Report into death of Caitríona Lucas finds no evidence of ‘effective management’

A draft report into the death of Doolin search and rescue volunteer Caitríona Lucas off the Clare coast almost two years ago has found the Irish Coast Guard did not have “an effective safety management system”.

The draft Marine Casualty Investigation Board (MCIB) report, which has been seen by The Irish Times, has also found there was no evidence of any effective management in place at Kilkee coast guard station from where she set out on the ill-fated search and rescue mission in September 2016. The Delta RIB she was on which capsized was used outside of the Irish Coast Guard's own operational limits, and there were "critical deficiencies" with the boat's communication and navigation equipment, the draft report states.

It also notes that there was a similar incident involving an Irish Coast Guard rigid inflatable boat (RIB) capsizing also in a "surf zone" off Dingle, Co Kerry in 2014. While there was no loss of life in the Dingle incident, a series of 20 recommendations relating to safety and procedures were not "fully implemented" by the Irish Coast Guard in the intervening two years, according to the draft.

A 41-year-old mother of two from Liscannor, Co Clare, Ms Lucas died on September 12th, 2016, when the Kilkee RIB she was crewing on capsized on its return from a search for a missing man.

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The Delta RIB had entered a small shallow cove – a potential “surf zone” which posed hazards, similar to the Dingle incident – and was 20m from the shoreline when it was hit by a large breaking wave.

Transmission difficulties

All three crew Irish Coast Guard volunteers were thrown overboard, lost their helmets, lifejackets were not inflated, and the Mayday was issued through the only working radio – a personal VHF radio owned by the deputy coxswain but this was not picked up by Valentia due to transmission difficulties involving hand-held devices.

Both the coxswain and deputy were rescued.

The draft report describes how Ms Lucas held onto the RIB, as she was trained to do, but was repeatedly washed off by waves, and after three minutes she lost her grip. A postmortem confirmed she had sustained a head injury.

The Irish Times has learned that Ms Lucas was not expecting to go to sea on the date in question but to help onshore with the search. The Kilkee unit had lost a number of qualified coxswains in preceding months due to “management issues”, the draft report says.

The Irish Coast Guard says it cannot comment on operational and safety systems while two investigations by the MCIB and Health and Safety Authority are continuing. It has employed a health and safety officer to manage oversight of safety management systems for volunteers.