When Caitríona Lucas responded to a request on September 12th, 2016 to help find a young man missing off the north Clare coastline, she wasn’t aware that she would be going to sea.
The 41-year-old librarian, mother of two and highly experienced volunteer with the Irish Coast Guard's Doolin unit, anticipated she would be walking the shoreline with fellow volunteers from Kilkee who had sought additional back-up. This tends to be the norm when neighbouring units help each other out.
Little did she expect that it would be her last call-out, due to the lack of effective safety and people management systems within the Irish Coast Guard and, in particular, a failure to implement fully recommendations made after a very similar incident in Dingle, Co Kerry, two years earlier.
A draft of the official investigation into Ms Lucas's death by the Marine Casualty Investigation Board (MCIB), which has been seen by The Irish Times, highlights a number of serious issues, including the absence of a safety systems manager which was recommended in a value-for-money review in April, 2012. A health and safety officer has been appointed since the draft report's completion.
With 10 years of experience under her belt, Caitríona Lucas was one of the most respected and competent volunteers with the Irish Coast Guard in Co Clare. The Doolin unit – with which her husband, Bernard, also serves – has been headed latterly by Mattie Shannon who retired recently after 30 years of service. It has earned a reputation as one of the top Irish Coast Guard teams of its type, due to the diverse and challenging range of call-outs it had responded to for vessels at sea, climbers and walkers in difficulty on nearby sea cliffs, or people reported missing off the Cliffs of Moher.
Caitríona Lucas’s experience was backed up by a range of qualifications from coxswain and navigation to climbing, first aid and emergency response, along with suicide-prevention training. She was also national secretary and active member of the Search and Rescue Dog Association.
School inspector David McMahon from Lissycasey had been missing for the best part of a week when Ms Lucas travelled to Kilkee to help out, believing she would be walking the high cliffs and scanning the shoreline. Both the Civil Defence and Kilkee Coast Guard had been tasked to assist by the Irish Coast Guard maritime rescue sub-centre at Valentia.
However, Kilkee Coast Guard was having difficulties in mustering volunteers due to internal tensions dating back to its reconstitution in 2013, when a 30-year-old community marine rescue service founded by Manuel di Lucia was taken over by the Irish Coast Guard. The community had initially favoured the takeover as it was finding it difficult to raise funds, but the transition did not run smoothly.
As Independent Clare TD Michael Harty told the Dáil on February 15th, 2018, many volunteers with experience and local knowledge were not accepted on the new rota, a plaque commemorating the activities of the former community service was removed, and the number of people involved at Kilkee dropped from 26 to 12. This loss of valuable experience included qualified coxswains.
The Irish Coast Guard had appointed an experienced member of the Doolin Coast Guard unit, Martony Vaughan, as officer-in-charge (OIC) at Kilkee in 2013, initially for six months. It was felt that a skilled outsider could best deal with any issues arising during the transition. His style is reflected in an email to all members of the Kilkee unit, seen by this newspaper, dated January 29th, 2016.
It concludes in capital letters: “THIS UNIT IS A TEAM EFFORT NOT ATTENDING TRAINING AND PUTTING IN THE BARE MINIMUM IS UNACCEPTABLE AND WILL NOT BE TOLERATED FROM NOW ON. THIS IS NOT A SOCIAL CLUB.”
On March 24th, 2016, Irish Coast Guard coast unit sector manager Michael O’Toole, covering a region of the west coast, was formally alerted to problems when four members of the Kilkee unit sent him a copy of a communication with Mr Vaughan, dated March 23rd, 2016.
The memo referred to problems with communication, lack of clear definition of roles and responsibilities, and adequate supervision of training. It also referred to an “air of distrust” over use of CCTV to “monitor people”.
The memo identified a need for head office training for new officer roles, along with familiarisation of policies, procedures and protocols, and said there should be “no more one-on-one chats”, and there should be full debriefs with all crew in relation to incidents and occurrences.
“While we are acutely aware that we are an emergency service which requires a professional, safe and efficient response . . . the social aspect of the unit no longer exists,” the memo said, suggesting “an active training plan and more openness within the entire team” would “help in rectifying this issue”.
“Morale and enthusiasm are at an all-time low within the unit, and there is a danger of a significant number of people exiting the unit which could severely hamper our ability to respond to taskings,” the memo warned.
Sources close to the Irish Coast Guard have confirmed that the unit's deputy OIC Orla Hassett, who was one of the four signatories to the memo, contacted the unit manager in late March 2016. The Irish Coast Guard management held a meeting with volunteers in July 2016 to discuss issues raised.
At another meeting with Irish Coast Guard management on Friday, September 9th, Kilkee volunteers were told that Mr Vaughan was “stepping aside” as and from September 12th, 2016, and taking another position within the Irish Coast Guard, and Ms Hassett would be appointed interim OIC until a permanent replacement. That same day, a search for Mr McMahon was initiated.
This sequence of events is confirmed in the draft MCIB report which says the handover was deferred until September 12th to allow for the Valentia Coast Radio station and other relevant parties to be informed. It also refers to a loss of experienced coxswains “with local knowledge”.
There were several search launchings for Mr McMahon over the weekend of September 10th and 11th which Mr Vaughan co-ordinated, and on the evening of the 11th he asked volunteers to be at the station early on the Monday of September 12th. Ms Hassett was due to take over that morning.
Shortage of boat crew
Due to the ongoing shortage of qualified boat crew available, Valentia Coast Radio was asked to request assistance from Doolin. Launching involves a “triple lock” system of approval by the rescue co-ordination centre, as in Valentia, the OIC and the cox.
Met Éireann had issued a small craft warning, but specified that southerly winds would reach force 6 or 7 on coasts from Malin Head to Howth Head and to Roche's Point off Cork. However, its forecast from Roche's Point to Slyne Head, including the Clare coastline, was for a less severe westerly force three, with wind speeds further decreasing to force two to four in the afternoon.
It is understood that some of the draft report’s observations in relation to weather have been challenged by notified parties who point out that the small craft warning which the draft refers to did not apply to the west coast.
The draft report notes that a drone was available to conduct a search, which was a recovery rather than a rescue.
There was an early launch, and then a second at 10.30am, with qualified Kilkee coxswains James Lucey and Jenny Caraway requiring one more crew. Ms Lucas had the necessary qualifications, and her colleagues from Doolin had brought her drysuit and helmet from their station just in case. She would normally have brought her own personal flotation device (PFD) or lifejacket if she had known she was going out on the water, but was given one at Kilkee.
The Kilkee Delta RIB’s search plan aimed to head towards Intrinsic Bay and then north of George’s Head to Chimney Bay. It was returning to base at 13.06 when it reported that it was just off the back of the Pollack holes and would do “one search around underneath the shelter and we will head in”.
The Delta RIB entered a small cove north-east of Foohagh point – a shallow area and potential “surf zone” which posed hazards. The draft report cites local knowledge that the seabed rises in “sharp cliff faces”, rather than a gradual shelving, and this can cause a “sudden uprising in certain sea conditions and large swells can appear, as if from nowhere”.
The Delta RIB was 20m from the shoreline when a large breaking wave directly to starboard struck it, tipping it over before it righted itself off Knockroe point. All three crew were thrown overboard.
Ms Caraway had the only functioning radio, her personal hand-held VHF, and issued a “Mayday” call on channel 16 . It was not picked up by Valentia due to transmission difficulties involving hand-held devices. However, a member of the public witnessed what had occurred and phoned Kilkee station, which in turn contacted Valentia.
The shore response was “immediate”, the draft report says, with the Shannon-based Rescue 115 helicopter, the RNLI Aran island lifeboat, Civil Defence and local fire service being tasked to assist.
The draft report records that three different GPS co-ordinates were recorded for the capsize location, all within the general area, but the most accurate was recorded by an eye witness. The Delta RIB was not equipped with an emergency position indicating radio beacon (EPIRB) which could have pinpointed location if activated.
The report says Mr Vaughan arrived at Kilkee coast guard station some time after noon. “There is conflicting evidence as to whether he was briefed on the ongoing search operation or had called to return equipment,” the report states.
It said he had arrived at the station between 12.30 and 12.50. and took charge of the incident, liaising with other agencies and with the Irish Coast Guard helicopter.
Recognising an “imminent threat to life”, Ms Hassett who was officially in charge at the station, asked the local Garda to task a privately owned RIB, which she joined. This RIB then rescued second coxswain Ms Caraway, who had managed to swim offshore, but had ingested a lot of water and was taken to hospital.
Caitríona Lucas stayed with the Kilkee Delta RIB, as she had been trained to do; but as with her two other crew, she lost her helmet in the impact. The draft report says it has been unable to establish “definitively” how the helmets came off, but says that their security depends on being properly fitted/inflated and secured according to suppliers’ instructions.
A postmortem identified a trauma to the side of Ms Lucas’s head at a point where it should have been protected by her helmet. She had “expended a lot of energy holding on to the boat, would have ingested water”, the report says, and probably sustained an impact to her head when she was submerged.
Lost her grip
Civil Defence drone video footage recorded her holding on to the port bow section of the RIB, but being repeatedly washed off by waves. After three minutes, she lost her grip and was next seen lying face down in the water. Her lifejacket was not inflated.
The draft report notes that two of the three PFDs or lifejackets examined afterwards did inflate, and observes that the three crew either had difficulty in finding the activation toggle or decided not to use it. “A fully inflated lifejacket can reduce swimming and manoeuvrability and may have been a factor” in this, it says. Volunteers also know it can be virtually impossible to board a RIB from sea unaided if wearing a fully inflated lifejacket.
Back in Doolin, volunteers had been tasked by Valentia Coast Radio Station to respond to an "incident" off Kilkee. On board with Conor McGrath were Davy Spillane and Bernard Lucas. The first indication that something was different about this call-out came in one of several transmissions on VHF radio channel 67 to the Doolin RIB, directing it into Kilkee, rather than to the incident. Gardaí were waiting at the Kilkee slipway.
At that stage, Caitríona Lucas had been winched on board the Shannon-based Irish Coast Guard helicopter, and flown to a cliff top where she was attended to by paramedics. Bernard Lucas was escorted to her in a Garda car, and flew with her to Limerick University Hospital.
The Doolin RIB with Mr McGrath and Mr Spillane on board proceeded to the incident where the RNLI Aran island lifeboat was standing by. Kilkee coxswain James Lucey was trapped to the rear of a cave entrance, which was inaccessible to both lifeboat and helicopter. Several jetski teams tried to approach him, and one of two from a Lahinch team made several highly risky attempts to swim in to the cave.
Eventually, a combination of Doolin Coast Guard and Kilrush fire service cliff teams managed to get a line to Mr Lucey and he was then winched off by the Waterford-based Rescue 117 helicopter at 17.25, after a four-hour ordeal.
At this stage, it had been clear from VHF communications that Caitríona Lucas was critical, and might not make it. She was pronounced dead in hospital at 16.05. On its way back to Doolin, the Doolin RIB was observed stopping under the Cliffs of Moher and raising one of its engines, suggesting it was in difficulty.
Irish Coast Guard crews hold debriefs immediately after call-outs, to mitigate the impact of trauma and identify potential difficulties. There was no immediate debrief for the Doolin crew after the Kilkee mission of September 12th, 2016. However, there was a critical incident stress debrief for both Kilkee and Doolin crews, held by a trained independent person. Sources close to the volunteers say there has been no concerted effort to provide ongoing counselling for all those involved, including the Lucas family.
The Irish Coast Guard has said an offer of counselling was “personally made” to an individual in Co Clare in February. It says counselling may be availed of by volunteers which is paid for by it, and a confidential number for a counselling company is available at each station.
Very shortly after Ms Lucas’s death, a regular training session with the Doolin unit involved a survival exercise off the pier. A drysuit or survival suit worn by one of the volunteers began to fill with water, and the volunteer returned to the station, only to find that the neck seal on the suit had failed.
He was not aware there had also been a neck seal problem on a different drysuit worn by the second coxswain on the Kilkee crew Jenny Caraway. Fortunately, this had been spotted in time by one of her colleagues before she went on the water on September 12th, but it indicated there was a wider problem with gear.
The MCIB draft report notes that new marine safety helmets and drysuits were provided to both Doolin and Kilkee Coast Guard units before the incident in which Caitríona Lucas died, but there was no evidence of formal instruction or training on use of the equipment. It notes that two of the three helmets recovered after the incident did not have the inner air bladder, which is adjustable and is essential in keeping a helmet in place and providing maximum protection.
It notes that there was no evidence of any effective management in place in Kilkee with “associated oversight”. It has found that the Delta RIB 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.
It also notes that there was no record of any pre-launch risk assessment when Kilkee’s second craft, the D-class vessel,was launched, although this was in response to the Mayday from the Delta.
The draft report notes the Delta RIB was not licensed or certified for the activities it was engaged in – as in a passenger boat’s licence – which would have required regular surveys, nor did it have a ship’s radio station licence. It notes the boat coxswain James Lucey had “undertaken all of the relevant training” for his role with the Irish Coast Guard, but did not have a passenger boat licence.
However, an Irish Coast Guard spokesman told The Irish Times that rescue boats were not passenger boats, were not available for hire, and it operated an "effective boat operations system which is regularly audited and reviewed".
Most significantly, the draft report says the Irish Coast Guard did not have an effective safety management system, which draws on accident reports and other “non-compliances” to review procedures and constantly seek improvements. The draft report highlights one example of this – the capsize of a Delta RIB in Dingle on August 25th, 2014 which, it notes, had “many attributes similar” to the Kilkee case.
An internal inquiry dated February 2015 into that incident in Dingle reported that the Irish Coast Guard RIB capsized when it tried to out-run a breaking wave in a “surf zone” or shallow area. Surf-zone operations are precluded by Irish Coast Guard policy due to the safety risks, and the first of 20 recommendations made by the internal inquiry called for a review of procedures on this.
The draft report into the Kilkee incident says “it is apparent that not all of the recommendations [arising from Dingle] were implemented”.
The Kilkee Delta RIB capsized in a surf zone. The shallow cove had been deemed unsafe by other coxswains. Although volunteers say they heard talk about the Dingle incident of August 2014, they did not receive any formal memo about it from the Irish Coast Guard or the internal report into same which was never published.
“If we had known everything we should have known about Dingle, Caitríona Lucas could still be alive,” sources close to volunteers have told this newspaper.
The sources believe there are still many unanswered questions which may be outside the scope of the inquiry, including a failure to address a particular management culture.
Operational issues relating to the management of more than 900 volunteers is not within its scope, the draft report states, but does allude to extra responsibility placed on coxswains as a result of additional training requirements from 2013. Volunteers, who give of their time during rigorous training which can take five years to complete and is ongoing, can claim very minimal out-of-pocket allowances, amounting to €12.70 for training and station-based activities, and an allowance of €10.16 for the first hour of a call-out and €3.81 for any subsequent hour.
Kilkee Coast Guard has still not been able to return to full sea duty since September 2016, and Minister for Transport Shane Ross told the Dáil in February 2018 that this was to “allow time for the training of new crews and for existing members to be recertified to a sufficient standard”.
A number of complaints have been made by Kilkee members to Irish Coast Guard management, and four legal cases against the State over post-traumatic stress are in train. A separate Health and Safety Authority (HSA) investigation is also continuing. After Ms Lucas's death, the Irish Coast Guard did request a review from the British Maritime Coast Guard which has not yet been published.
The former OIC at Kilkee Martony Vaughan is back with Doolin Coast Guard, where he had dedicated so much time from 2000. Contacted by the The Irish Times, Mr Vaughan said he did not wish to comment on the draft report or other issues raised.
The Irish Coast Guard said a merger of teams in Kilkee under its remit had been “complicated”, but the situation was “assessed” as ready for “local management” and the September 9th, 2016 meeting was to formalise this, with Mr Vaughan being reassigned to project work on remote piloted aircraft for search and rescue.
It said that tensions “naturally re-arose” at Kilkee after the death of Ms Lucas, some members left or stood down temporarily, and a number of members “made criss-crossing complaints against each other”. It said it had appointed an independent company to “holistically manage” the complaints, through mediation and “if necessary” investigation. Separately to this, the Kilkee unit is trained by an expert on “team building and personal communication”.
The Irish Coast Guard has said it will not comment on operational and safety systems while the investigations are continuing, but said it had employed a health and safety officer, along with the services of a “competent company” to conduct a “gap analysis” which was “ongoing”.
It has said there is “extensive” formal training in boat management, correct use of drysuits and helmets, and drysuits and lifejackets are serviced on an annual basis and neck seals routinely replaced.
A safety notice was issued in January 2018 on boat operations, it added, reiterating key requirements on safety and risk management, dynamic risk assessments, buddy checks and surf/breaking waves, and other safety and survival checks and procedures.