A PLANE crash at Cork Airport in which six people died was caused by a disastrous loss of control during an attempted 'go-around' by the aircraft in heavy fog.
Poor decisions by the air crew of the Manx2.com flight, combined with a lack of oversight by Spain's aviation regulator of the Spanish airline operators, have been highlighted as factors in the tragedy.
Six people died and six survived, four with severe injuries, when the US-built Fairchild turboprop crashed and caught fire while attempting to land at Cork Airport on February 10, 2011.
The Department of Transport's Air Accident Investigation Unit (AAIU) published its hard-hitting 240-page report into the tragedy just two weeks before the third anniversary.
The UK solicitors representing seven of the survivors and victims warned that it was "a preventable accident ... where lives were needlessly lost."
The report was remarkable in that it also cited Spain's aviation regulator. It emerged that the Spanish regulator was not aware that the operator was using that specific aircraft on Irish passenger services.
The AAIU found "systemic deficiencies at the operational, organisational and regulatory levels", in relation to pilot training, scheduling of flight crews, maintenance and inadequate oversight of the operation by both the operator and the state of registration (Spain).
It ruled that the pilot was ill prepared for the very challenging conditions he found himself facing and his co-pilot hadn't even finished his training.
The AAIU cited nine major accident factors, including crew fatigue; attempting an approach in poor visibility; a power level set at a prohibited level; a power differential between the two engines; and inappropriate flight crew pairing.
Crucially, the flight crew had been informed that there were no visibility problems at Kerry Airport but opted not to divert.
The AAIU also issued 11 separate safety recommendations. These involve recommendations for the European Commission, European Aviation Safety Agency, the operator, Flightlin, the Spanish Civil Aviation Authority and the International Civil Agency Organisation.
Manx2.com, which is in liquidation since December 2012, welcomed the AAIU findings.
"The devastating impact of the tragic accident at Cork three years ago is not something that the passing of time has diminished and the thoughts and sympathies of all those involved are first and foremost with the families of those who lost their lives and those who were injured," the firm said.
"Unfortunately, the report is clear that the prime causes of the accident were decisions made by the Flightline crew in adverse weather conditions, compounded by inappropriate crew rostering by the operator and a significant lack of oversight by the Spanish air safety authority."
The aircraft involved, a US-built Fairchild/Swearingen Metroliner, has a good safety record but has been involved in 14 major accidents since 1980.
Compensation claims will now be dealt with in the Republic. Legal actions have been signalled against the aircraft's owners and leasing agents but not against Manx2, the airline which scheduled the flight.
The six dead were Brendan McAleese, a cousin of President Mary McAleese's husband, Martin; Pat Cullinan, a partner in KPMG's Belfast office; Michael Evans, Belfast Deputy Harbour Commissioner; pilot Jordi Sola Lopez; co-pilot Andrew Cantle from England; and businessman Richard Noble from Belfast. The six passengers who survived were Heather Elliot, Peter Cowley, Brendan Mallon, Mark Dickens, Donal Walsh and Laurence Wilson.
Solicitor for seven of the families, James Healy-Pratt, praised the AAIU report. He said: "The families are very thankful. It is now critical that the 11 safety recommendations are followed up and delivered on.
"The pilots ran three red stop lights in poor weather with tragic results. Lives were needlessly lost and others seriously injured in what was a preventable accident." The Irish Airline Pilots Association (IALPA) demanded immediate action on the safety recommendations.