Darren O'Rourke (Meath East, Sinn Fein) | Oireachtas source

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.

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