Catherine Connolly (Galway West, Independent) | Oireachtas source

Like all other speakers on this issue, I extend condolences to the families of the commander, Dara Fitzpatrick; her co-pilot, Captain Mark Duffy; the winch operator, Paul Ormsby; and the winchman, Ciarán Smith. We have to match our extension of condolences with holding the system to account. I only have three minutes to speak on this issue so it is difficult to deal with it thoroughly. I hope this is the start of a process through which we ensure that every single one of the 42 recommendations is implemented.

I am not convinced of that today. The investigation started immediately, within hours of the accident on the night of 14 March, and continued right up to when the report was published on 5 November. That, in itself, begs the question of what happened during that time. There was a preliminary report, four interim statements and a draft report.

I pay tribute to the authors of the report. It is a very well-written, clearly set out and factual report, and analysis, conclusions, findings and recommendations are provided. It is a model in terms of how it is set out. The mother and baby homes commission of investigation might wish to have a look at it.

When the draft report became available to the Department, I understand one of the parties involved exercised their right to have a review of that draft report. Perhaps the Minister of State can confirm that this party was not one of the State entities. When that entity exercised that privilege and right, the review board was set up. Six months later, the review board of two people had to be set aside because of a conflict of interest that suddenly became known six months after the event. That person had a conflict of interest and was associated with the company. Perhaps the Minister of State might explain how that happened, and what oversight was in place - or not in place - for that to occur. The review board was then set up with a senior counsel. That report became available this year. The families had to go through all of that, as well as a 44-day hearing in relation to that review board. That, in itself, needs looking at.

The final report has been published. It contains 42 recommendations, findings and conclusions, and sets out 12 contributory causes of the accident. It is important to state that the probable cause is set out in the paragraph preceding those detailing the 12 contributory causes in the report. The report states that the probable cause was the fact that:

The Helicopter was manoeuvring at 200 ft, 9 NM from the intended landing point, at night, in poor weather, while the Crew was unaware that a 282 ft obstacle was on the flight path to the initial route waypoint of one of the Operator’s pre-programmed FMS routes.

In relation to that, what jumps out at me is the comment of the psychologist, who is quoted on page 190 of the report. Writing of the care that must be taken when describing safety systems, the psychologist states:

The use of silly and meaningless safety language matters, it creates a distraction and delusion that safety and risk are being addressed. We may feel good about speaking such words but they dumb down culture and distract people from taking safety seriously.

If we learn anything, we should learn from those words. What have we learned from all of the reports that we have been given, on top of the accident, already referred to, that happened in Waterford 18 years before this accident? How many reports have been produced?

Let us look at the illusion of safety and oversight. The report details the 12 contributory causes, but I do not have time to read them out. One of the contributory causes was the fact that: "There was confusion at the State level regarding responsibility for oversight of SAR operations in Ireland." The report also states:

There were serious and important weaknesses with aspects of the Operator’s SMS including in relation to safety reporting, safety meetings, its safety database SQID and the management of FMS Route Guide such that certain risks that could have been mitigated were not.

These are basic matters.

On the Irish Coast Guard, the report states:

Neither DTTAS nor the IRCG had aviation expertise available within their own personnel resources, and lacked the capacity to remain an "intelligent customer" in relation to contracted helicopter operations or auditing.

The IRCG relied on an external contractor to conduct annual audits of the Operator’s bases.

The report goes on to state that when audits took place:

The IRCG appears not to have appreciated the severity of some of the matters the Auditor raised and it appears that the Auditor’s reports and supporting evidence were not scrutinised by the IRCG.

The IRCG did not have a Safety Management System, and IRCG management completed their first aviation SMS training in October 2018.

The report goes on to discuss the IAA. Time precludes me from going into more detail and the Ceann Comhairle has allowed me some discretion.

I have read the 350-page report. I have had four or five minutes to deal with the issue. It is not the way to deal with such a report if we are seriously interested in learning how to hold the system to account.

I totally agree with Deputy Smith in relation to the privatisation of the service. If we learn anything, that is the most fundamental lesson we should learn here. We need an explanation as to how, when the business case was assessed for renewing the contract, it was found that it would not be valuable economically to have the Air Corps involved. Further, in my opinion, there was a conflict of interest in relation to company used for that business case.

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