Dáil debates

Wednesday, 17 November 2021

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

 

6:22 pm

Photo of Catherine MurphyCatherine Murphy (Kildare North, Social Democrats) | Oireachtas source

I join other Members of the House in expressing sympathies to the families of Captain Dara Fitzpatrick, Captain Mark Duffy, winch operator Paul Ormsby and winchman Ciarán Smith. The accident involving helicopter R116 was, for many reasons, an entirely preventable tragedy. In 2013, the mapping of the terrain of Black Rock Island was notified as an omitted hazard on the EGPWS in 2013 by a pilot, as has already been said. The information was circulated to the manufacturer of the system and to CHC Ireland, but no action arose from the communication. There was no proactive follow-up; it was a closed case in 2015. The lands and the lighthouse remained a blind threat. This is a tragedy that has been lodged not only in the minds of the families who have been so directly impacted by it, but also in the minds of the public. The loss of lives that occurred in this way resonated deeply with people on that day and still does today. In the days and weeks following the crash, the maritime community from all corners of the island travelled to north Mayo to assist with the search and rescue, and to stand and acknowledge in person the event that had unfolded.

It is difficult to address such a sizable report in six and a half minutes. While the AAIU report was constructed so as not to apportion blame or apply liability on anybody or any failings detailed, we can draw some conclusions. A passage in the analysis summary of the report makes stark reading. It illustrates that working in the most perilous of environments was further compounded by the fact that "The cockpit operating environment appears to have been sub-optimal regarding the combination of cockpit lighting and coloured documents, the size of font used in some documents, the tabulation of a large amount of numerically dense information" and further factors listed in the report.

The flight crew of the search and rescue aircraft, R116, which was primarily east coast oriented, were dispatched to the very different environment of the west coast of Ireland. There was inadequate equipment and inadequate training. The crew were fully vindicated in the report.

I will raise some aspects of the State's role in the context of the Air Navigation and Transport Bill 2020 and the loss of the crew of R116. These matters have been drawn to my attention by IALPA. The mapping and navigation data the crew were relying on failed them. It was during the course of the final flight of R116 that systemic shortcomings and regulatory failure met to create the circumstances in which the crew found themselves in the early hours of the morning of 14 March 2017. It was described as an organisational accident. To me, that is an accident that should not have happened.

The IAA produced the State's plan. SAR operations are excluded from the regulatory framework for civil aviation and are thus outside the remit of the authority. This needs to change, if it has not already. The authority is calling for a number of amendments to be made to the legislation that is going through the Seanad at the moment. That is one of its calls. The State needs to take full responsibility for this matter and needs to ensure that there are no gaps in oversight.

There are three critical findings in the AAIU report. Black Rock Island was not on the EGPWS database, the aeronautical chart did not extend as far as Black Rock Island and the OSI imagery available on the Toughbook did not display Black Rock Island. The ICAO sets out Ireland's obligations as a contracted state when it comes to implementing the most accurate mapping information standards available.

On pages 328 and 329 of the AAIU report, it is stated that:

50. From the IAA’s Annual Safety Reviews and Aeronautical Notice it appeared that the IAA was responsible for, and carrying out, oversight of SAR helicopter operations in Ireland, but after the accident the IAA questioned whether it had the necessary mandate.

51. The IAA asserted that it was subject to oversight by the ... [Department], but [the Department] informed the Investigation that it did not have specialist aviation expertise within the Department to discharge such oversight.

These are really damning admissions that need to be addressed in legislation. I know a review is to be done but are there things that can be done immediately by way of amendments to that legislation?

At a meeting of the Committee of Public Accounts last week, we were told that a tender was being prepared for the contract currently held by the existing contractor and is likely to be issued in December. I am of the view that the State should run this service directly. Failing that, the tender must take full account of the AAIU's findings. We owe that to the crew and their families, who have been failed so badly, and we owe it to those who put their lives at risk every time they go out to do this very dangerous job. The State must have their back. I agree with the Minister that we cannot turn back the clock. We must do everything we can to prevent accidents such as this occurring but there will come a day when there must be accountability for this accident. Without accountability, behaviour will not change. This report outlines absolutely unbelievable shortcomings. I would like to hear when they occurred. It is not just a question of rectification. There must be accountability.

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