Hildegarde Naughton (Galway West, Fine Gael) | Oireachtas source

I am grateful to the House for affording me this opportunity to make a statement on the final report of the Air Accident Investigation Unit, AAIU, on its investigation into the Rescue 116 accident.

The Minister for Transport and I spoke yesterday in the Dáil on this matter and it is fitting that this House should also be fully briefed and given the opportunity to respond. The R116 accident was a tragedy that claimed the lives of four crew who dedicated their lives to saving others. I again express my sympathies to the families and loved ones of pilot, Ms Dara Fitzpatrick, co-pilot Mr. Mark Duffy, winchman Ciarán Smith and winch operator Paul Ormsby. I recognise also the tremendous recovery effort in the days and weeks after the accident, often by people who knew them well, both professionals and volunteers. They deserve our deepest gratitude.

The Government acknowledges and appreciates the completion and publication of the AAIU report. The completion of the investigation and the publication of the report is a key step in ensuring that such accidents are prevented in the future. I commend the chief inspector of air accidents and his team for compiling such a comprehensive and detailed report. Search and rescue aviation operations will benefit greatly from its findings and the implementation of its safety recommendations both in Ireland and internationally.

The AAIU is an operationally independent unit within the Department of Transport and is responsible for the investigation of aircraft accidents, serious incidents, and incidents that occur within Ireland. The AAIU conducts investigations in accordance with global and European legislation and under the provisions of the 2009 Air Navigation (Notification and Investigation of Accidents, Serious Incidents and Incidents) Regulations of 2009.

The fundamental purpose of an AAIU investigation is to determine the circumstances and causes of air incidents and accidents, with a view to the preservation of life and the avoidance of similar occurrences in the future. It is not the purpose of such investigations to apportion blame or liability. The report of the investigation into the R116 accident is wide-ranging in scope, with findings and safety recommendations that cover all aspects of search and rescue aviation, both nationally and internationally.The main conclusion by the AAIU is that the accident was an organisational accident. Organisational accidents have multiple causes involving many people operating at different levels of their respective organisation. In total, there were 71 findings and 42 safety recommendations, of which ten findings and 14 safety recommendations are directly relevant to the Minister for Transport.

My Department fully accepts all recommendations from the AAIU report and I will ensure that recommendations addressed to the Minister are implemented. It is a large and complex report and deserves to be given due consideration and this my Department and I will do. It is proposed to formally respond to the chief inspector of air accidents in respect of each safety recommendation addressed to the Minister, in advance of the 90-day timeframe required under the relevant EU legislation governing the investigation and prevention of accidents and incidents in civil aviation.

The Department did not wait for the publication of the final report in order to implement changes on foot of lessons learned following the accident. Since March 2017, and specifically following receipt of the draft final report in September 2019, the Department and especially the Irish Coast Guard, have undertaken a significant programme of change across key areas to take account of issues raised and recommendations addressed to the Minister of Transport.

On foot of the interim report of the Air Accident Investigation Unit, the then Minister for Transport, Tourism and Sport commissioned an independent review of oversight arrangements for search and rescue aviation operations in Ireland. Following publication of the independent review, known as the AQE report, in September 2018, the then Minister committed to implementing its 12 recommendations.

The measures that have been taken fall under six broad categories: development of a new national search and rescue framework, the national search and rescue, SAR, plan; enhancing safety and oversight across the search and rescue system; addressing oversight of search and rescue aviation elements, nationally and internationally; review and revision of all relevant standard operating procedures and training for Coast Guard personnel, especially rescue co-ordination centre staff training, with a focus on aviation tasking - this includes the introduction of a formal course on tasking of aviation assets delivered by an IAA authorised training organisation, ATO; development of an externally accredited safety management system in the Coast Guard; review of governance arrangements in relation to the aviation contractor; and enhancing aviation expertise in critical areas and legislative reform of the Irish Aviation Authority, IAA.

A new search and rescue framework, the national search and rescue plan, NSP, which provides for more explicit governance, assurance and oversight roles across the SAR system was noted by the Government and published in July 2019. The key objectives of the NSP are as follows: to achieve a rebalancing of the previous maritime-centric SAR framework to encompass air and land SAR more comprehensively; to establish effective governance, oversight and assurance across the SAR system, to take account of national and international obligations; to achieve clarity on roles, inter-relationships and responsibilities from the strategic, through tactical to operational levels; to develop a common approach to managing SAR incidents across the three domains; to set priorities, objectives and performance expectations; to measure performance at system level; and provide a sound and clear basis for continuous improvement.

The national search and rescue plan sets out more explicit governance, assurance and oversight roles across the search and rescue system. The plan resets a more strategic-focused national search and rescue committee with a leaner, more coherent set of subcommittees, including a search and rescue consultative committee and regulators', health and safety and aviation forums. The plan also sets out a clear description of the national search and rescue system including roles, inter-relationships and responsibilities.

The national SAR committee, NSARC, set up under the national SAR plan is a strategic level committee with oversight of the national SAR plan as a whole and covers all three SAR domains: maritime, aeronautical and land based. Its membership includes senior managers from the three SAR co-ordinators, the Coast Guard, the IAA and An Garda Síochána and their respective Departments, as well as senior representatives from supporting Departments and agencies. It meets at least three times per year and has an independent external chair. The NSARC gives strategic direction to the SAR system and has both a forward-looking remit to ensure investments in SAR are strategically sound and a review remit to examine performance, disseminate best practice and learn from experience.

A second deliverable was an implementation plan for the recommended model for a joint rescue co-ordination centre, JRCC. This is a special type of rescue co-ordination centre that is operated by personnel from the maritime rescue co-ordination centre and the aviation rescue co-ordination centre. This virtual JRCC is intended to capitalise on the strengths of the current model, minimising disruption and exploiting opportunities for enhanced technology, closer co-operation and revised operating procedures, notably to address vulnerabilities identified in the existing model and provide for stronger oversight arrangements.

Significant progress has been made on the implementation of the new joint model. The Coast Guard and IAA have agreed a concept of operations and procedures manual, and this work has resulted in increased collaboration between the Irish Coast Guard, IRCG, and the aeronautical rescue co-ordination centre. Formal establishment is subject to the filling of newly established positions in the IRCG rescue co-ordination centre, following a Public Appointments Service process.

As an appendix to the national search and rescue plan, guidance is provided on the development of a common approach to managing search and rescue incidents across all three domains of land, maritime and aeronautical search and rescue, including the transition from search and rescue to search and recovery. This plan will be delivered on a phased basis to enable a managed and integrated approach to the development of the new search and rescue structures, along with the coherent development of memoranda of understanding and service level agreements between all relevant stakeholders.

Progress in delivering key aspects of the implementation plan has been good, with the majority of actions completed and the remainder on track for delivery in 2022. The actions include the first annual report of the national search and rescue committee on the national SAR plan, which was approved in July of last year. The second annual report will be presented shortly. The new or reformed structures envisaged by the national search and rescue plan are fully up and running. The national search and rescue committee meets at least three times per year. The national search and rescue consultative committee, which has a wide membership across all SAR providers, meets twice a year. A national SAR stakeholders forum takes place annually. The aviation forum meets on a quarterly basis.

One of the key innovations in the new NSP is the SAR assurance mechanism. This places an onus on all participants to provide annual assurance statements across key areas of performance and safety and risk management. Significant progress has been made on implementation of the new virtual joint rescue co-ordination centre. Clarity has been provided regarding roles and responsibilities and formal agreements are being finalised with all key stakeholders.

A mechanism has been formalised and tested for reviewing international SAR agreements. IRCG's standard operating procedures have undergone a major review and refresh. Key performance indicators for the national SAR plan have been developed by a dedicated key performance indicator, KPI, working group Development of a new SAR assets register is under way. A new aviation training programme for IRCG staff provided by an IAA-approved training provider is ongoing and the ninth such course is currently taking place. In addition to IRCG staff, course participants include aeronautical rescue co-ordination centre, ARCC, staff and members of An Garda Síochána from the Garda air support unit.

The provision of an effective maritime search and rescue service is critical to Ireland as an island nation with a strong maritime sector. The sector depends on the reliability and professionalism of the Irish Coast Guard and all its component parts, including the Coast Guard aviation service, to offer a service which can deploy at a moment's notice to rescue people in distress and bring them to a place of safety. As mentioned earlier, in light of safety recommendations, the Coast Guard is building on its safety management system, which encompasses all aspects of its operations. The safety management system will be externally accredited to ISO 45001.

A review and revision of all relevant standard operating procedures and training of Coast Guard personnel was completed and these are updated on foot of incident reviews under the Coast Guard's continuous improvement regime. Training for personnel involved in decisions to launch Coast Guard helicopters is being provided to the Coast Guard by an authorised training organisation approved by the Irish Aviation Authority.Eight such courses have been held so far, encompassing 70 staff, and are ongoing. In regard to implementing a safety management system to ISO 45001, the Coast Guard is undergoing pre-certification audit, which will be completed by quarter 1 of 2022.

The Coast Guard is also implementing a range of measures that represent a SAR assurance system. This includes updating and renewing its memorandums of understanding, MOUs, with SAR co-ordinators and SAR facility providers. The vast majority of these MOUs have been completed. Work is ongoing with the remaining support organisations with which the Coast Guard has links. The AAIU report found a lack of clarity concerning oversight of search and rescue aviation operations. As I mentioned previously, the NSP sets out more clearly the roles and responsibilities regarding oversight.

The SAR review report also describes the measures undertaken by the IAA as the national aviation regulator to address recommendations arising from the AQE review of search and rescue aviation oversight, which are clearly relevant to those aspects of the AAIU's report. The role of the IAA concerning search and rescue covers the aviation safety regulation and oversight of search and rescue operations performed by air, the operator and the aircraft, as well as oversight and operational responsibility for search and rescue aviation co-ordination centres and sub-centres. At the time of the R116 accident, as is the case today, the IAA exercised safety oversight of the search and rescue operator through its air operator certificate and a national search and rescue approval. The air operator certificate allows an operator to perform specific operations of commercial air transport. The national search and rescue approval provides for alleviation or exemptions that are necessary to operate outside the requirements used to conduct commercial air transport, without which some of the search and rescue operations would not be possible. There are safety cases for all exemptions and these are reviewed by the IAA yearly.

We continue to enhance the legislative framework for the regulation of Coast Guard aviation activities. The IAA has developed a revised set of regulations and detailed rules specific to search and rescue, which are being considered by the Department and the Coast Guard. I am out of time.