Mr. Alan Brereton:

I will start and then hand over to Mr. Cullen. The Rescue 116 report highlighted that it was an organisational accident. It was not a matter of a singular event occurring in the flight deck on that particular night. It highlighted that there was a series of issues in the Department of Transport, the IAA and the operator that culminated in the accident that took the lives of those four brave crew members. That was the point. In aviation, we talk about the Swiss cheese model where a number of holes line up to create a gap in the so-called "safety margin", and this is exactly what happened. We have a series of events, say, within the operator, where a number of issues were raised with the authority. They were not acted upon.

That then led those pilots to be in the situation they were in that night with inaccurate maps, inaccurate databases and faulty safety equipment. If we had a proactive effective regulator, as we see in other countries in Europe, one of those issues could have been stopped or trapped, which could have prevented that accident. That is the point that the Rescue 116 report highlighted.