Errors in mapping and navigation aids ‘contributed significantly’ to tragedy
Accident would never have happened ‘in normal circumstances’, says coroner
Families of the deceased thank those who helped in rescue search
THE jury in the inquest into the Irish Coast Guard R116 helicopter crash, which resulted in the deaths of four crew members – the pilot Captain Dara Fitzpatrick, co-pilot Captain Mark Duffy, and winchmen Paul Ormsby and Ciaran Smith – have returned a verdict of accidental death.
The jury foreman became emotional as he read aloud their findings and recommendations.
He told the bereaved families the respect and sense of responsibility felt by the jury towards frontline rescue service professionals, their families and to those lost in service “cannot be overstated.”
The jury found all four crew members died accidentally following a helicopter crash into the sea on March 14, 2017, in Blacksod Bay, Co Mayo.
In a series of recommendations, the jury foreman called for there to be “definitive medical criteria informing any decision to dispatch an emergency helicopter.”
They added: “There should be no ambiguity as to who the decision-maker is.
“There should be reliable top cover available at all times ideally not using another SARs aircraft.
“Based on clear evidence, errors in mapping and navigation aids contributed significantly to this accident.
“There needs to be cohesive oversight in relation to the various bodies and agencies who bear collective responsibility for the provision of these services.”
“In making this statement, we wish to acknowledge the painstaking work undertaken by An Garda Síochána, the Air Accident Investigation Unit, the judicial and the many other agencies.
“We further wish to acknowledge the strength of those individuals who gave evidence and to the families and friends of the victims who have, for these past five years, been forced to relieve these harrowing experiences for the purposes of seeking the truth of these events.
“The burden of responsibility we collectively feel as a jury towards those who continue to operate on the front line of the rescue services, their families and to those lost in service cannot be overstated.
“We wish to take this opportunity to acknowledge the heroic efforts of the rescue services in the protection of the public on a daily basis.
“We offer our sincere sympathies to the family and loved ones of Dara Fitzpatrick, Mark Duffy, Paul Ormsby and Ciaran Smyth.
“Ar dheis Dé go raibh a h-anam dilís.”
Coroner Dr Eleanor Fitzgerald thanked the jury for their service and diligence in deciding their verdict.
“This tragic accident and the loss of four people occurred from a multiplicity of factors and in normal conditions, this accident would not have happened,” she said.
“But in their line of duty, is there such a thing as normal? In undertaking search-and-rescue missions there is always some risk involved.
“However, in this particular tragedy there were a few contributing factors.”
Dr Fitzgerald described the conditions the crew of R116 had to fly in that night as “treacherous”.
“I most certainly feel that should not be taken lightly ever, ever again.
“I convey my deepest sympathies to the bereaved families who have to live with this tragedy.”
Speaking on behalf of Ciaran Smith’s widow Martina, their children Caitlin, Shannon and Finlay, his parents Michael and Theresa and his brother and sister, barrister Derek Ryan thanked the coroner, the jury and An Garda Síochána for their work and efforts.
“A very difficult matter has been dealt with efficiently and very sensitively by everyone involved and for that, thank you,” said Mr Ryan.
He also thanked all the witnesses who gave “sometimes very difficult statements to this coroners court”.
“Ciaran’s family wish to thank all those involved in the original searches back in 2017, An Garda Síochána, the RNLI, the Coast Guard, Ciaran’s friends and colleagues, the military services, local boat owners and local fisherman.”
Mr Ryan also extended the Smith family’s thanks to the local people of the Belmullet area “who extended such kindness to Ciaran’s family at a very difficult time”.
John Fitzpatrick, the father of Capt Dara Fitzpatrick, echoed the comments of the Smith family.
Addressing the coroner and jury directly, he said: On behalf of the Fitzpatrick family I concur with everything said by Derek Ryan and the other representatives.”
In her summation of the evidence and guidance to the jury, North Mayo coroner Dr Eleanor Fitzgerald said a finding of accidental death would be akin to a straightforward drowning.
While a finding of death by misadventure was akin to a person swimming while intoxicated and then drowning.
The inquest heard harrowing evidence of R116’s final moments as the crew realised they were within 12 seconds of impacting Blackrock island.
All those on board the Rescue 116 helicopter lost their lives when the aircraft crashed into Blackrock Island at 00.46 on March 14, 2017, off the Mayo coast.
In the immediate aftermath of the tragedy, the body of Captain Fitzpatrick was recovered from the sea, and 12 days later, the remains of Captain Duffy were recovered from the cockpit of the submerged wreckage.
However, the bodies of Mr Ormsby and Mr Smith were never recovered, and their deaths have been recorded as lost at sea.
The inquest heard from 23 witnesses, including the chief air accident investigator who found the tragedy occurred due to a myriad of both operation and human factors.
During the deliberations, the jury sought clarification from the Air Accident Report Investigator Paul Farrell about the conclusions and safety recommendations he found.
Last November, a 350-page Air Accident Investigation Unit (AAIU) report into the tragedy laid out the chain of events that led to the accident.
The report found several issues relating to the navigational aids used by the crew on the night of the accident.
The inquest also heard there were also human factors such as crew fatigue and poor lighting in the cockpit as potential issues which led to the tragedy.
The AAIU made a total of 42 safety recommendations. Nineteen of those were addressed to CHC Ireland; the company contracted to operate air search and rescue (SAR) operations in Ireland.
These included suggestions to carry out a review of navigation aids, enhanced crew training and improved monitoring of missions and decision making.
Other recommendations were made concerning the Department of Transport’s oversight of SAR and Coast Guard operations. The Aviation Authority and the European Commission also advised to take action on foot of the report.
One finding to emerge from the investigation was that R116’s initial intention was to refuel in Sligo rather than Blacksod due to concerns by Capt Fitzpatrick about weather conditions.
However, during the flight from their base in Dublin, Capt Fitzpatrick was assured by her colleagues in R118 that weather conditions in Blacksod were fine, and the aircraft switched course.
The first witness called in person was Mr Ian Scott, the station officer at Malin Head Coast Guard station.
Mr Scott defended his decision to task R116 to provide top cover to R118 during a rescue of a fisherman who had amputated his thumb above the knuckle on a trawler 140 nautical miles off the west coast.
Top cover is where a second aircraft attends an incident at least 100 miles off the coast, observing the rescue operation and assisting if required.
The second aircraft also assists with communications between the vessel, rescue aircraft and the dispatcher.
Questions arose as to whether a medical evacuation by R118 of the injured fisherman was required in the first place.
Departing from his witness statement, Mr Scott offered his condolences to the bereaved families.
He said he had 42 years of experience and felt the thumb injury received by the fisherman on the trawler was life-threatening as he heard the words “bleeding out”, “blood spurting”, “severe pain”, and “amputation”.
“It is my opinion that man needed off that vessel,” he said.
“I would make the same decision now. I have to make decisions on the information I have.”
Coroner Dr Fitzgerald asked Mr Scott if he believed the injury to the fisherman, who caught his thumb while hauling in a fishing net, was “life and death”.
“It could well have been,” he replied.
Dr Fitzgerald asked if he still believed it was the right decision to evacuate the casualty “even in the middle of the night”.
Mr Scott said the person was bleeding and “If I had left him, he could have died”.
He added that before he tasked R116 to provide top cover, he initially tried the Air Corp and a British Nimrod fixed-wing maritime patrol aircraft, but neither were available.
Mr Scott said he was taken aback to hear subsequently that a doctor whom he consulted with on the night had said in a statement she did not recommend a medical evacuation of the casualty.
“At no time was I told she disagreed with that decision,” Mr Scott said
In her evidence, Dr Mai Nguyen, who was then an emergency department registrar in Cork University Hospital, said when she spoke to Mr Scott, the rescue helicopter had already been dispatched.
Dr Nguyen said from her memory of the incident, she felt the dispatch of the Sligo-based R118 Coast Guard helicopter “was probably an excessive thing” but that it was not her call.
“I was a first-year resident, I did not have the power to stop a helicopter making that journey,” she said.
“I personally felt the injury was minor in nature and wouldn’t have sent the Coast Guard out there because the thumb couldn’t have been saved.”
She told the inquest she provided medical advice on how to treat the injured fisherman but also said that given how far the vessel was out to sea, she did not think the thumb could be saved.
The AAIU report into the crash found that procedures governing the dispatching of a Coast Guard helicopter were not conducted in sequence.
Mr Scott detailed extensive efforts to contact R116 after he was informed by the lighthouse keeper at Blacksod lighthouse, Vincent Sweeney, that the helicopter did not arrive as scheduled to refuel.
Mr Scott said he was very alarmed to hear at 1.06am on March 14, R116 was missing and uncontactable.
The coroner heard both Mr Scott and Mr Sweeney made extensive efforts to make contact with the helicopter via radio and a satellite phone.
Mr Sweeney, the lighthouse keeper, told Dr Fitzgerald he was on duty having been alerted to the injured fisherman at 9.55 pm on March 13, 2017.
He told the inquest that R118 first arrived to refuel and he was informed R116 would follow later in the night.
Mr Sweeney said at 00.26, he spoke with R116 and understood they would be landing shortly.
It was previously established that R116 disappeared from radar at 00.46am.
Mr Sweeney said he went outside to wait for the helicopter but was unable to see or hear it approaching.
“The longer this went on, the more concerned I became,” he said.
Mr Sweeney also told the inquest that visibility deteriorated rapidly and what was initially “a mist” developed into “a deadly fog”.
“It happened in a matter of minutes,” he said.
Vincent Sweeney estimated visibility at 400-500ft earlier in the night on the night but minutes before R116 was due to land to refuel, visibility “dropped fast”, to the point that “you’d hardly see your arm in front of you”.