? There was a presumption that the IAA was overseeing CHC Ireland. This has not proved to be correct. What is the role of the Department here? It cannot be the case that huge sums of money are passed on to companies to provide these services but no checks or measures are in place to ensure they are being put to safe use. The families of those lost that night deserve clarity on this and the current active members of the service deserve this too. I urge the Minister to provide clarity on this and to step in to provide this oversight if it is not already in place. These are difficult conversations to have but we cannot shy away from them.

I understand the Minister has accepted the 42 recommendations in this report and will evaluate them in the coming weeks. I urge him to do so as quickly as possible. It is too late for us to save Captain Dara Fitzpatrick, Captain Mark Duffy, winchman Ciarán Smith and winch operator Paul Ormsby. It is not too late for us to honour them by ensuring this tragedy never happens again.

Once again, I thank the Minister for bringing this to the House, and the families of those lost for their perseverance and tenacity in facing such hardship. I urge the Minister to act as swiftly and thoroughly as possible.

We know that on 14 March 2017, the crew of R116, comprising Captain Dara Fitzpatrick, Captain Mark Duffy, winch operator Paul Ormsby and winchman Ciarán Smith lost their lives while participating in a rescue off the Mayo coast. This report shows that the loss of their lives was as needless as it was preventable. I choose to say each of their names in the Chamber for two reasons: to honour their service and to remind us that they were four people. They were not just numbers, statistics or collateral damage. They were four sons, daughters, brothers and sisters, and their loved ones are still waiting and watching to see if the Government will take seriously the findings of this report and take action to prevent more preventable deaths.

This was the first time in 25 years, involving over 1,000 investigations, that an AAIU report was referred to the review board. It is one of the most comprehensive inquiries the AAIU has ever done. The review has confirmed that the actions of the four Irish Coast Guard members on board did not contribute to the crash. However, it draws attention to the safety protocols and procedures of the IAA, the Coast Guard, and the helicopter operator, CHC Ireland. The report confirms that the crew did absolutely everything correctly. It shows that several safety devices were not working as they should have been. The locator beacons on their life jackets malfunctioned. Black Rock Island, which the helicopter crashed into, unfortunately, did not appear on their internal navigation system.

When this report was published on 5 November, I immediately heard alarm bells ringing. A few weeks ago, the Irish Coast Guard Volunteers Representative Association commemorated another tragic death of a Coast Guard comrade, Caitríona Lucas. On her anniversary, the volunteer group launched its representative body, comprising current and former volunteers who are united in their concerns over the management and safety procedures of the Coast Guard. They feel their concerns, their fears and, obviously, their voices are not being heard. These are not new issues. There are countless units along our coastline that have had these experiences. Unfortunately, they feel they cannot speak out. The dark irony that volunteers honour the loss of their colleague by launching a platform for the long-ignored cries for help from Irish Coast Guard volunteers is very concerning. If the Minister speaks to these volunteers and listens to them, I can assure him that he will be alarmed by their experiences.

The AAIU report makes more than 40 safety recommendations, and it is imperative that these recommendations are heeded. The report has shown that the loss of these four lives was preventable. It would be a disservice to the tragedy if these recommendations were to be shelved and not implemented. The families of Dara Fitzpatrick, Mark Duffy, Paul Ormsby and Ciarán Smith deserve that justice, at the very least. The rescue forces up and down the length and breadth of the country deserve the knowledge that the State is doing everything in its power to protect them.

I remember hearing about the R116 accident. It would send shivers through a heart made of stone. Having been in the Defence Forces, I know the adrenaline that pumps when there is a call for action. Living in County Clare, I know what a central role volunteers, emergency responders and SAR operators have in my county but also beyond it. It is worrying that since I was elected to this House last year, I have been contacted by virtually every one of these groups. They feel undervalued. They all have health and safety concerns. I refer to workers in Shannon Airport, air traffic controllers, lifeguards, Coast Guard personnel and firefighters in the fire and rescue service. Clearly, something is very wrong when the very people who put their lives on the line are undersupported in doing so. These brave people are risking their safety to ensure the safety of others. The very least the State can do is to take them seriously. They are our national treasures. They are our heroes.

I truly hope that the Minister, Deputy Eamon Ryan, will value and apply the 40 recommendations of this report. If it gathers dust, as has the wisdom of so many other reports, the lives of Dara, Mark, Paul and Ciarán will have been lost in vain, and the State's failure to improve the safety of our rescue workers will be unforgivable.

I join other Members of the House in expressing sympathies to the families of Captain Dara Fitzpatrick, Captain Mark Duffy, winch operator Paul Ormsby and winchman Ciarán Smith. The accident involving helicopter R116 was, for many reasons, an entirely preventable tragedy. In 2013, the mapping of the terrain of Black Rock Island was notified as an omitted hazard on the EGPWS in 2013 by a pilot, as has already been said. The information was circulated to the manufacturer of the system and to CHC Ireland, but no action arose from the communication. There was no proactive follow-up; it was a closed case in 2015. The lands and the lighthouse remained a blind threat. This is a tragedy that has been lodged not only in the minds of the families who have been so directly impacted by it, but also in the minds of the public. The loss of lives that occurred in this way resonated deeply with people on that day and still does today. In the days and weeks following the crash, the maritime community from all corners of the island travelled to north Mayo to assist with the search and rescue, and to stand and acknowledge in person the event that had unfolded.

It is difficult to address such a sizable report in six and a half minutes. While the AAIU report was constructed so as not to apportion blame or apply liability on anybody or any failings detailed, we can draw some conclusions. A passage in the analysis summary of the report makes stark reading. It illustrates that working in the most perilous of environments was further compounded by the fact that "The cockpit operating environment appears to have been sub-optimal regarding the combination of cockpit lighting and coloured documents, the size of font used in some documents, the tabulation of a large amount of numerically dense information" and further factors listed in the report.

The flight crew of the search and rescue aircraft, R116, which was primarily east coast oriented, were dispatched to the very different environment of the west coast of Ireland. There was inadequate equipment and inadequate training. The crew were fully vindicated in the report.

I will raise some aspects of the State's role in the context of the Air Navigation and Transport Bill 2020 and the loss of the crew of R116. These matters have been drawn to my attention by IALPA. The mapping and navigation data the crew were relying on failed them. It was during the course of the final flight of R116 that systemic shortcomings and regulatory failure met to create the circumstances in which the crew found themselves in the early hours of the morning of 14 March 2017. It was described as an organisational accident. To me, that is an accident that should not have happened.

The IAA produced the State's plan. SAR operations are excluded from the regulatory framework for civil aviation and are thus outside the remit of the authority. This needs to change, if it has not already. The authority is calling for a number of amendments to be made to the legislation that is going through the Seanad at the moment. That is one of its calls. The State needs to take full responsibility for this matter and needs to ensure that there are no gaps in oversight.

There are three critical findings in the AAIU report. Black Rock Island was not on the EGPWS database, the aeronautical chart did not extend as far as Black Rock Island and the OSI imagery available on the Toughbook did not display Black Rock Island. The ICAO sets out Ireland's obligations as a contracted state when it comes to implementing the most accurate mapping information standards available.

On pages 328 and 329 of the AAIU report, it is stated that:

50. From the IAA’s Annual Safety Reviews and Aeronautical Notice it appeared that the IAA was responsible for, and carrying out, oversight of SAR helicopter operations in Ireland, but after the accident the IAA questioned whether it had the necessary mandate.

51. The IAA asserted that it was subject to oversight by the ... [Department], but [the Department] informed the Investigation that it did not have specialist aviation expertise within the Department to discharge such oversight.

These are really damning admissions that need to be addressed in legislation. I know a review is to be done but are there things that can be done immediately by way of amendments to that legislation?

At a meeting of the Committee of Public Accounts last week, we were told that a tender was being prepared for the contract currently held by the existing contractor and is likely to be issued in December. I am of the view that the State should run this service directly. Failing that, the tender must take full account of the AAIU's findings. We owe that to the crew and their families, who have been failed so badly, and we owe it to those who put their lives at risk every time they go out to do this very dangerous job. The State must have their back. I agree with the Minister that we cannot turn back the clock. We must do everything we can to prevent accidents such as this occurring but there will come a day when there must be accountability for this accident. Without accountability, behaviour will not change. This report outlines absolutely unbelievable shortcomings. I would like to hear when they occurred. It is not just a question of rectification. There must be accountability.

The lives of Dara Fitzpatrick, Mark Duffy, Ciarán Smith and Paul Ormsby are forever in the hearts of the people of Erris and Mayo. Their families are also in our hearts and thoughts constantly, particularly since the publication of this report. They have suffered the biggest loss and are entitled to ask questions and to seek answers and accountability. They have shown enormous strength and courage during the last four and a half years. That needs to be respected and the Minister needs to have ongoing engagement with these families rather than just marking the issuing of this report. Their concerns must be respected.

Every day, I am very proud to be from Mayo but I was particularly proud during the days, weeks and months following this tragedy. The communities of Belmullet, Aghleam, Binghamstown, Blacksod, the Erris Peninsula and Erris rallied in a way that had never been seen before. It was truly a meitheal. All of those who opened their homes, their hearts and their lives to people coming from all over the country to assist in the search deserve great recognition and credit. Mayo County Council, An Garda Síochána, our Defence Forces, the Coast Guard units of Ballyglass, Killala and Achill, the RNLI and local medical personnel all rallied in the most extraordinary effort, initially to find and save the crew and then to walk with the family on those terrible nights. That too needs to be acknowledged. I hope that the Minister will get the chance at some stage to visit the community, to see it for himself and to meet members of the community and hear their recollections of that time.

Those of us who live in coastal communities know the sound of that chopper as it flies over our homes. We know that, whatever part of the country those crews are coming from, they are on their way to assist. However, we did not know much of what has been outlined in the report with regard to the confusion over roles, call-outs and the management of that particular service. It is appalling that it took this tragedy to bring these issues to light. When we hear that chopper flying over us, we immediately think of families who may be about to get bad news or, hopefully, to be saved from bad news because of the efforts of those in the chopper and those behind them on the ground. That too needs to be supported.

The current challenges within the Coast Guard are incredibly unfortunate and unfair on volunteers right across our coastline and on our islands who are willing to stop their lives at any given minute to go to the assistance of others in very unpredictable and dangerous conditions 24-7. They deserve certainty and respect. They deserve for their voices to be heard in a co-operative and collaborative manner. That is not happening at the moment and that needs to be addressed urgently because, if that gets in, it ruins the spirit of volunteerism within the Coast Guard.

I wonder why we are contracting out our search and rescue service. As an island nation that is dependent on those who work on the sea, we at least owe them assurance that the State will protect them. It should do so with our own service either through our Air Corps or a specific State-run search and rescue air service. We cannot allow our search and rescue operations to be run for profit. We cannot allow them to be an asset on a balance sheet. It is a national service to protect our sea-faring communities in the work that they do. It is time that we ask ourselves whether this is an appropriate way to run that service.

There is a commitment to an EU review of search and rescue services. This matter needs to be part of that EU review. I have seen the defence given that EU procurement laws dictate our current procurement and tender system in this area but surely, given the challenges in respect of migrants and many other issues, there would be an appreciation at EU level that search and rescue and the protection of our coast is a State function that should be carried out and staffed by the State. The most important thing is that we give a commitment that this will not be allowed to happen again and that the many flaws identified in what was a limited report will not arise again.

The very notion that a structure such as Blacksod Lighthouse and Black Rock Island were not in the so-called enhanced ground proximity warning system is still incredible. As for the fact that had been highlighted some years beforehand and was not dealt with, who is being held responsible for that? So many issues of fault have been laid out in detail in the report. I acknowledge it was designed not to find fault, but facts have been laid out that show somebody was responsible. They show that if somebody had dealt with these issues in time, then maybe, just maybe, this would not have occurred. We cannot say that for definite, but the odds of it occurring would have been much lower. We have to hold people accountable for that because if they are not held to account, what else are others getting away with throughout the system? Four people lost their lives in the service of the State, yet some of the factors contributing to that, laid out in the report, had been highlighted ahead of it happening.

We owe it to them, their families and everyone who tonight is at the end of a bleeper awaiting a Coast Guard or search and rescue call, that is, every member of our emergency personnel whose life is dictated by a bleeper, full time and voluntary, that everything laid out in the report will be pursued. We owe it to them that the people who ignored the signposts highlighted in the report will be held accountable. If there is a culture of accountability, throughout the emergency service but especially, in this context, within the SAR service, people will know they have to do their job.

There are a number of other issues that could be dealt with. The Ballyglass Coast Guard, with which Deputy Conway-Walsh works closely, is a phenomenal unit and needs a permanent base. It carried out the most extraordinary work during that time, although it does so all the time. It has been messed around by various State agencies in trying to get a permanent functioning base that is fit for purpose. Will the Minister pursue that within his Department, as a mark of the unit's considerable work? The same goes for the RNLI and all the units in that area. They will do this work again tonight and every night. They are ready, willing and able to go to sea. What they need is the infrastructure and support. Most important in the context of the Coast Guard at the moment, they need respect, and that drive for respect has to come from the Minister's office.

I would like to be associated with Deputy Calleary's comments. Instinctively, my first contribution to the debate is to offer my condolences to the families of Captain Dara Fitzpatrick, Captain Mark Duffy, winch operator Paul Ormsby and winchman Ciarán Smith for their bravery and unnecessary and tragic loss. I live at the mouth of the Malahide Estuary and from my window I can see as far as Skerries. In fact, on the horizon I can see the Mountains of Mourne and County Down, and almost every day I also see Rescue 116 because I live along the flight path the aircraft takes into and out of Dublin Airport. In the summer, it often operates on Malahide and Donabate beaches conducting training exercises, so it is a regular sight. When I do not see it, I often feel it because of the size of the aircraft involved and the speed at which it deploys to sea on rescue missions.

This disaster was a tragedy but it casts a dark shadow on us as a nation. While the report, rightly or wrongly, does not identify specific persons at fault, it finds fault collectively except, of course, on the part of the pilot and crew. It is, therefore, right to know what happened, which is why I welcome the report and the lengths to which the agency went to produce it, but it has been more than four and a half years since the aircraft went down in the Atlantic Ocean. We know the equipment on board Rescue 116 that was designed to aid navigation during night-time flights or in low-visibility scenarios did not show the island, leaving the crew without crucial information. We also know the communication between relevant authorities was not clear, and incorrect and incomplete information was conveyed, leading to the deployment of the aircraft. The tragedy underscores the importance of ensuring extensive mapping of the island and land mass is completed, and it is frankly inconceivable that to this day this has not been done. The crew itself also raised issues, as had prior crews, with lighting within the cockpit and the difficulties this caused. Indeed, as was raised by other Deputies, the fact the island had not been mapped was raised as far back as 2015.

We must ensure our emergency services have the equipment and the resources they require to conduct their operations safely. The voices from the coal face must be heard with regard to these safety challenges in order to move forward appropriately. For example, Ireland does not have primary radar; we are the only country in the EU that does not. It is an extremely important navigational aid for pilots but we do not have it. Our first responders play a vital role in society, selflessly serving the community, and this often means them putting themselves in dangerous scenarios and risking their lives. They do so in order that they can protect others. They are often overlooked in society and we must, therefore, remind ourselves of their value and the service with which they provide us.

The Minister concluded his remarks by stating we must learn lessons, and I would add we must do so quickly.

I welcome the opportunity to speak on the publication of this final report but I do so with a heavy heart and a deep sense of sadness, which was echoed by other Deputies. I place on record my sincere condolences to the families, loved ones and friends of Captain Mark Duffy, Captain Dara Fitzpatrick, winch operator Paul Ormsby and winchman Ciarán Smith, the four members of R116 who lost their lives on that tragic night in Black Rock almost five years ago while providing top cover. I acknowledge the work done by all those in the investigation for producing what must be, if not the most comprehensive air accident report ever, certainly one of them.

The report, published by the air accident investigation unit, has laid bare many unacceptable shortcomings in its 350 pages, including 42 safety recommendations. While I acknowledge and welcome the Minister's contribution fully accepting its recommendations and committing to evaluate the findings in the coming weeks, that simply does not go far enough. He must also commit to ensuring the recommendations will be implemented fully and within a timeline that reflects the urgency communicated in the report. Given the nature of the incident and the report, I call on him also to provide regular updates to the House on the progress made. Vital lessons must be learned from what occurred to ensure all crews will be able to work safely and have confidence that sufficient provisions to protect them are in place.

There must also be accountability for this tragic loss of life. When IALPA commented on the report, it said it was preventable and must result in regulatory and systemic change in order that those on whom we most rely when we are in perilous danger will never be placed in a similar position again. The association went on to state it had been let down by a regulatory system that left its crews ill equipped to carry out the vital work that same system had tasked them with, and I fully agree with that statement. The report found that the probable cause of the crash was a combination of factors, including altitude, poor weather and the crew being unaware of a 282 ft obstacle on the flight path towards a pre-programmed route it was using.

Each of those conclusions should strike fear into the heart of anybody with a responsibility for search and rescue operation, but that a rescue helicopter crew was not aware of an obstacle of that size is almost beyond belief. How, in this day and age, with the technology advancements that are at our fingertips, can this happen and why?

How and why was Black Rock Island not identified as an obstacle on the flight management system? How and why were there so many anomalies on that route, some of which had gone uncorrected for years? In addition, how and why did the maps accessible to the crew not extend as far as Blackrock Island or appear to show open water in the vicinity of the island?

I wish to highlight two of the other 12 contributory causes of the accident, namely, that "There were serious and important weaknesses" in how the helicopter operator managed route testing and risk mitigation and that "There was confusion at the State level regarding [...] oversight of SAR operations in Ireland". That is just not acceptable and cannot be allowed to continue in any scenario. The inquiry's final report has concluded that there is a lack of clarity regarding the role of the Irish Aviation Authority in respect of the regulation of search and rescue flights. Despite how the operations "were classified as a ’State’ activity and were to be regulated by the National Aviation Authority, the IAA subsequently expressed uncertainty about its mandate to regulate SAR". Again, that is absolutely unacceptable.

Furthermore, the report stated that the Department "lacked the technical expertise to oversee the IAA". If the Minister's Department does not have this expertise, then what organisation does? In reality, it is the Department which should be in charge of this area. The last audible comment recorded was Captain Duffy saying "We're gone". None of us can imagine the grief that the loved ones of that crew have lived with daily since that tragic night. This report cannot be allowed to wither on the vine. This should not have happened and it cannot be allowed to happen again.

I wish to start by asking the Minister some questions. Can he confirm why the report was delayed for so long, prolonging the suffering of the families and their loved ones? Can he also confirm if CHC was the interested party that objected to the report's findings? In addition, can he clarify whether this report was altered or amended in any way as a result of those objections?

The families have rightly said that the crew was let down badly, and this is true of CHC and of the IAA. The family of Captain Dara Fitzpatrick said that when the crew was killed that they were badly let down, and that "We believe that Dara and the other crew members of Rescue 116 were badly let down [not just] by [...] CHC [in] not providing them with the safe operating procedures and training", mapping, proper life jackets etc. They were indeed let down by CHC, but also by the Irish Aviation Authority, by the Department, by the Ministers who over many decades allowed this to happen and by the State itself in its enthusiasm for contracting out core services and the responsibility of the State itself.

The Minister said that he believes this was a tragic, unforeseen accident, but I do not believe that this was a tragic, unforeseen accident. When costs are prioritised in tendering out core services, then serious risks are created and the potential for costs in lives. It would not be said that the CervicalCheck debacle was an unforeseen accident and it cannot be said that this was a tragic accident either, because the awarding of such core public services to for-profit companies, whose bottom line is their profit, ensures that nothing takes priority over that profit. That includes safety, training, workers' conditions and putting people's lives at risk.

On the question of mapping, I encourage Deputies to go back over Katie Hannon's "Prime Time" report on the accident. I say that because it was not just Blacksod Bay that was missing off the map. In addition, Achill Island was depicted on the quarter-inch map as having no high ground, whereas in fact, Achill Island has two peaks that are over 2,200 ft high. Equally, the most westerly of the Blasket Islands off the coast of Kerry appears on the chart to have the highest point of 276 ft - I am referring to when these maps were being used - when in fact 660 ft is its highest point. On Rathlin Island, the map shows a lighthouse with an elevation of 243 ft, whereas the island has a highest point of 440 ft. Moreover, it was reported that there is no spot height on the map referring to the 1,400 ft mountain peak near Malin Beg. It goes on and on. People should read back over those reports and articles. There is then also the question of how the life jackets were faulty and the fact that the crew members complained continuously while maps were not kept up to date and they were blurry. Indeed, right up into the months before the accident happened, the crew members continued to complain about the faulty life jackets and the warning beacons that were misplaced inside them.

The responsibility and the failures here start with the failure of this State in every way. It includes the failure to provide wing cover from the Air Corps because of a lack of funding or a lack of personnel. That responsibility and failure continues with the role of the Irish Aviation Authority. I am sure that the Minister will say that has been dealt with through the reorganisation of the IAA and the commercial arm that deals with airlines but the underlying weakness and light-touch regulation of the IAA is not addressed in the new and more powerful body. In fact, the head of that new body is a former CEO of Ryanair, an airline with a notorious view on the rights of workers and consumers and on general safety and concerns for its staff. If that is not enough to confirm that light-touch regulation continues, then I will eat my hat.

Despite what the report said, there is also no doubt where responsibility lay for the maps and safety. A briefing provided by IALPA to all Deputies makes it clear that the IAA had the responsibility and that is a State body. If we are to fully honour the crew of Rescue 116 and all Air Corps and sea rescue personnel, then we must do more than to simply accept the recommendations in this report. We must end the light-touch regulations in bodies such as the IAA and we must also end the tendering of and obsession with cutting costs for vital public services and ensure that the State operates such vital services itself. Therefore, I call on the Minister to say to us, perhaps not here tonight, but before the contract in this regard is awarded, that it will not be awarded to CHC. If that contract is awarded to CHC, which has major responsibility for the loss of life in this case, then the dedicated staff and personnel employed to look after our safety at sea and to rescue us will be highly insulted. It would be ironic, and tragic, for the State to do this.

I express my solidarity to the families of the crew and I commiserate with them for having had to wait for so long for this report to be published. Regarding the contract for this service, which is worth billions of euro, should not the State itself, as has been said by previous speakers, take full responsibility in the role of providing our air and sea safety and rescue services? I say that in the context of this potentially service being contracted out for billions of euro to a company that has put the lives of people at risk, instead of taking on the responsibility ourselves. I ask the Minister to comment on those points and to try to answer the questions that I asked him about the criminality inherent here. Ultimately, I believe the State owes the families an apology. This accident would not have happened were it not for things that happened through previous decades. Indeed, when Deputy Calleary was making his contribution, I was reminded that Fianna Fáil established the IAA in its initial form and contracted out the services and structured that aspect in the way it did when it was in power. Those aspects must be addressed by the State, and the families are owed that full apology and explanation from the Minister.

I just had a text to tell me that Deputy Durkan is not going to make it into the Chamber. He said that I can use a little of his time, but I will not be using the full 11 minutes.

The Rescue 116 accident tragically claimed the lives of crew members, Captain Dara Fitzpatrick, Captain Mark Duffy, winchman Ciarán Smith and winch operator Paul Ormsby in March 2017. These individuals were highly skilled and trained and also highly committed to their jobs. They were dedicated to saving the lives of others, and there is a tragic irony to the fact that they died in the course of their work to keep those who go to sea safe.

I am glad that the investigation into this accident has now concluded. Dáil Éireann must recognise the terrible grief that this accident and loss of lives has caused the affected families. For two of these families, the Smiths and Ormsbys, that grief has been compounded because the bodies of Ciarán and Paul were lost at sea and have not yet been recovered.

I am glad that the Department of Transport fully accepts the recommendations contained in this report. It is important that all actionable recommendations are now followed through and this House must maintain a level of oversight in that regard.

IALPA recently made a statement regarding the crash investigation. It stated, "They [the R116 crew] relied on the data production standards of Irish regulation to guarantee them correct information. They were let down." By way of elaboration on that point, I will refer to pages 326 and 327 of the air accident investigation unit's report. The finding listed at No. 26 was, "Black Rock was not in the EGPWS database." The finding at No. 27 stated, "The 1:250,000 Aeronautical Chart, Euronav imagery did not extend as far as Black Rock." No. 28 stated, "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."

In 2006, I went off to achieve something I always wanted to do as a child. I undertook some private pilot licence, PPL, training at Coonagh Airfield in Limerick, not too far from my home. I trained in a small light aircraft. There is a night rating that very experienced pilots go off and get. It is an entirely different kettle of fish for an aeroplane to take off during the night, as the Minister will understand. Pilots in that scenario are hugely reliant on the EGPWS terrain-mapping system to know what is ahead of them. The pilot and crew in the aircraft that night flew a hazardous mission believing they were above open water while going full tilt in a helicopter. Therein lies the ultimate problem. The terrain, the lighthouse and the rising of the land were not there for them to see from the cockpit that night. They were flying very much in the dark.

The role of aviation regulatory authorities in Ireland is to provide for or oversee the provision of accurate charts and aeronautical data. This requirement is set out by the International Civil Aviation Organization, which publishes a series of annexes relating to nation state responsibilities. Annex 4 of chapter 1 makes specific references to the Irish State. It states that Ireland, the contracting state, should take all reasonable measures to ensure the information it provides and the aeronautical charts made available are adequate and accurate, and that they are maintained up-to-date by an adequate revision service. We can assume that Ireland has, and had, the responsibility to produce adequate and accurate charts or to arrange for their production by a third party, if it wishes to contract it out. That clearly did not happen in the case of R116.

In the Minister's opening statement, he referred to the section 32 examination of the Irish Aviation Authority. That comes under the Irish Aviation Authority Act of 1993 and deals with the requirement for an examination of the safety and technical performance of the Irish Aviation Authority every three years. It is important to note that this safety examination did not happen between 2007 and 2014. It is also important to note that some of the officials who should have overseen that safety examination are still in the Minister's Department, advising him and his ministerial team not to adopt amendments to the Air Navigation and Transport Bill.

I wish to mention Caitríona Lucas, who also tragically lost her life. She was an Irish Coast Guard volunteer who lost her life while on active service when her boat capsized as she was out searching for a missing man off the coast of Kilkee in County Clare. The investigation that followed that incident identified a number of serious flaws in the rib boat that Caitríona and her crew members were using that day. Accident investigations make recommendations, and rightly so, but what we have seen in Clare and, indeed, throughout Ireland, is that rather than bolstering and enhancing the Irish Coast Guard service, the Department of Transport has, in effect, diluted pretty much everything the Coast Guard does. These days in Kilkee, the Coast Guard's inflatable boat cannot go out beyond the confines of the bay area. If a rescue is required further out at sea, local fisherman and boaters must step into the breach. The Doolin Coast Guard station is currently closed and we anxiously await its reopening following a mediation process to resolve HR problems. That process will begin next Monday. The HR dispute is only one of the problems faced by volunteers at that station. I was alarmed to discover recently that the Coast Guard hierarchy no longer allows its members to undertake climbing training in the station building. They can no longer use a bolting system when training for climbing missions in the Burren area and they have been told that there are sections of the Cliffs of Moher they simply should not go near.

We need a strong Coast Guard. It is there to save lives and keep people who go to sea safe. We need to ensure that all recommendations within the air accident report relating to Rescue 116 are now fully implemented in a timely fashion.

All of us remember the circumstances and what we were doing when the news broke of the accident involving the aircraft Rescue 116 and, indeed, subsequently when it was discovered that Captain Dara Fitzpatrick, Captain Mark Duffy, winchman Ciarán Smith and winch operator Paul Ormsby died in the crash on 14 March 2017. All of us send our sympathies to their families and friends as part of this discussion. We also send our sympathies to all of their colleagues who today and every night are sitting and waiting for a call to go out and possibly save somebody's life.

Following the crash, as those days turned into weeks while the search for the missing continued, people came to that part of Mayo from all over the country. We recall the openness of that community, how they welcomed people and threw their doors open. I recently heard a discussion on the radio of what it is to be Irish. We can all identify with the aspect of being Irish that was displayed at that time. When a crisis happens in our lives at any time, people rally around and come to rescue each other. That was the case in what we saw in Mayo during those days. It gave great heart to people for that to be happening in the context of such tragedy.

To the Minister's credit, he has accepted the recommendations of the air accident investigation unit. The report was delayed and the reason for that needs to be addressed. However, I am sure it brings some comfort to everyone who was involved that at least now there is a sense of certainty as to what happened and how things went so badly wrong. As my colleague, Deputy O'Rourke, has said, some of the recommendations are incredibly important and need to be acted upon immediately. Credit is due to everyone who was involved in bringing the comprehensive report together for the work they put into it. However, the report ultimately tells us these were preventable deaths that should not have happened. The mapping and the whole structure these four brave people who went out to rescue others were depending on, including the instruments and everything else they needed to do their jobs appropriately, were not there for them. The State has a responsibility for that which must be acknowledged.

We would all echo the calls for a specified timeframe around the implementation of the recommendations by the Department. Having said that, there are a number of these recommendations that warrant immediate action. My colleagues have already outlined what they are.

After reading through parts of the report, one of the main issues that requires serious consideration is the confusion at State level as to who holds responsibility and oversight of operations across Ireland. It is clear from the report that there were significant problems with the imagery and charting systems at the time of the accident. A whole island was missing from the charts. That is a reflection of what this is about and the problems we have. All of us talk about responsibility, but responsibility is not always about blame. It is about people being responsible for what they are doing, being responsible for others and recognising that if all of us do not shoulder a certain amount of responsibility, it can have devastating consequences. That is clearly what happened and continues to happen around this whole situation.

I urge the Minister to provide a specific timeframe for the implementation of these recommendations. He should act upon them without delay. While it is important to have this discussion in the House, we must acknowledge that our words will never ease the pain being felt by the families who lost loved ones on 14 March 2017.

I welcome the opportunity to speak. I offer my condolences to the families and friends of the four crew members who tragically lost their lives in March 2017 while trying to save the lives of others. This tragic accident claimed the lives of Captain Dara Fitzpatrick, Captain Mark Duffy, winch operator, Paul Ormsby, and winchman, Ciarán Smith.

I acknowledge the comprehensive report produced by the Air Accident Investigation Unit, which operates independently in the Department of Transport. The publication of this report represents a very difficult time for the families and friends of the deceased crew members. The report, which extends to 350 pages, goes into great detail on the events of the tragic night. Now is not the time for blame. This will not bring back the heroes who lost their lives on the night. Now is the time to reflect on the report and its recommendations. The relevant authorities need to study the findings of the report very closely and ensure a tragic accident of the kind in question does not happen again.

The final report contains 42 recommendations and 71 findings. Each and every one of the recommendations must be carefully considered and implemented immediately. I note that the Minister, Deputy Ryan, said the Department of Transport fully accepts the recommendations contained in the report and will continue to evaluate the findings in the coming weeks. Although he said he fully accepts the recommendations within the report, I would much rather he gave a firm commitment that his Department will now implement each one of them. Implementation, which would enhance the future safety of flight crews, would at least give some indication to the families of the deceased that their loved ones did not die in vain.

The Minister of State, Deputy Hildegarde Naughton, noted that the report contains safety recommendations and said she looks forward to seeing these implemented. Again, it is important that both Ministers make a firm commitment to implementing all the recommendations as a matter of urgency.

I offer my condolences to the family and friends of Mark Duffy. Mark, along with his wife and two young children, lived in my constituency, Louth. At first hand I witnessed the sorrow and grief that followed his tragic passing. We must not forget that Mark was a father and husband. He dedicated his life to saving others. His job meant that he risked his own life to save the lives of others. Unfortunately for Mark and his family, he paid the ultimate price.

Mark Duffy was only 51 years of age when he died. He had saved many lives and assisted many people who needed help during his 16-year career. He paid for his first flying lessons when he was just 16 with money he got from a summer job working in Dundalk. He loved his job and was dedicated to it.

We must not forget Dara, Paul and Ciarán as well because they also had families. Once more, I offer my sincere condolences to the families and friends of the heroes who lost their lives on the dreadful night. I hope they did not lose them in vain. The report on the accident contains 42 recommendations and 71 findings. Each and every one of the recommendations must be implemented without delay. This will not bring back the four lives lost on the night but it might prevent something similar from happening in the future. We have to learn. Five years have elapsed since the accident. I beg of the Minister to implement the recommendations.

I extend my sympathies to the family of Captain Dara Fitzpatrick, chief pilot, Mark Duffy, winch operator, Paul Ormsby, and winchman, Ciarán Smith. I also want to remember the four Air Corps members of R111 who lost their lives in Waterford in 1999, also as a result of a tragic accident: Captains Dave O’Flaherty and Mick Baker, Sergeant Paddy Mooney and Corporal Niall Byrne. They were all courageous people who risked their lives and ultimately gave them to help others in significant and perilous danger.

The R116 report clearly shows specific measures are now needed to ensure that the air and sea rescue service is properly supported. The State needs to invest now in a new 24-7, available, fixed-wing aircraft, to be based in Dublin or Shannon and to operate on a national basis. Sporadic availability of Air Corps top-cover aircraft is no longer sufficient, as the report has shown. The aircraft I advocate could provide top-cover support on scene for extended operational hours and assist with the monitoring of marine pollution, as well as providing much-needed patient transfer capability across the island and to the UK.

The Irish Aviation Authority needs to adopt a management reference document, such as the UK Civil Aviation Authority’s CAP999 document, which assists organisations in determining procedures and in respect of operational guidance manuals for search and rescue helicopter services and missions.

Night-vision goggles are being deployed across the search and rescue fleet, yet they are approved solely for helicopter emergency medical service, HEMS, operations. Will the Minister update the House on why there is a delay and when approval will issue for the use of night-vision goggles in all search and rescue aircraft activity?

Captain Dara Fitzpatrick had a very close association with Waterford’s R117 service. She was a chief pilot in Waterford for many years and had many friends there. The R117 service is a service that was recently distinguished by its being awarded bravery honours by the Ceann Comhairle for the rescue of seven crew members from a ship that was sinking off the Kerry coast in March 2021. Dara would have revelled in the fact that the rescue mission was assisted by the only female winchman in the national service, Ms Sarah Courtney.

With reference to the R117 service in Waterford, perhaps the Minister will comment on why his Department is now reneging on a commitment to provide stopgap funding of €350,000 per annum to Waterford Airport, the home of R117, while the airport awaits planning permission for a new runway extension. This reneging comes at a time when the Minister has announced funding of €126 million to support all other regional airports. The hypocrisy shown by the Government in failing to support or secure Waterford Airport and its R117 helicopter service is breathtaking in light of the funding of €126 that was announced. The withdrawal of the Waterford Airport service and moneys dishonours those in our Waterford rescue base, which provides life-saving assistance to the population of the south east from Waterford Airport each day. I hope the report on R116 and the planned implementation of recommendations can bring some comfort and closure to the families involved and to all those with loved ones who operate in the air and sea rescue service. Regarding R116, mistakes have been identified. They must now be fully acknowledged and rectified. Remediating action must be plain to see for everybody involved in the air and sea rescue service so some good can come of this tragedy and to ensure such an accident will never happen again.

While listening to previous contributions, I was very struck by the affinity of Deputies, particularly those from coastal communities, with the services that serve us so well. The residents of my home town, Tramore, are no different in that they have a deep emotional connection with their helicopter rescue service, R117. The crew often train in the bay. There are nights – often stormy – when we hear the helicopter going over the town and realise it is responding to the call of somebody in trouble.

We have a deep connection with R116, as Deputy Shanahan mentioned. Captain Dara Fitzpatrick, who died along with winch operator, Paul Ormsby, winchman, Ciarán Smith, and Captain Mark Duffy when their helicopter crashed into Black Rock Island off the coast of Mayo on 14 March 2017, had spent ten years in Waterford with R117 and is very fondly remembered there. As Deputy Shanahan said, we still remember a similar tragedy, which occurred 22 years ago. After midnight on 22 July 1999, returning through dense fog on a rescue mission off the Waterford coast, the crew of R111 died when their helicopter hit the sand dunes at Tramore beach. Captain Dave O’Flaherty, Captain Mick Baker, Sergeant Paddy Mooney and Corporal Niall Byrne all lost their lives on the night. Their names remain in the memory of my local community, just as I know the names of the crew of R116 will be held in the memory of the community of Blacksod. The report acknowledges the support the local community gave to the large number of personnel, particularly the mariners who took part in the search and who worked in difficult sea conditions.

The final report of the Air Accident Investigation Unit on the R116 air accident attributes neither blame nor liability; that was not its job.

It is a technical report that lays out probable and contributory causes. There were clear failings with safety systems, processes, oversights and usability issues, all of which resulted in this needless loss of life. I welcome the 42 safety recommendations within the report. They are clearly explained and outline what is required in order to help prevent another aviation tragedy such as this, but we had reports after R111 as well. The responsibility to implement each of the 42 safety recommendations outlined in this air accident report spans the operator, CHC Ireland, as well as the Irish Aviation Authority, the Sikorsky Aircraft Corporation, the European Union Aviation Safety Agency, the European Commission and the Department of Transport. I am glad the Department fully accepts all the recommendations of the report and has undertaken a programme of change to address several of the issues raised, but every agency with responsibility to implement these safety recommendations needs to do so, and quickly.

As is evident from the contributions in this debate, all coastal communities throughout the island really hold the volunteers and professionals involved in search and rescue in the highest regard. They respond when the buzzer goes and that is a significant act of courage. However, unless we match that sincere regard with the action required to ensure every barrier to their work is removed and the best safety systems are deployed for them, then it is only lip service. The RNLI lifeboat at Tramore has to contend with water quality issues when it launches. The RNLI lifeboat stationed at Helvick Harbour is on restricted service because of the build-up of silt in the harbour which makes it unnavigable at low tide. We need to ensure our search and rescue crews, both sea and air, have robust safeguards and the best possible working conditions. We can memorialise the brave people tragically lost in R116 and it is right and fitting to do so, but it would be a much more fitting tribute to make sure that we do not have another such tragedy and report in the future. Suaimhneas síoraí orthu.

It has been mentioned previously, but it is worth reminding ourselves, that the reports published by the air accident investigation unit contain the facts relating to the reported occurrences that have been determined. This information is published to inform the aviation industry and the public of the circumstances of these occurrences. The unit is clear that issues concerning liability are neither investigated nor described in association with its investigations, and matters relating to blame, liability, responsibility and damages are generally dealt with by the judicial authorities or insurance companies, for example.

This was a tragic accident and I express my condolences to the families of all the crew who died on that night. I pay particular tribute to Captain Dara Fitzpatrick, who lived on the Ennis Road in Limerick when she worked as a helicopter pilot in Shannon. She volunteered at Milford Care Centre in her spare time and she represented an ethos of serving her fellow citizens diligently and selflessly. We would do well to continue to remember her and the values she represented.

We should stick to the facts and learn from this tragedy. I will start with mapping and imagery. The Irish Air Line Pilots Association points out that the IAA is responsible for the provision of electronic terrain and obstacle data for use by GPS and flight management system suppliers. The report notes that some imagery and databases did not have Black Rock mapped. It was not in the enhanced ground proximity warning system, EGPWS, databases. EuroNav imagery did not extend as far as Black Rock and Ordnance Survey Ireland imagery did not show the lighthouse or terrain, but appeared to show open water. The report also notes that the extensive activity undertaken by the operator in respect of the testing of routes in the flight management system route guide was not formalised, standardised, controlled or periodic.

It seems to me that we urgently need to ensure the mapping data is accurate and that it is disseminated and integrated into the systems that are being used by aircraft. This is particularly relevant when it comes to the rapid deployment of onshore and offshore wind. The tip height of newer turbines is up to 200 m and we must make absolutely sure that these turbines are incorporated into the systems as soon as they are erected. It is not just the physical height of the wind turbines, it is also their effect on airflow in their vicinity and downstream effects on the aerodynamic stability of aircraft. We need to make sure we have an adequate regulatory regime to deal with this issue. This tragic incident is a reminder that we need to make sure our airspace and features on the ground and sea underneath are adequately mapped and assessed for safety.

The other issue I wish to raise is that of State oversight. We in this House must take partial responsibility for the legislative framework that governs the Coast Guard, the Irish Aviation Authority and search and rescue operations in Ireland, and the oversight of this framework. The report found there was considerable confusion. We must ensure clarity replaces that confusion. It may be that we need to amend legislation to remove ambiguities and ensure all agencies have utter clarity on their roles in the operation and oversight of search and rescue operations.

I have been impressed by many of the contributions tonight and I hope the families of those who died in this tragic accident hear how seriously this accident is being taken and that there is a real desire to make sure the factors that led to the accident do not happen again so that we can prevent another family suffering this unimaginable grief.

I am sharing time with Deputy Connolly. Coming from a coastal community, I recognise the importance of the Coast Guard and know of the sheer devastation felt by a coastal community when an accident such as the R116 air accident occurs. I take this opportunity to extend my sympathies to the families of Paul Ormsby, Mark Duffy, Dara Fitzpatrick and Ciarán Smith and to their communities which are, no doubt, feeling the impact of this tragedy.

The report of the air accident investigation unit makes for sobering reading and outlines further the tragedy that this was. It highlights that it was an avoidable tragedy. It seems to me that it could have been avoided by the company doing its job properly and the State actually providing oversight of the contract that it has given out on our behalf. The report shows almost a 50:50 split between the State and the operator of the aircraft in terms of the steps that need to be taken in light of this tragic disaster. Of the recommendations, 19 relate to State agencies and 23 to the operator.

All present know that Black Rock Island was not on the maps that were used on the helicopter and that the crew, not being based on the west coast, may not have been totally familiar with it. However, the question has to be asked as to how, in this day and age, that situation was allowed to continue. Has it been sorted since? It seems crazy that the situation does not seem to have been picked up by the operator, the Department or the Coast Guard.

The report and its highlighting of the oversight findings on the deficiencies of the Department, the Coast Guard and the Irish Aviation Authority are stark and have to be addressed to ensure this cannot happen again. It is extremely worrying that oversight finding No. 46 states, "Neither [the Department of Transport, Tourism and Sport] nor the [Irish Coast Guard] had aviation expertise available within their own personnel resources, and lacked the capacity to remain an ‘intelligent customer’ in relation to contracted helicopter operations or auditing". That is shocking. What is the State going to do to correct that situation? There is no doubt that there were massive failings on behalf of the contracted company but that does not remove the duty of care on the State, as the contractor, to make sure that everything is correct and to protect citizens.

To whom does it fall to have the recommendations of the report implemented? The recommendations are so damning that they have to be implemented in full and it seems to me that, unfortunately, neither the Department nor the Coast Guard are competent to do that. I know the Minister outlined that he is implementing the report but I think this House has to insist on oversight of the Department because it failed miserably through the whole process. There has to be oversight to make sure the report is implemented. That is vital. We will see what happens in that regard and from there on.

Like all other speakers on this issue, I extend condolences to the families of the commander, Dara Fitzpatrick; her co-pilot, Captain Mark Duffy; the winch operator, Paul Ormsby; and the winchman, Ciarán Smith. We have to match our extension of condolences with holding the system to account. I only have three minutes to speak on this issue so it is difficult to deal with it thoroughly. I hope this is the start of a process through which we ensure that every single one of the 42 recommendations is implemented.

I am not convinced of that today. The investigation started immediately, within hours of the accident on the night of 14 March, and continued right up to when the report was published on 5 November. That, in itself, begs the question of what happened during that time. There was a preliminary report, four interim statements and a draft report.

I pay tribute to the authors of the report. It is a very well-written, clearly set out and factual report, and analysis, conclusions, findings and recommendations are provided. It is a model in terms of how it is set out. The mother and baby homes commission of investigation might wish to have a look at it.

When the draft report became available to the Department, I understand one of the parties involved exercised their right to have a review of that draft report. Perhaps the Minister of State can confirm that this party was not one of the State entities. When that entity exercised that privilege and right, the review board was set up. Six months later, the review board of two people had to be set aside because of a conflict of interest that suddenly became known six months after the event. That person had a conflict of interest and was associated with the company. Perhaps the Minister of State might explain how that happened, and what oversight was in place - or not in place - for that to occur. The review board was then set up with a senior counsel. That report became available this year. The families had to go through all of that, as well as a 44-day hearing in relation to that review board. That, in itself, needs looking at.

The final report has been published. It contains 42 recommendations, findings and conclusions, and sets out 12 contributory causes of the accident. It is important to state that the probable cause is set out in the paragraph preceding those detailing the 12 contributory causes in the report. The report states that the probable cause was the fact that:

The Helicopter was manoeuvring at 200 ft, 9 NM from the intended landing point, at night, in poor weather, while the Crew was unaware that a 282 ft obstacle was on the flight path to the initial route waypoint of one of the Operator’s pre-programmed FMS routes.

In relation to that, what jumps out at me is the comment of the psychologist, who is quoted on page 190 of the report. Writing of the care that must be taken when describing safety systems, the psychologist states:

The use of silly and meaningless safety language matters, it creates a distraction and delusion that safety and risk are being addressed. We may feel good about speaking such words but they dumb down culture and distract people from taking safety seriously.

If we learn anything, we should learn from those words. What have we learned from all of the reports that we have been given, on top of the accident, already referred to, that happened in Waterford 18 years before this accident? How many reports have been produced?

Let us look at the illusion of safety and oversight. The report details the 12 contributory causes, but I do not have time to read them out. One of the contributory causes was the fact that: "There was confusion at the State level regarding responsibility for oversight of SAR operations in Ireland." The report also states:

There were serious and important weaknesses with aspects of the Operator’s SMS including in relation to safety reporting, safety meetings, its safety database SQID and the management of FMS Route Guide such that certain risks that could have been mitigated were not.

These are basic matters.

On the Irish Coast Guard, the report states:

Neither DTTAS nor the IRCG had aviation expertise available within their own personnel resources, and lacked the capacity to remain an "intelligent customer" in relation to contracted helicopter operations or auditing.

The IRCG relied on an external contractor to conduct annual audits of the Operator’s bases.

The report goes on to state that when audits took place:

The IRCG appears not to have appreciated the severity of some of the matters the Auditor raised and it appears that the Auditor’s reports and supporting evidence were not scrutinised by the IRCG.

The IRCG did not have a Safety Management System, and IRCG management completed their first aviation SMS training in October 2018.

The report goes on to discuss the IAA. Time precludes me from going into more detail and the Ceann Comhairle has allowed me some discretion.

I have read the 350-page report. I have had four or five minutes to deal with the issue. It is not the way to deal with such a report if we are seriously interested in learning how to hold the system to account.

I totally agree with Deputy Smith in relation to the privatisation of the service. If we learn anything, that is the most fundamental lesson we should learn here. We need an explanation as to how, when the business case was assessed for renewing the contract, it was found that it would not be valuable economically to have the Air Corps involved. Further, in my opinion, there was a conflict of interest in relation to company used for that business case.

I want to use my time to offer my deepest sympathies to the families and friends of Captain Dara Fitzpatrick, Captain Mark Duffy, winchman Ciarán Smyth and winch operator Paul Ormsby. The accident and loss of the crew were a terrible tragedy. We must surely learn lessons from this terrible tragedy and insist that something like it never happens again.

The R116 accident was a tragedy that claimed the lives of four crew who dedicated their lives to saving others. I express my sympathies to the families and loved ones of pilot Dara Fitzpatrick, co-pilot Mark Duffy, winchman Ciarán Smyth and winch operator Paul Ormsby. I thank Members for their contributions. It is clear that we all share a common goal of seeking to prevent similar accidents occurring in the future.

I thank the chief inspector of the Air Accident Investigation Unit and his team for completing such a comprehensive report. The work they have done will greatly enhance the safety of search and rescue aviation operations in Ireland and internationally. I reiterate that I fully accept the recommendations addressed to me contained in the report. It is a large and complex report and deserves to be given due consideration. This my Department and I will do.

My Department fully accepts all recommendations from the AAIU report. I will ensure that recommendations addressed to the Minister are implemented. 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 Cost 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.

The national search and rescue, SAR, plan is the key means by which we implement search and rescue policy in Ireland. The new national SAR plan is the baseline reference document for use by all search and rescue organisations in Ireland, and promulgates the agreed method of co-ordination through which search and rescue operations are conducted in Ireland's search and rescue region. The new national SAR committee, the national SAR consultative committee and the other structures, such as the SAR health and safety forum, provide a good framework to progress the co-ordination of the implementation of safety recommendations across all relevant bodies.

The IAA has reviewed and fully accepts the recommendations addressed to it as the national aviation regulator, many of which have already been implemented or are proceeding to full implementation. The IAA will respond independently to the findings addressed to it. More broadly, in the overall context of improving safety in search and rescue operations, my officials have been engaging with the safety regulation division, SRD, of the IAA and the regulator himself. A team of technical experts within the safety regulation division is examining in detail the report, each finding and each safety recommendation. The IAA will use its regulatory oversight role to examine the implementation of the wider recommendations and provide any necessary support. The IAA will also continue to work with the European Commission and the EU Aviation Safety Agency in the development of safety rules.

The Air Navigation and Transport Bill 2020 provides legislation underpinning an even more enhanced role for the IAA in terms of the oversight of Coast Guard aviation activities generally.

The new provisions provide clarity and strengthen to the regulatory framework by ensuring the IAA, in making regulations that apply to the Coast Guard, takes into consideration the public benefit of the activities of the Coast Guard, which are very different in nature from commercial air transport activities, and consults with the Coast Guard as is good practice. The provisions further provide that in making regulations the IAA must align them with certain elements of European aviation safety regulations that are appropriate and relevant to Coast Guard aviation activities. In conjunction with the provisions in the Air Navigation and Transport Bill, secondary legislation is being prepared by the IAA to provide further operational clarity to operators of search and rescue. The IAA has developed a revised set of regulations and detailed rules specific to search and rescue that are being considered by the Department and the Coast Guard. The Irish national search and rescue rules are being developed to assist operational search and rescue stakeholders in determining the appropriate procedures and operations manual guidance to operate civil search and rescue helicopters in Ireland.

With regard to the Department's oversight of the IAA's role in regulating search and rescue and other aviation activities, the Department engages aviation expertise for periodic oversight audits as required by national legislation. The Coast Guard has been operating and delivering an aviation search and rescue service for the past 30 years through a mix of private contractors and military. The Coast Guard carries out regular audits of the aviation service provider to ensure compliance with the contractual arrangements. The Coast Guard has in place a contract for the provision of helicopter aviation consultancy services. In addition to this, the Department has approved an aviation manager post in the Coast Guard. The successful candidate will have the requisite aviation knowledge, skills and experience and will manage the aviation contract and related operational and safety issues. The Department and Coast Guard are examining options to increase its in-house expertise on foot of the air accident investigation unit's recommendations.

Recognising the detailed complex and interconnected findings, conclusions and safety recommendations contained in the report, I encourage Members to go to the report as the definitive source of information as to what contributed to the accident. It is unhelpful for findings to be inferred from the report that are not the findings of the investigation. I have listened very carefully to suggestions offered by Members on how we can further improve search and rescue operations. While a detailed programme of change is under way in the Coast Guard, I will continue to reflect on ways of further improving governance, oversight and safety procedures to ensure that Ireland can have a world-class search and rescue service.

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 future.

I asked a question on night vision technology, which has been deployed in Sligo. I asked why there is a delay in deploying it to other aircraft and why it is only approved for helicopter emergency medical services activity. Will the Minister of State come back to the House and to me with regard to search and rescue?

The Minister of State will correspond with the Deputy on that. I invite Members to stand in memory of the four victims. Ar dheis Dé go raibh siad.

Members rose.
Sitting suspended at 8.44 p.m. and resumed at 9 p.m.