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Seanad Éireann debate -
Thursday, 18 Nov 2021

Vol. 280 No. 6

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

I welcome the Minister of State at the Department of Transport, Deputy Naughton, to the House. I put on record my deepest sympathies - I know all Members join with me - to the families, friends and colleagues of the members of the Irish Coast Guard who lost their lives in the accident involving R116, namely, Captain Dara Fitzpatrick, Captain Mark Duffy, winchman Ciarán Smith, and winch operator Paul Ormsby. The R116 air tragedy was a result of a lot of systems failures, This very comprehensive report makes recommendations that I truly hope will ensure that no further lives are lost in incidents with the Coast Guard service.

In 2011, I worked with the community in Valentia to ensure that the Valentia marine rescue co-ordination service for the Coast Guard was kept open along with the Malin marine rescue co-ordination centre. A number of issues were raised in the Fearon report, but these were not included in the final report that was given to the Minister. At the close of the debate I propose that we have a minute's silence in the House for Captain Dara Fitzpatrick, Captain Mark Duffy, winchman Ciarán Smith and winch operator Paul Ormsby. Ar dheis Dé go raibh a n-anamacha dílse.

I am grateful to the House for affording me this opportunity to make a statement on the final report of the Air Accident Investigation Unit, AAIU, on its investigation into the Rescue 116 accident.

The Minister for Transport and I spoke yesterday in the Dáil on this matter and it is fitting that this House should also be fully briefed and given the opportunity to respond. The R116 accident was a tragedy that claimed the lives of four crew who dedicated their lives to saving others. I again express my sympathies to the families and loved ones of pilot, Ms Dara Fitzpatrick, co-pilot Mr. Mark Duffy, winchman Ciarán Smith and winch operator Paul Ormsby. 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. They deserve our deepest gratitude.

The Government acknowledges and appreciates the completion and publication of the AAIU report. The completion of the investigation and the publication of the report is a key step in ensuring that such accidents are prevented in the future. I commend the chief inspector of air accidents and his team for compiling such a comprehensive and detailed report. Search and rescue aviation operations will benefit greatly from its findings and the implementation of its safety recommendations both in Ireland and internationally.

The AAIU is an operationally independent unit within 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 main conclusion by the AAIU is that the accident was an organisational accident. Organisational accidents have multiple causes involving many people operating at different levels of their respective organisation. In total, there were 71 findings and 42 safety recommendations, of which ten findings and 14 safety recommendations are directly relevant to the Minister for Transport.

My Department fully accepts all recommendations from the AAIU report and I will ensure that recommendations addressed to the Minister are implemented. It is a large and complex report and deserves to be given due consideration and this my Department and I will do. It is proposed to formally respond to the chief inspector of air accidents in respect of each safety recommendation addressed to the Minister, 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 in order to implement changes on foot of lessons learned following the accident. Since March 2017, and specifically following receipt of the draft final report in September 2019, the Department and especially 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: development of a new national search and rescue framework, the national search and rescue, SAR, plan; enhancing safety and oversight across the search and rescue system; addressing oversight of search and rescue aviation elements, nationally and internationally; review and revision of all relevant standard operating procedures and training for Coast Guard personnel, especially rescue co-ordination centre staff training, with a focus on aviation tasking - this includes the introduction of a formal course on tasking of aviation assets delivered by an IAA authorised training organisation, ATO; development of an externally accredited safety management system in the Coast Guard; review of governance arrangements in relation to the aviation contractor; and enhancing aviation expertise in critical areas and legislative reform of the Irish Aviation Authority, IAA.

A new search and rescue framework, the national search and rescue plan, NSP, which provides for more explicit governance, assurance and oversight roles across the SAR system was noted by the Government and published in July 2019. The key objectives of the NSP are as follows: to achieve a rebalancing of the previous maritime-centric SAR framework to encompass air and land SAR more comprehensively; to establish effective governance, oversight and assurance across the SAR system, to take account of national and international obligations; to achieve clarity on roles, inter-relationships and responsibilities from the strategic, through tactical to operational levels; to develop a common approach to managing SAR incidents across the three domains; to set priorities, objectives and performance expectations; to measure performance at system level; and provide a sound and clear basis for continuous improvement.

The national search and rescue plan sets out more explicit governance, assurance and oversight roles across the search and rescue system. The plan resets a more strategic-focused national search and rescue committee with a leaner, more coherent set of subcommittees, including a search and rescue consultative committee and regulators', health and safety and aviation forums. The plan also sets out a clear description of the national search and rescue system including roles, inter-relationships and responsibilities.

The national SAR committee, NSARC, set up under the national SAR plan is a strategic level committee with oversight of the national SAR plan as a whole and covers all three SAR domains: maritime, aeronautical and land based. Its membership includes senior managers from the three SAR co-ordinators, 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 per year and has an independent external chair. The NSARC gives strategic direction to the SAR system and has both 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. This 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 vulnerabilities identified in the existing model and 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 between the Irish Coast Guard, IRCG, and the aeronautical rescue co-ordination centre. Formal establishment is subject to the filling of newly established positions in the IRCG rescue co-ordination centre, following a Public Appointments Service process.

As an appendix to the national search and rescue plan, guidance is provided on the development of a common approach to managing search and rescue incidents across all three domains of land, maritime and aeronautical search and rescue, including the transition from search and rescue to search and recovery. This plan will be delivered on a phased basis to enable a managed and integrated approach to the development of the new search and rescue structures, along with the coherent development of memoranda of understanding and service level agreements between all relevant stakeholders.

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 national search and rescue committee on the national SAR plan, which was approved in July of last year. The second annual report will be presented shortly. The new or reformed structures envisaged by the national search and rescue plan are fully up and running. The national search and rescue committee meets at least three times per year. The national search and rescue consultative committee, which has a wide membership across all SAR providers, meets twice a year. A national SAR stakeholders forum takes place annually. The aviation forum meets on a quarterly basis.

One of the key innovations in the new NSP is the SAR assurance mechanism. This places an onus on all participants to provide annual assurance statements across key areas of performance and safety and risk management. Significant progress has been made on implementation of the new virtual joint rescue co-ordination centre. Clarity has been provided regarding roles and responsibilities and formal agreements are being finalised with all key stakeholders.

A mechanism has been formalised and tested for reviewing international SAR agreements. IRCG's standard operating procedures have undergone a major review and refresh. Key performance indicators for the national SAR plan have been developed by a dedicated key performance indicator, KPI, working group Development of a new SAR assets register is under way. A new aviation training programme for IRCG staff provided by an IAA-approved training provider is ongoing and the ninth such course is currently taking place. In addition to IRCG staff, course participants include aeronautical rescue co-ordination centre, ARCC, staff and members of An Garda Síochána from the Garda air support unit.

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 these are updated on foot of incident reviews under the Coast Guard's 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 Irish Aviation Authority.

Eight such courses have been held so far, encompassing 70 staff, and are ongoing. In regard to implementing a safety management system to ISO 45001, the Coast Guard is undergoing pre-certification audit, which will be completed by quarter 1 of 2022.

The Coast Guard is also implementing a range of measures that represent a SAR assurance system. This includes updating and renewing its memorandums of understanding, MOUs, with SAR co-ordinators and SAR facility providers. The vast majority of these MOUs have been completed. Work is ongoing with the remaining support organisations with which the Coast Guard has links. The AAIU report found a lack of clarity concerning oversight of search and rescue aviation operations. As I mentioned previously, the NSP sets out more clearly the roles and responsibilities regarding oversight.

The SAR review report also describes the measures undertaken by the IAA as the national aviation regulator to address recommendations arising from the AQE review of search and rescue aviation oversight, which are clearly relevant to those aspects of the AAIU's report. The role of the IAA concerning search and rescue covers 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 search and rescue 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. The national search and rescue approval provides for alleviation or exemptions that are necessary to operate outside 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 exemptions and these are reviewed by the IAA yearly.

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, which are being considered by the Department and the Coast Guard. I am out of time.

The Minister of State can continue. It is important we hear it all because people will respond to her remarks.

The Air Navigation and Transport Bill 2020 provides for further enhancement and strengthening of this framework. It underpins the IAA's role in 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 Union Aviation Safety Agency, EASA, regulation, to apply certain elements of it to Coast Guard search and rescue aviation activities, which are currently outside the EU regulations. The opting in to the European regulatory framework for search and rescue is one of the recommendations in the report.

Given that the aviation activities of the Coast Guard are not confined to search and rescue, and to ensure consistency across the regulation and oversight of Coast Guard aviation activities, we will opt in to Coast Guard activities as well as search and rescue. This will ensure that whether Coast Guard aircraft and personnel are flying a search and rescue or non-search and rescue mission, specified elements of the basic regulation will apply. 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 European 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 to the regulatory role of the IAA in search and rescue.

On 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 Bill has been passed by the Dáil and is currently before this House. All the necessary administrative arrangements are being made in preparation for the new arrangements.

This year, at the request of my Department and following the 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 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 ICAO annexes. The IAA is also regularly audited by EASA and ICAO. The IAA performs strongly in safety regulation within the European and global regulatory framework.

I record my thanks to the AAIU for its report, which comes after a long period of investigation and deliberation. I accept its recommendations, addressed to the Minister, and I and my officials will accord the report the time and consideration it deserves in the coming weeks. I am confident that measures taken to date since receipt of the final draft report in 2019 by my Department 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 this report of the investigation are fully implemented to prevent similar accidents occurring in the future.

I welcome the Minister of State to the House. In his speech to the Dáil last evening, the Minister, Deputy Ryan, should have clearly and unambiguously informed the House that there is no Act of the Oireachtas on the Statue Book giving legal responsibility for Irish SAR to the Irish Aviation Authority. I will say that again: today, as I speak, the IAA is not legally responsible for Irish SAR. This is a jaw-dropping scandal of monumental proportions. It is distressing to have to address this House on the tragic loss of Rescue 116 and her four valiant crew members - Dara Fitzpatrick, Mark Duffy, Ciarán Smith and Paul Ormsby - at Blackrock Island in 2017. I offer my condolences to their families and call on those close to them to ensure they get legal advice for whichever jurisdiction they deem best.

It is a tragedy, but one that should have been avoided long before the helicopter took to the sky. The litany of abysmal failures by Ministers and senior civil servants at the Department of Transport, the Irish Coast Guard, the Irish Aviation Authority and, most especially, the operator CHC Ireland DAC, have had grave and unacceptable ramifications.

Those who held a ministerial brief in respect of or had a management role in these organisations, especially since 2010, need to reflect honestly on their respective records.

CHC must not be allowed to tender for any part of the next SAR contract. The current procurement process must be halted in light of the report, and we must have some part of the next contract provided by our sovereign service, the Irish Air Corps. The Department of Transport has failed and, incredibly, continues this very day to fail to legislate and legally assign responsibility for SAR regulation and operational safety to the appropriate Irish entity, namely, the IAA. The group that produced the 2010 report on constructing a future Irish airborne SAR service, chaired by the then head of the Irish Coast Guard, Mr. Chris Reynolds, sensibly recommended that the IAA legally oversee SAR safety and operations. In 2014, the IAA, acting on its own initiative, published a notice regarding SAR safety and operations; however, the notice had no legal import as the Department of Transport had failed to legislate to give legal responsibility for SAR oversight to the IAA. Eleven years later, and with four lives lost, the Department has still not given legal responsibility to the IAA. That is astonishing, reckless and barely believable.

The Air Navigation and Transport Bill that is currently before the Oireachtas will, if passed, finally give legal certainty to the IAA in respect of overseeing SAR operations. Incredibly, no Opposition amendments to the Bill will be accepted by the Government. These are amendments recommended by the pilots.

Ireland is a founding member of the UN International Civil Aviation Organization. For many years, Ireland has led innovations in civil aviation, with the development of the aircraft-leasing sector and the low-cost airline industry, thereby democratising air travel for all. The R116 report casts a dark shadow over these achievements, highlighting a catalogue of errors, omissions, faulty communications procedures, substandard navigation route designs, the use of maps that are not fit for the purpose for which they are being used and a continuing lacuna in the law, meaning there is no entity with legal oversight for Irish SAR services.

The R116 disaster was preventable and SAR crews, their families and the citizens of Ireland have been failed. R116 should not have been out on the ill-fated night, tasked with providing top-cover air communications. These are most effectively provided by fixed-wing aircraft because of their greater communication range. At the time of the disaster, reckless Government policy had resulted in the inability of the Air Corps to provide fixed-wing top cover on a 24-7 basis due to a pilot shortage. The Air Corps was then officially only able to provide fixed-wing top cover on an as-available basis. In 2015 and 2016, respectively, boards convened by the Department of Defence recommended a retention policy with financial incentives for Air Corps pilots to remain in State service. The reports were left gathering dust and the Air Corps pilot shortage continued. Since the R116 tragedy, a proper pilot retention policy was put in place in the Air Corps. It has been a success but still has some way to go. Let us join the dots. If in 2015 and 2016 boards’ recommendations on Air Corps pilot retention had been acted upon, we would have had 24-7 fixed-wing capability. Most probably, it would have been in place in 2017 and R116 would not have had to take on its fateful mission.

Ireland is one of only two European countries that have privatised the SAR service. The other is the UK. Unlike Ireland, however, the UK has substantial sovereign SAR capability in both helicopters and fixed-wing aircraft via the Royal Air Force. Ireland has failed to resource properly its Air Corps with aircraft and personnel to retain appropriate sovereign capability. All responsible states retain sovereign SAR capability in case of the loss of a privatised SAR service due to industrial action and in the unlikely event that an entire fleet of aircraft will be grounded for technical reasons.

Ireland has recklessly allowed its Air Corps to be under-resourced in terms of aircraft and crews despite countless warnings about this folly. In 2011, the £6 billion sterling UK SAR bidding process was halted when a scandal broke. An inquiry during the bidding process revealed that there was widespread insider trading of a kind. An official in the Ministry was leaking information on the bidding to one company. That company was CHC, which was then the preferred bidder in the UK but which was ultimately removed from the process. Incredibly, almost at the same time, CHC was fortunate to find a home for its aircraft, having been awarded a ten-year contract in Irish SAR by the Irish Department of Transport for the Irish Coast Guard. With the rich financial pickings, not alone was CHC rewarded with a ten-year contract for the SAR service but it could extend that contract for up to a further three years, leading to an estimated cost of some €1 billion.

Now we come to the real nub of the problem: neither the Department of Transport nor the Irish Coast Guard has any aviation expertise. To overcome the deficit, what do they do? They contract in UK-based aviation SAR consultants. A number of examples will shock even those who are not already shocked. After the R116 tragedy, and after the draft final report was published, a review body was set up by the Department and a UK expert was appointed to it. Guess what: within a short period, that expert had to resign because of an identified conflict of interest. Who vetted his appointment?

Another example from after the R116 tragedy concerns where the Department of Transport awarded a tender to another UK-based company, Aerossurance, to advise on aviation compliance. It was a one-man operation that, when contracted by the Department, had a turnover in the previous year of £40,000 sterling and only one continuing contract. Most incredibly, after the R116 tragedy, the Department decided to recruit an aviation manager for the Irish Coast Guard. This competition had an application closing date of Thursday, 3 December 2020, one year ago. Guess what: the position remains unfilled to this day.

The pre-procurement process for the next ten-year SAR contract had been ongoing for some time. The Department contracted KPMG to produce a business case for the proposed contract. Astonishingly, KPMG had no suitable internal aviation expertise in this space. Therefore, what did it do? It contracted a UK-based company called Frazer-Nash to be its aviation adviser. Guess what: Frazer-Nash, at the time of the contract, was owned by an aviation company called Babcock, a likely bidder for the Irish upcoming ten-year contract. Did Frazer-Nash and KPMG recommend, in the business case, the Department of Transport and the Irish Coast Guard for the next SAR contract? Did they recommend that the Air Corps be excluded from any part of the helicopter element of the next SAR contract — even the east coast helicopter SAR service, which the Air Corps can easily deliver with State-owned assets and State-paid crews from Baldonnel? After all, why would Frazer-Nash and KPMG not make such a recommendation? I am referring to more gravy for the boys and girls in the UK-based aviation companies and to milking the Irish Exchequer with substandard equipment and outputs this past ten years. This is continuing. Awarding Irish SAR delivery solely to the UK-based clubby boys I have just referred to, the private operators, continues the gravy train for them and degrades sovereign Air Corps capability. The business case produced by KPMG and Frazer-Nash for the Department has not been published, for reasons that are entirely spurious and suspicious. In the public interest, it must be published before any formal tendering process for the next ten-year contract begins.

The Irish Coast Guard has recently come to further unwelcome attention in reports by the Comptroller and Auditor General and the Committee of Public Accounts. The real culprit is not the Coast Guard; it is the Department of Transport itself. First, it was revealed that the State paid €7.5 million in 2013 to retrofit the cockpits of CHC’s helicopters to make them night-vision-goggle compatible. In addition, the State bought night-vision goggles and ancillary night-vision equipment, along with providing a budget for the conversion and training of CHC pilots for night-vision operation. The training has not yet been completed; however, this all started back in 2013. To date, the training has not been completed.

In the AAIU report on R116, frequent reference is made to Captain Dara Fitzpatrick, her co-pilot, Captain Mark Duffy, and other pilots commenting on the poor state of cockpit lighting in the Sikorsky S-92 CHC helicopters. Who carried out the retrofitting of the Sikorsky S-92 cockpits paid for by the State? Could the retrofitting of the cockpits explain the poor lighting? Has this been examined? Is there a requirement for a switch in the cockpit that can turn night-vision capability on and off? Who certifies the equipment as operational?

Delivery of SAR in Ireland solely by private operators needs to end for sound operational reasons. An east coast SAR service and fixed-wing top cover must be provided by the sovereign Irish State Air Corps. We need to go back and rethink everything about the current process. It is deeply flawed.

On 14 March 2017, Dara Fitzpatrick, Mark Duffy, Ciarán Smith and Paul Ormsby went to work and never came home. While we are here talking about reports and 71 recommendations, which I will get to in a second, the families of those four people, who did nothing every single day of their working lives but try to keep us safe, are dealing with grief beyond imagination. They are the people who have to go to funerals and we are the people who have to browse reports and recommendations. Some of those families, as the House is well aware, do not even have graves to go to, yet today we will mince words about what we have and have not done, who was and was not responsible before 2017 and how great we are because of what we have done since. The recommendations, however, point to multiple major flaws in probably every aspect facing the search team that night. What is really difficult for the families is subsequently knowing there was not even a need for Rescue 116 to leave Dublin that night and head to Blackrock.

We knew from the interim reports what some of the 71 recommendations would be. We have a responsibility to the legacy of those people who lost their lives that day. We are all well aware, because of the mapping situation, that the four lives that were lost are not the only lives that were lost in these tragic circumstances because of the OSI maps. I have to read out some of the most incredible recommendations from the report. Regarding the aeronautical charts, "Euronav imagery did not extend as far as Black Rock". The report states that the OSI imagery available on the Toughbook did not show Blackrock lighthouse or any of the terrain surrounding it at all in the open water vicinity of where the crew were flying. Blackrock was not identified on their radar. Blackrock was not even in the EGPWS database. The Minister of State said the State's response is to make sure we have appropriate maps for the pilots and winch crews who go up every single day as part of our search and rescue teams and all aviation operators in this country. They do not want appropriate maps; they would love accurate maps. That would be a very good start. Given the trauma the staff who work in the OSI have suffered in recent years, it is an absolute disgrace that the IAA is not taking responsibility for its part in respect of the maps.

Oversight will centre my thoughts and my views on the IAA, the Coast Guard and, unfortunately, the Department. I take no pleasure in any of this, and most of it happened long before the Minister of State and the Minister, Deputy Eamon Ryan, ever even arrived in the Department.

The then Department of Transport, Tourism and Sport and the IRCG stated that neither of them had aviation expertise or search and rescue expertise, yet they are the Department and the regulator responsible for making sure that the activities of all our pilots are safe and monitored. I cannot think of anything more damning than to be told that the people who are responsible for making sure that our pilots are safe do not, did not then and still do not now have expertise in search and rescue and aviation regulation. As early as about a month ago, the Minister of State's colleague, the Minister, Deputy Eamon Ryan, received a letter asking for a working group to be established between the IAA, which said it did not even know it had responsibility for search and rescue when Rescue 116 crashed with the tragic loss of lives. As recently as a number of weeks ago, however, it was asked to set up a working group in order that it could share the information, or lack of expertise, between the sea, the Coast Guards, the operators - and whoever that will be after the next tender is irrelevant to me - and the Department of Transport. The Minister has not even acknowledged the letter, let alone taken seriously the deficit that still exists arising from the recommendations of the report issued last week.

Senator Craughwell is right that we have a real opportunity to respond to the legacy of the lives of the four people who lost their lives in March 2017 by looking at the aviation Bill currently going through the House. For the past 18 years, while the IAA has been in operation, we have had what I can only suggest to the Minister of State is light-touch regulation. The legislation in front of us will continue to do exactly the same on the basis that the regulator wants to be able to do what it needs to do to mend a relationship that has been fundamentally broken between the pilots in this country and the people recommending regulations for those pilots. Our pilots are crying out for more regulation, more transparency and more co-operation, and the Department and the IAA are saying, "No, thanks. We do not need that." If there is a lesson we need to learn from this fundamentally important report, while the families of these people are still grieving, it is that we can show them that we have taken the recommendations seriously by changing the legislation in the coming weeks and reinforcing in primary legislation the responsibilities, the transparency and the directions of the Department, which does not have the expertise to govern and regulate aviation. It needs the people who are supposed to have the expertise and the oversight for regulation, which is the IAA, to give it very clear directions in primary legislation to establish peer support groups and biannual forum reviews in order that we can share information, learn and make sure that mistakes never happen again and that there is transparency and audits. Our aviation companies are now regulated by this new regulator from a safety perspective. We must ensure that we have sharing and an even playing field in how they are audited, how crew fatigue is managed and how mental health issues are co-ordinated and addressed.

I am sorry. I have gone well over my time but I feel incredibly passionate about this. We have thousands of pilots and air crew who go up and take their lives in their hands to make sure we are safe when we go travelling on business or for holidays or pleasure. We cannot as a State even assure and give them the transparency they are crying out for in the regulation of their safety and, ultimately, ours.

The Minister of State is very welcome to the House. "These things we do that others may live." "That others may live" is the closing line in the para rescue creed. This creed has been adopted as a motto by many search and rescue organisations around the world. I wish to start my contribution on behalf of the Green Party - An Comhaontas Glas by commending all those in the Coast Guard and all services who risk their lives daily in order that others may live. We remember and commend the bravery of Captain Dara Fitzpatrick, Captain Mark Duffy, winchman Paul Ormsby and winchman Ciarán Smith, who tragically lost their lives off the Mayo coast on that fateful night in 2017. Their families and loved ones are foremost in our thoughts today, and I commend the Cathaoirleach on the way he opened these statements and the Minister of State's genuine, sensitive remarks. In my thoughts today are also the family and loved ones of Coast Guard volunteer Caitríona Lucas, who died tragically a number of months before her colleagues, in 2016, and Air Corps members Captain Dave O'Flaherty, Captain Michael Baker, Sergeant Paddy Mooney and Corporal Niall Byrne, who died on a similar rescue mission in 1999.

Air accident reports do not assign fault or blame. That is not the purpose of the process. They do provide a factual timeline of the event, critically analyse operating practices, highlight possible contributory factors to an accident and make recommendations for safer practices in the future. I commend our national broadcaster on the way it extrapolated and analysed this report and made it easy to follow and accessible for all. Many have such serious concerns about this issue. The AAIU report into the crash of Rescue 116 is deeply troubling and highlights a number of serious systemic failures by the State, the Coast Guard and the private helicopter operator. Reading this report and the reports into the 2016 and the 1999 accidents, I wonder whether we are learning the lessons of previous tragedies and whether the State is exhausting all its professional responsibilities and taking the matter with the 110% seriousness, the utmost seriousness, that it merits.

Ireland's search and rescue system is derived from the Government's adherence to a number of international conventions. These conventions impose obligations on the State to ensure that the necessary arrangements are in place for the rescue of person in distress. Thus, search and rescue is a recognised State responsibility. In all cases, the sole tasking agency for operational missions is a State agency and all operational missions are completed on behalf of the State. While the State has decided to outsource service provision to a private helicopter company, it cannot abdicate its responsibility to those in distress and the brave men and women who provide the service.

The AAIU report concludes that neither the Department of Transport nor the Irish Coast Guard had aviation expertise available and thus lacked the proper capacity to act as intelligent customers in respect of contracted private helicopter operations and auditing. The report also concludes that there was also confusion at State level with regard to responsibility for the oversight of search and rescue operations in Ireland. How is it possible that the State outsourced a vital life-saving service and lacked the ability to act as intelligent customer? The State has long-established aviation expertise in the Department of Defence and the Air Corps, but this was never availed of. Where the State already has an agency with this experience, why were personnel from Air Corps not seconded or transferred to the Irish Coast Guard to provide assistance? I wonder if the State would be better served in having the Irish Coast Guard functions moved to the Department of Defence and all State aviation services managed within one Department.

It would be a safer way forward. If that could be the outcome of this, it would give some comfort in terms of this awful tragedy.

The mission of Rescue 116 on that night was to provide top cover for another helicopter that had been tasked with airlifting a casualty from a fishing vessel. Traditionally, top cover missions have been provided by long range aeroplanes that have greater endurance than rescue helicopters. The role of top cover aircraft is critically dependent on it having significantly greater endurance than rescue helicopter. In the years running up to the loss of Rescue 116, the Air Corps was regularly unable to provide aeroplanes and the Irish Coast Guard and so the private operator decide to initiate a process whereby other helicopters would fulfil this role. The AAIU report clearly questions the efficiency of this approach. The question that must be asked is why the State allowed this approach to proceed. We must ask ourselves why the State allowed a situation to develop whereby the Air Corps was in such crisis it could not regularly provide aeroplanes to assist the Irish Coast Guard.

At the time of the accident, the Irish Coast Guard did not have a safety management system. There were also serious and important weaknesses with aspects of the private helicopter company's safety management system, including in regard to safety reporting, safety meetings and its safety database. How did the State allow this to go unchecked? How could the Irish Coast Guard, the Department of Transport and the Irish Aviation Authority have allowed this situation to arise and continue without correction?

Many questions arise on foot of this report. I can only conclude that the State has been planning, developing and regulating different State aviation services in silos. This must end now. We must do better. We need to learn in a tangible way from tragedies such as that we are discussing. We need a whole-of-government approach to the provision of State aviation services, with a clear regulatory framework. We owe it to our citizens, those who end up in distress and the dedicated responders in our rescue services to ensure that these services are planned, co-ordinated and tasked in a competent and effective manner and that oversight and regulation are robust and proactive. These things we do in order that others may live.

Earlier today, An Taoiseach addressed the Seanad and made reference to the Upper House being a place for independent commentary and constructive criticism, and being less partisan than the Lower House. I commend the Leader, Senator Doherty, on her comments despite being a affiliated to a party in government. Long may it continue that in the Seanad, we call things as they are. We take no pleasure in doing so. As stated by Senator Doherty, it is not a direct criticism of the Minister of State, Deputy Hildegarde Naughten. These are systemic failures that were there long before she took office. We are here to support her and her colleagues in trying to make things better. She can be assured of our support.

I thank Senator Martin for his comments. The next speaker is Senator Horkan, who is sharing time with Senator McGreehan. Is that agreed? Agreed.

I thank the Minister of State for her comprehensive, almost 20-minute, contribution. Senator Craughwell has a great deal of experience in the area of defence and the Air Corps, and in regard to this particular incident. At a meeting of the Joint Committee of Transport this morning, we spent a great deal of time discussing the Irish Coast Guard in general, as well as other issues. We barely touched on the issue of the R116, but it was mentioned.

I want to put on record my perspective and that of the Fianna Fáil Party regarding the tragic accident that claimed the lives of Captain Dara Fitzpatrick, Captain Mark Duffy, winchman Ciarán Smith and winch operator Paul Ormsby on 14 March 2017, at which time I was a new Senator in this House. These individuals were dedicated, all day every day of their working lives, to saving other people's lives. What happened was an enormously traumatic event not only for the nation, but for the four families, friends and work colleagues, their lives were changed forever by a needless accident that we are now, unfortunately, calling an organisational accident, as if it was a slip on the stairs. I do not mean that against the Minister of State. It is about much more than that. It is about real families. Dara Fitzpatrick grew up in Dublin. Her family live in Kilternan, where I went to pay my condolences to her father, whom I know. She was there on 17 March 2016, St. Patrick's Day. It was shocking to be there after the incident happened. It was all so needless. As a Parliament, we owe it to the families to ensure that something like this never happens again. More than anything else, that is what I want to get across today. There is no point in my repeating all that has been said by the Minister of State and Senators Craughwell, Doherty and Martin. We must make sure that every recommendation is implemented in a timely fashion. There is no point in my repeating exactly what happened and the 71 failures in terms of what happened.

As a State with have great expertise in aviation. An Irish person leads one of the world's largest low cost carriers, an Irish person leads IATA and an Irish person leading British Airways. Half of all the aircraft in the world that are leased are based out of this jurisdiction. How could this have happened? It was the most basic stuff that went wrong, such as structures not being identified on maps. We built lighthouses hundreds of years ago around the coast to let people know where there were rocks, but the crew of this mission did not know where this structure was. It was traumatising for all of us to learn of what happened at the time. Two of the families never even got closure in terms of getting their loved ones back, being able to bury them and having a grave to visit. That makes the situation even more difficult for those families.

As has been stated already, nobody is blaming the Minister of State. I hope she knows that. The report states that the actions of the crew were not a factor in the crash. It is important to highlight that there is no ambiguity there; it was not their fault. There were many people at fault in many different ways. It is a pity that R116 was called out because, as Senator Doherty stated, it really did not need to be there at all.

It is a pity they were called out when, as Senator Doherty said, they did not really need to be there at all. People can be called out and something happens but the fact is that the most basic objects that should have been on the map as a danger to aviation were not on those maps. I cannot comprehend that most basic of facts. Somebody implemented these systems and loaded them but did not check the detail of what was clearly known to everybody. Anybody who had been there knew of these physical features. It is a traumatic case.

From my perspective and that of my party, I know we will help the Minister of State. As a Member in a party of the Government, I will certainly help her in any way I can but it is not about me. It is about the Government, the Cabinet, the Department of Transport, the Irish Aviation Authority, the Coast Guard and everyone dealing with this in the most immediate and timely way. We must ensure that nobody flying at any stage is again in a position where he or she literally does not know exactly what is being flown into. That should never happen again.

The Minister of State is very welcome for what is an incredibly important debate. Not only is it about recognising the lives lost and grieving families but it is also important so the Government can listen and implement all the recommendations. We must listen to the expertise in this House as well, as Members have clearly highlighted and articulated some really valid points. We must create a legacy from this so it does not happen again.

I want to remember the individuals who died in this tragic accident. The crew members were Captain Dara Fitzpatrick, Captain Mark Duffy, Mr. Ciarán Smith and Mr. Paul Ormsby. These are not just names but they are part of families. One can think of all the love their families are missing because of this incredible tragedy. These people were dedicated to saving our lives and died in the course of a rescue. I live in north Louth and often see these helicopters flying over the Cooley mountains and Carlingford Lough. We can hear a constant hum of a helicopter over our house and we might think about who they are saving today. We never really think somebody would have to rescue them. It is important that we acknowledge the incredible grief that this loss has caused families. For two families in particular, the Smiths and Ormsbys, the grief is absolutely compounded because no bodies were recovered.

It is so infuriating to see the series of outrageous mistakes that occurred. I am no expert but I read the report. There was a series of human and system errors and they must not happen again. Blackrock island was not even on the map and it is huge. If a child was drawing a map of the area, it would put it in. It is absolutely shocking. The main conclusion of the investigation unit is that this was an "organisational accident", which is a really soft and nice term for something that was caused by major incompetence. It was a completely preventable tragedy, according to the Irish Air Line Pilots' Association, IALPA. It is really upsetting as the report indicates operator manuals were inconsistent with some areas and did not provide sufficient detail of processes or procedures for the discharge of some safety-critical functions. It is a really damning report. It may not draw conclusions on who was wrong or right but it is really damning. I am glad the Department of Transport fully accepts these findings and recommendations. None of this is any good unless there is action and we can accept what people are saying. Changes are needed and unless we ensure we can listen to practitioners and experts, we will passively fly into another tragedy.

The State and systems clearly let down people. We let down families and the system let down those same families. We must fix this and ensure the families of the people who go to work every day, putting their lives at risk, can feel their loved ones are safe doing their job. These people are protecting us and we must put in place systems to protect them.

I also welcome the Minister of State and thank her for her comprehensive reply. As a previous Senator said, the reply extended to 20 minutes. It will take some time to examine it, as noted by Members in the Lower House last night. There is much contained in that statement given by the Minister of State. I welcome it but we should also take some time to digest it before coming back to discuss the matter even further, given the seriousness of what is before us today.

The R116 accident of 14 March 2017 was, without doubt, an appalling tragedy. Unfortunately, it claimed the lives of four of our front-line emergency personnel, to whom we all owe a great debt of gratitude. I take the opportunity afforded to me today to extend my heartfelt sympathy to the families, loved ones and friends of the pilot, Captain Dara Fitpatrick; the co-pilot, Captain Mark Duffy; winch man Mr. Ciarán Smith; and winch operator, Mr. Paul Ormsby. It is also important to recognise and thank, as the Minister of State did, all those involved in the tremendous recovery effort in the days and weeks after the accident. It is vital we mention all those today, and as the Minister of State has said, many of them were friends of the people involved in the accident.

As noted by two of my colleagues and other Members, I sincerely hope the two families which have not received home their loved ones will eventually see them put in a resting place. I hope time will move quickly in allowing that to happen.

The report into the R116 crash in March 2017 was published earlier this month by the air accident investigation unit. As other Members said, I thank all those involved with compiling this important report for their time and efforts. The report includes detailed findings and 42 safety recommendations. I listened to statements in the Lower House last night and acknowledge the assertion from both the Minister of State today and the Minister for Transport last night that they totally accept the recommendations in the report. Of course, as indicated by a number of contributors last night, the Minister and Minister of State's acceptance of these recommendations is the right course of action. Even more important would be the announcement of the timeline for the implementation of these 42 recommendations.

I also acknowledge and will read into the record the response of the Irish Air Line Pilots' Association, given the importance of listening to those involved with the day-to-day operations of air travel in this country. I am sure the Minister of State agrees with that. IALPA is the representative body for professional pilots in Ireland, representing 1,200 pilot members. It states:

On 14 March, 2017, the crew of Rescue 116, 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. 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.

I will take this opportunity to bring up a discussion we had in May of this year when my colleague raised the matter of the operation of SAR in Ireland. The SAR contract must again begin to include, as other Members have said, the Air Corps and Defence Forces. There must be a whole-of-government needs analysis of Ireland's air services. Along with many experts in this area, we believe that synergies can be made by incorporating a sovereign element in the forthcoming SAR contract. In the early 2000s, this country began to include a civilian provider, in addition to the Defence Forces, in providing the SAR contract. The military involvement in SAR ended in 2003. We in the Labour Party feel the time has now come to incorporate and involve the Defence Forces once again in the provision of search and rescue in this country. This would provide obvious benefits to the Defence Forces in building up its competence and assets. It would also ensure that the State is not beholden to one private operator and any unforeseen events that could result from that. The Government must recognise that the forthcoming SAR contract provides this country with an ideal opportunity to begin this process, which is long overdue.

A number of experts have come to the same initial conclusion when reading the report into this tragic accident. The loss of the lives of these brave crew members was as needless as it was preventable. For the families and their memories, an accident like this must never happen again. I urge the Minister for Transport and the Minister of State to ensure the Government puts in traceability and audits that the 42 recommendations in the final report recommend. We must also ensure that any publicly-awarded contract for search and rescue has all the necessary public and Oireachtas oversights that should be in place. Today is a day to remember but it is also a day never to forget.

I welcome the Minister of State to the House. I offer my deepest sympathies and condolences to the families of Paul, Mark, Dara and Ciarán. They were brave citizens of our country who lost their lives in our service. They protected and saved lives. What a noble calling. Today at our committee, we heard that in this year alone, 121 lives have been saved by the Irish Coast Guard. Some 391 people were saved last year. In quarter 3 of this year, 1,089 incidents were responded to. The Coast Guard undertook 315 missions. The legacy we, as legislators, create for the crew of R116 must be the implementation of the recommendations contained in the final report of the Air Accident Investigation Unit. That is our duty. It is what we must do. In keeping with that, there must be a non-partisan debate around the whole role of the Coast Guard.

I have had the pleasure of meeting with men and women who serve. From my information, the crews of our Irish Coast Guard helicopters are the only emergency service workers who work 24-hour shifts, starting at 1 p.m. and finishing at the same time the following day. These are aviation professionals who work for 24 hours at a time. Shifts can regularly be extended for up to 30 hours. Coast Guard helicopter crews typically work three consecutive 24-hour shift periods over six days. That is 72 hours on duty. The IAA allowed that to be reduced to 51 hours and 45 minutes through a combination of half-time and quarter factoring, arbitrarily applying the duty hours between 9 p.m. and 7.30 a.m. That has led to fatigue in our air crews. In reality, if duty hours were properly accounted for, the crews would be far in excess of the 2,000 hour EU working limit under the working time directive.

We have heard from many different stakeholder representatives about the whole issue of crews and the concerns of IALPA, the International Air Transport Association, IATA, and whoever else. They are concerned about the safety of their members. The key word that has come back is "fatigue". What is the regulator doing about that? We have spoken in the course of this debate about the mapping system and the failure to identify the island. None of us, on behalf of the staff and crews, mentioned the hours they spend awake. That has been captured in the recommendations in the report we are debating. Recommendation 41 states:

The IAA should review the Operator's 24-hour SAR shift pattern to ensure that it adequately accounts for concerns arising from published research on human performance; and that the Operator's FRMS [fatigue risk management system] and SAR variation to Aeronautical Notice O.58 provide appropriate levels of safety and protection for crews.

We should look at the working time directive. We can have a debate about the Air Corps and the whole Coast Guard service level agreement another time. Tonight and today, it is about the men and women of R116, but it is also about the Coast Guard service. The overarching theme I took from our committee meeting today was about the protection of others and the saving of lives. We were Members of this House when the news came of the tragic death of those four Irishmen and Irishwomen. Their legacy and that of the Minister of State must be to ensure, insofar as we can, that we will never have to return to this debate. Senator Horkan was right in his remarks. It is not about a cold, calculated computer printout. These are human lives that were lost in saving other human lives. That is our duty.

I believe the Minister of State has the capacity to lead. She has done so thus far. I believe she is a compassionate and caring person who will drive change. We will work with her in that respect. Tonight and today, our debate is framed by the lives that have been tragically lost and the families who are grieving. They want us to act and I believe we will.

I welcome the Minister of State to the House. I join colleagues here and in the Lower House in expressing my deepest sympathies and those of Sinn Féin to the families, friends and colleagues of Captain Dara Fitzpatrick, Captain Mark Duffy, winchman Ciarán Smith and winch operator Paul Ormsby. The crew of Rescue 116 were fearless, selfless and dedicated to helping others in distress and in life-threatening circumstances. They were typical of the members and volunteers of the Irish Coast Guard and our emergency services. As we debate here today, our thoughts are with the families, friends and colleagues of those involved in the awful circumstances of that tragic mission.

I thank the members of the Air Accident Investigation Unit for their extensive report into the crash. The investigation was thorough, so too the report's recommendations. The Minister has accepted the recommendations and that is important. It is more important that the Minister presents a timeline for when each of those 42 safety recommendations will be fully addressed and implemented, and how those organisations referred to in the report will also implement those recommendations relating to them. The recommendations require urgent attention and speedy implementation if we are to avoid the risk of another tragedy. Part of the implementation plan should include the Department or the Minister appearing before the Oireachtas Joint Committee on Transport to give an update on the plan.

The report's findings raised questions for the State, its agencies and the operator. One of the findings is very alarming. It states that there was confusion at State level regarding the responsibility for oversight and rescue operations. The Minister needs to ensure that this key finding has resolved the issue of confusion and there is now no confusion regarding responsibility for oversight.

The report's comments about the aeronautical data, including maps, charts and imagery, available to the crew on that night are also striking. The Irish Air Line Pilots Association has said that the crew:

[...]relied on the data production standards of Irish regulation to guarantee them correct information. They were let down.

It is alarming, to say the least, that the report highlights documented concerns about absent aeronautical data some four years before the crash of R116 and that no action was taken to address these. I hope and expect that new and more effective procedures are now in place to pick up on issues and concerns as they arise and that they are rectified immediately. The report also highlights issues to do with the training of the crew and the comments of the family of Captain Dara Fitzpatrick reflect these concerns. The family has said the crew was not provided "with the safe operating procedures and training that they were entitled to expect."

This report provides the basis for ensuring that the correct lessons are learned and acted upon. It is not an opportunity to be missed. I know the Minister of State knows that. It is an opportunity to ensure that no other families will experience the heartbreak felt by the families of the crew of R116. I thank the Minister of State again for coming to the House this evening.

Cuirim fáilte roimh an Aire Stáit. Is lá brónach é sin do gach duine sa Teach seo. Is lá an-bhrónach é do na teaghlaigh freisin. I will take a few short moments to pay tribute to those people and their families. Once I saw this on the agenda last week, I wanted to do this because many people would expect me to. The Irish people have never forgotten this tragedy. When I go to towns like Castlerea and Ballaghaderreen in my own county, people still tell me they were out walking late that night and heard or saw that helicopter going overhead. That comment has been made to me on several occasions. I am sure it is a tragedy that the Fitzpatricks, the Duffys, the Smiths and the Ormsbys left behind will never come to terms with. There is never any closure for a family in situations like this. Nowadays, we often talk about people getting closure. As far as I am concerned, people do not get closure following tragedies such as this.

I welcome the Minister of State coming here and I welcome her statement. We now have the recommendations. Many Members have mentioned the many recommendations. I am not going to go through them again but, like others, I will say that it is really important that we implement all of them as quickly as possible. The Minister of State lives close enough to the sea in Galway. I visit areas by the sea quite a lot every year. She will know as well as I do that - by God - the Atlantic Ocean is vicious when it gets going. That is why we should have everything possible in place for those people. The shortcomings are there with regard to the rock itself and all of that. It really shows that, for an island country, we have not done enough to protect these people to the best of our ability. I hope that following this terrible tragedy and loss of life, we can rectify many of the existing issues and implement the recommendations as quickly as possible. Those people love their jobs. They are very committed and dedicated, as we all know. However, they work in very challenging environments a lot of the time.

I go walking by the sea in Galway and Mayo. I like going along on a windy day because it is great for clearing the mind but, when doing so, people may suddenly spot a rescue helicopter and find themselves all of a sudden thinking of those people going out into the choppy oceans, perhaps to try to save somebody from a boat or somebody who went too far from the coastline and got in trouble. It is only then that people really reflect on how challenging everything is for them. It is really important that we provide the best conditions and put in place everything necessary in respect of safety. I will finish with that. I hope that we can rectify a number of issues that need to be rectified without delay.

Again, my thoughts are very much with the four families. It is particularly tough for two of the families, although it is tough for them all. I was involved with a voluntary choir, the Roscommon Solstice Choir, and we did a remembrance concert for them, close to the part of the sea where it happened but, of course, inland. There were members of each family present. It was a sad evening but uplifting in another way because what we did meant an awful lot to those families. I came away inspired because, despite all their grief, those people were so thankful for the hand of friendship and the evening of remembrance. We think of them in a very special way.

I sincerely thank the Senators for their contributions this afternoon. We all share the common goal of seeking to prevent similar accidents occurring in the future. The provision of an effective maritime search and rescue service is critical to Ireland as an island national with a strong maritime sector. The sector depends on the reliability and professionalism of the Irish Coast Guard and all of its component parts, including the Coast Guard aviation service, and on its ability 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. Senators have clearly outlined that here this evening.

The national SAR plan is the key means by which we implement search and rescue policy in Ireland and the new national SAR plan is the baseline reference document for use by all search and rescue organisations in Ireland. It also 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 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 of the relevant bodies. Formalised meeting arrangements have also been established between the Coast Guard and the SAR aviation contractor to enable early identification of, and response to, safety issues, as highlighted. A safety interface arrangement has been agreed and this is overseen by a quarterly safety meeting.

The IAA has reviewed and fully accepts the recommendations addressed to it as the national aviation regulator. Many of these have already been implemented or are proceeding to full implementation. The IAA will be responding 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 SRD 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 continue to work with the European Commission and the European Union Aviation Safety Agency in the development of safety rules.

The Air Navigation and Transport Bill 2020 provides legislative underpinning for an even more enhanced role for the IAA in terms of oversight of Coast Guard aviation activities. The new provisions provide clarity and strengthen the regulatory framework by ensuring that 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 of 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 currently 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, operations and manual guidance to operate civil search and rescue helicopters in Ireland.

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 the military. The Coast Guard carries out regular audits of the aviation service provider to ensure compliance with 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 key safety issues. The Department and the 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 would 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 the suggestions offered by Members on how we can further improve search and rescue operations, and 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 Ireland can have a world-class rescue service. I thank the Senators for giving of their time.

I thank all Senators for their presence here today to discuss this report. I ask Members to be upstanding in memory of Captain Dara Fitzpatrick, Captain Mark Duffy, winchman Ciarán Smith and winch operator Paul Ormsby.

Members rose.

When is it proposed to sit again?

Next Tuesday, 23 November 2021, at 12 noon.

The Seanad adjourned at 5.04 p.m. until 12 noon on Tuesday, 23 November 2021.