Sorca Clarke (Longford-Westmeath, Sinn Fein) | Oireachtas source

I welcome the opportunity to speak on the publication of this final report but I do so with a heavy heart and a deep sense of sadness, which was echoed by other Deputies. I place on record my sincere condolences to the families, loved ones and friends of Captain Mark Duffy, Captain Dara Fitzpatrick, winch operator Paul Ormsby and winchman Ciarán Smith, the four members of R116 who lost their lives on that tragic night in Black Rock almost five years ago while providing top cover. I acknowledge the work done by all those in the investigation for producing what must be, if not the most comprehensive air accident report ever, certainly one of them.

The report, published by the air accident investigation unit, has laid bare many unacceptable shortcomings in its 350 pages, including 42 safety recommendations. While I acknowledge and welcome the Minister's contribution fully accepting its recommendations and committing to evaluate the findings in the coming weeks, that simply does not go far enough. He must also commit to ensuring the recommendations will be implemented fully and within a timeline that reflects the urgency communicated in the report. Given the nature of the incident and the report, I call on him also to provide regular updates to the House on the progress made. Vital lessons must be learned from what occurred to ensure all crews will be able to work safely and have confidence that sufficient provisions to protect them are in place.

There must also be accountability for this tragic loss of life. When IALPA commented on the report, it said it was preventable and must result in regulatory and systemic change in order that those on whom we most rely when we are in perilous danger will never be placed in a similar position again. The association went on to state it had been let down by a regulatory system that left its crews ill equipped to carry out the vital work that same system had tasked them with, and I fully agree with that statement. The report found that the probable cause of the crash was a combination of factors, including altitude, poor weather and the crew being unaware of a 282 ft obstacle on the flight path towards a pre-programmed route it was using.

Each of those conclusions should strike fear into the heart of anybody with a responsibility for search and rescue operation, but that a rescue helicopter crew was not aware of an obstacle of that size is almost beyond belief. How, in this day and age, with the technology advancements that are at our fingertips, can this happen and why?

How and why was Black Rock Island not identified as an obstacle on the flight management system? How and why were there so many anomalies on that route, some of which had gone uncorrected for years? In addition, how and why did the maps accessible to the crew not extend as far as Blackrock Island or appear to show open water in the vicinity of the island?

I wish to highlight two of the other 12 contributory causes of the accident, namely, that "There were serious and important weaknesses" in how the helicopter operator managed route testing and risk mitigation and that "There was confusion at the State level regarding [...] oversight of SAR operations in Ireland". That is just not acceptable and cannot be allowed to continue in any scenario. The inquiry's final report has concluded that there is a lack of clarity regarding the role of the Irish Aviation Authority in respect of the regulation of search and rescue flights. Despite how the operations "were classified as a ’State’ activity and were to be regulated by the National Aviation Authority, the IAA subsequently expressed uncertainty about its mandate to regulate SAR". Again, that is absolutely unacceptable.

Furthermore, the report stated that the Department "lacked the technical expertise to oversee the IAA". If the Minister's Department does not have this expertise, then what organisation does? In reality, it is the Department which should be in charge of this area. The last audible comment recorded was Captain Duffy saying "We're gone". None of us can imagine the grief that the loved ones of that crew have lived with daily since that tragic night. This report cannot be allowed to wither on the vine. This should not have happened and it cannot be allowed to happen again.

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