There can be few rescuers in any coastal community anywhere occupying the tough and lonely position held by west Clare farmer Bernard Lucas.
Bernard and his wife, Caitríona Lucas, trained as advanced search-and-rescue coxswains with one of the Irish Coast Guard's leading voluntary teams in Doolin, Co Clare. More than two years ago, the 41-year old mother of two became the first Irish Coast Guard member to die on duty . She drowned when the rigid inflatable boat (rib) she was in capsized on September 12th, 2016, during a search for a missing man with a neighbouring unit in Kilkee.
In his first interview since publication of one of two State investigations, Bernard is calm and measured as he recalls how his wife had not expected to go to sea that day. She had agreed to make up the numbers when Kilkee were short of seagoing crew.
He was not initially aware that the Kilkee unit was the focus of a rescue when he responded to an emergency tasking some hours later. "I was in Milltown Malbay when I got a phone call and turned the car around for Doolin," he says. "At that stage we just knew a boat had capsized off Kilkee."
He was en route to the location with fellow Doolin volunteers Conor McGrath and Davy Spillane when a message over the VHF radio directed their rib into Kilkee. A Garda car was waiting at the pier head. Bernard was driven to a cliff top, where his wife was being attended to by paramedics before being flown by Irish Coast Guard helicopter to Limerick University Hospital. Several hours later, she was pronounced dead.
The two Kilkee crew with her – coxswain James Lucey and second coxswain Jenny Caraway – were rescued. The damning final report of the Marine Casualty Investigation Board (MCIB) has identified a catalogue of safety defects and lack of regulatory compliance, and criticises the Irish Coast Guard for failing to have an effective safety management system in place.
Although its role is not to apportion blame, the report states that the Kilkee rib had critical equipment deficiencies, that it was out beyond its operational limits, that it should have had a passenger boat licence and that its coxswain should have had the necessary certification for this.
It also notes how recommendations arising from a similar incident in a shallow "surf zone" off Dingle in 2014 had not been fully acted upon by the Irish Coast Guard in order to prevent a recurrence. And it says criteria for launching in a situation where the focus is on "recovery", as opposed to search and rescue, should be reviewed.
‘Flawed and misleading’
In its response to the MCIB draft report, which it described as “flawed” and “misleading”, the Irish Coast Guard pointed out that more than a million “man hours” had been spent on more than 30,000 rescue missions since 1991 and that this was the first fatality. It also argued against passenger boat legislation – on the basis that rescue ribs are not ferries – and defended the Kilkee unit’s decision to launch.
The Irish Coast Guard also defended its safety-management system and contended that it represented a “significant leap” for the MCIB to suggest a “tragic accident in one instance in one Coast Guard unit is representative of a whole organisation”.
Bernard is taking legal advice on the report, so he does not want to comment on its specifics, and he is conscious that a separate Health and Safety Authority (HSA) investigation is pending. He is also due to meet Minister for Transport Shane Ross, who holds responsibility for the Irish Coast Guard, this week.
However, in a submission to the draft MCIB report, which has been published as part of a length appendix to the final version, Bernard raised a number of issues relating to faulty equipment that the investigation had identified but, in his view, had not adequately explored.
He also stated that he believed “bullying and harassment” at Kilkee in the preceding couple of years was “a contributing factor in this accident”. Kilkee had “lost an awful lot of experience” and “morale within the team was very bad”, he noted.
The MCIB report does record management difficulties at Kilkee, which led to a number of coxswains with local knowledge leaving the unit. Irish Coast Guard senior management was first alerted to the issue in late March 2016, and met with volunteers in July. At a further meeting, on September 9th, 2016 – three days before Caitríona's death – Kilkee volunteers were informed that their officer in charge was taking up a new posting, and that the deputy officer in charge, Orla Hassett, would take over in the interim.
Hassett had previously initiated a grievance procedure, after she says she was isolated and excluded from training schedules by her senior officer, Martony Vaughan. Her concerns about safety were compounded by two incidents with a ladder deemed unsafe at the Kilkee base. She fell off it, and one of her colleagues also fell off it and had to be airlifted to hospital with an injured back.
Not a democracy
Events overtook the new management transition, as the sea search for missing school inspector David McMahon was initiated on September 10th. Bernard’s submission to the MCIB states that there seemed to be “confusion about who was in charge during and after the accident” two days later.
It took more than four hours to rescue coxswain James Lucey from an inaccessible cave entrance. Several jet-ski teams risked their lives to try and approach him. Doolin Coast Guard and Kilrush Fire Service cliff teams eventually managed to get him a line and he was winched to safety by the Irish Coast Guard Rescue 117 helicopter from Waterford.
Hassett had to ask for Garda help to requisition a privately owned rib, and then boarded Kilkee’s D-class rib and rescued one of the two Kilkee crew, Jenny Caraway.
Bernard believes that the Irish Coast Guard's management system allowed no recourse for volunteers who might have concerns that could lead to differences with an officer in charge. His colleague Davy Spillane, musician and also an advanced search-and-rescue coxswain, agrees. "If you questioned issues, you were told by your senior 'This was not a democracy' and were pointed to the door," Spillane says. Bernard recorded one key instance in September 2017, at a memorial ceremony in Doolin for his wife and for the four Irish Coast Guard helicopter crew who lost their lives in a crash off the north Mayo coast in March 2017. After the ceremony, he says he was admonished by his officer in charge, Mattie Shannon, for travelling to Blacksod six months previously to assist in the search for the helicopter crew.
I wish Bernard every goodwill in his endeavours and solace and peace to him and his family for Christmas
"I just couldn't stay at home," Bernard says. " I suppose I was up there the best part of two weeks, and I had brought my all-weather gear with me – but I went as a civilian. I met Michael Hurst, officer in charge of the Ballyglass unit, and he was very welcoming and asked me to put on my gear."
During one of many shoreline scans, Bernard found a glove worn by one of the crew. He also met the families. More than most, he understood their shock and pain.
Mattie Shannon, who retired from the officer-in-charge post after 30 years of distinguished service with Doolin, has declined to comment on Bernard’s claim in relation to participating in the Blacksod search but said: “I wish Bernard every goodwill in his endeavours and solace and peace to him and his family for Christmas.” It is understood that Shannon would have been under pressure to ensure there was no “self-tasking” during a highly pressurised search situation when the emphasis was on avoiding further accidents or casualties.
Bernard says he recorded the exchange and submitted it as one of two complaints to the Irish Coast Guard, but it was not admitted on the grounds that Shannon had already retired.
The Irish Coast Guard says it would not be appropriate to comment on individual grievance processes in the interests of all those involved.
There was another key moment for Bernard just over 12 months ago, when he learned that Martony Vaughan, former officer in charge at Kilkee, was transferring back to the Doolin unit.
“I wasn’t suggesting any blame – it was just that it was so insensitive. I asked the Irish Coast Guard to defer it until at least the reports were completed,” Bernard says. “That didn’t happen.”
“The Irish Coast Guard was my life, it was what I did, and I felt protected by my comrades. That was all blown apart when I heard about this.”
“It made it impossible for me to be there and prevented me from grieving. I needed the Irish Coast Guard. I was clinging on by my fingernails.” Spillane believes that Bernard has been effectively abandoned by headquarters at a time when he needed support. The Irish Coast Guard says an offer of counselling support was offered to an individual last February. Meanwhile, Spillane has been left in his own limbo, he says. There was no official debrief for the Doolin crew on its return to base from Kilkee, he says. Such debriefs allow for issues to be aired and provide a “safe space” after traumatic circumstances.
As part of Irish Coast Guard practice, so-called “hot” debriefs take place immediately after every operation to allow for any issues to be aired, and a “cold” debrief may take place some days later if there are outstanding issues. Neither happened in Doolin on this occasion.
Not normal practice
A separate critical incident stress management debrief was offered to both the Doolin and Kilkee units several days later, but it was attended by two senior Irish Coast Guard officers – against normal practice. During a safety check also attended by Irish Coast Guard management, Spillane reported that his dry suit had begun to fill with water.
Further examination showed the seal was at fault. Unbeknown to him, a similar problem had been identified with a dry suit neck seal in Kilkee. The Irish Coast Guard says its dry suits are serviced annually by service agents.
Orla Hassett, who is a paramedic by profession, is on sick leave from volunteering with Kilkee. She is one of several members taking legal action on post-traumatic stress relating to the incident and events before and after. She also made a lengthy submission to the MCIB, questioning the accuracy of its location of the incident, among other issues.
Like Bernard, Hassett believes the MCIB report did not adequately address equipment failure. The MCIB report confirms that life jackets worn by the three crew were not inflated, and that helmets came off. Volunteers wear life jackets that have to be manually inflated, but this can restrict manoeuvrability in a situation where one is trying to swim or board a rib.
Hassett says volunteers understood that the type of life jacket used by the Irish Coast Guard has sufficient buoyancy to keep a head above water in a situation where the wearer is unconscious – as Caitríona Lucas was latterly. Drone footage from the scene confirms she was washed ashore under the cliff with the rib and was holding on to the port bow section but was repeatedly washed off by waves.
“After approximately three minutes, the casualty lost her grip and was next sighted lying face down in the water and drifting freely with the seas,” the report states. Preliminary post-mortem evidence confirmed she had sustained a head injury.
The Irish Coast Guard says it would not be appropriate to comment on equipment issues while a separate HSA investigation is ongoing, but says its equipment is maintained to a very high standard.
It says that while no certified life jacket can be guaranteed to “self-right” an unconscious user – and this is stated in a manufacturer’s warning panel – “the buoyancy provided should ensure they will in the great majority of cases”.
It also says it has conducted independent testing of life jackets in Britain and found them to be “fully compliant” for use in Atlantic waters.
Late and limited
Co Clare solicitor Joe Chambers, who is acting for Hassett and two other clients, says the care provided to the volunteers "post incident" by the Irish Coast Guard was "late and limited", and the trauma was in some cases "compounded by its actions. He says his three clients continue to receive private help at their own expense.
Kilkee still has no fully restored search unit, and the Irish Coast Guard says it has appointed a project manager, and training is ongoing , with a view to returning the unit’s D class boat to “full operability” next spring.
Minister for Transport Shane Ross has pledged to implement the MCIB report recommendations in full. He says he has broadened the national search-and-rescue framework review, and has also instructed the Irish Coast Guard to accelerate its work in developing an independently accredited ISO safety-management system.
However, Lucas, Spillane, Hassett and her Kilkee colleagues Lorraine Lynch and Gary Kiely firmly believe that the Minister must also address the fundamental culture within the Irish Coast Guard which, in their view, is anathema to effective teamwork and safety.
The Irish Coast Guard says it does offer both critical incident stress management and confidential counselling for volunteers in the aftermath of stressful incidents. It also says it recently contracted a human resources company, which verified that its code of practise in relation to handling grievances represented “good practice for the type of operation involved”.
It says training has been and “continues to be” provided by sectoral managers, officers in charge and deputies on “grievance management and other HR supports”.
Former Kilkee officer in charge Martony Vaughan did not respond when contacted by The Irish Times. The MCIB said "all relevant facts are contained in the published report " and it had "no further comment to make".
The HSA investigation is understood to be nearing conclusion.