Rescue 116: HSA investigation opens possibility of prosecutions
Faulty locator beacons in crew’s life jackets highlighted five years ago, RTÉ reports
Four Irish Coast Guard air crew – Capt Dara Fitzpatrick, Capt Mark Duffy, winch operator Paul Ormsby and winchman Ciarán Smith – died when their helicopter collided with Blackrock island on March 14th. The bodies of the two winch crew are still missing.
The Air Accident Investigation Unit (AAIU), which has ruled out mechanical fault in its preliminary report, is still the lead investigating agency. However, its remit is to prevent further accidents and not to apportion fault or blame, whereas the HSA has powers of enforcement action – up to and including prosecutions – in relation to crew workplace safety.
The AAIU highlighted issues with quality of navigational data available to the crew, along with faulty functioning of locator beacons in their life jackets, in its preliminary report, and RTÉ’s Prime Time reported last night that faulty function of the beacons was highlighted five years ago. Prime Time quoted repeated warnings in reports filed by crew referring to the beacon producing “absolutely zero receivable transmissions”.
The AAIU established that the crew’s beacons had been installed in the same pouch as the GPS antenna, as per a service bulletin issued by the life jacket manufacturer, when in fact the beacon manufacturer recommended a minimum separation distance of 30cm between the GPS antenna and beacon.
When Capt Dara Fitzpatrick was found in Blacksod Bay, she had been in the water for almost 90 minutes, and she was pronounced dead later in hospital. Her life jacket was fully inflated, and her colleagues believe that if her beacon had been working she could have been located much sooner.
It was only after colleagues of the four Dublin-based crew demanded action that the company tested the life jackets and beacon functioning – eight weeks after the crash, according to Prime Time.
The pilots are now using Mk15 life jackets, and Mk44 life jackets have been withdrawn for retrofitting. Manufacturer RFD Beaufort said it was “liaising closely both with the [AAIU] and the Irish Coast Guard, and cannot make any further comment until the final outcome of the investigation”.
Prime Time also highlighted issues with the quality of the moving map system used by the air crew, and says the pilots were testing iPads that were not approved for navigation – with a discrepancy in the height for Blackrock island between the two systems.
The programme said Capt Fitzpatrick planned her flight, which was to provide top cover for a medical evacuation off the west coast, using the Skydeamon flight planning tool. It shows Blackrock island off north Mayo at the correct highest point of 282ft in the moving map system, but the island is hidden behind a location code when zoomed in to at close range. Maps on the iPads listed Blackrock island at a height of 46ft.
Neither CHC Ireland or the Department of Transport would comment on Prime Time’s report.