Transport Minister pledges to implement recommendations in report into Caitríona Lucas death

While the Coast Guard has described the report as “flawed” and called for a full reappraisal of its analysis, Mr Ross said he welcomes the report which found that the rescue boat Ms Lucas was thrown from was launched in conditions beyond its operational capability; that there were critical deficiencies with its communication and navigation equipment; and that the Coast Guard does not have an effective safety management system.

Ms Lucas, a volunteer from the Doolin Coast Guard Unit, was one of three crew in a Delta RIB which was deployed from Kilkee twice that day as part of a search for a man, reported missing three days earlier.

Their boat capsized in heavy seas as they searched a cove near Foohagh Point just after 1pm during what was their second launch of the day. All three lost their helmets and their personal flotation devices were not inflated.

The boat Cox was washed inshore and clung to rocks until winched off by rescue helicopter R117. The second Cox swam offshore and was rescued by a privately owned boat.

Ms Lucas clung to the upturned boat, as per her training, for at least three minutes. But she suffered a head injury and was submerged under the boat several times before finally being washed away.

She was recovered by rescue helicopter R115 a short time later but was pronounced dead in hospital. She had drowned.

The MCIB identified several issues with the fatal incident itself, including “management issues” in the Kilkee Coast Guard unit, which had seen the departure of several coxes with local knowledge, and which ultimately required the intervention of Coast Guard headquarters.

But it concluded that the Delta RIB cox did not hold the required statutory operator’s licence; that the RIB was not permitted to operate in surf; that its radar was not operational; that there was “water ingress into the GRP hull” during operations; that there was air leaking from the air suspension in one of its seats; and that additional faults were reported, including a broken echo sounder, and a non operational ‘fixed VHF transceiver’.

The report also found that the so-called ‘Triple Lock System’ - a decision-making process required before a boat is launched - was “not adequately adhered to” before the RIB’s second launch that day.

In its conclusions, the MCIB said the Irish National Search and Rescue Framework does not provide adequate clarity as to when a search and rescue operation becomes a search and recovery operation, especially in incidents where search and recovery operations take place close to cliffs and in surf conditions.

It said while there were specific issues linked to this tragedy, it is necessary to consider a wider context, including a similar incident involving a coast guard RIB capsizing in a “surf zone” off Dingle in 2014.

While there was no loss of life in this incident, the MCIB said some of the 20 recommendations linked to safety and procedures have not been “fully implemented”.

Mr Ross said he has broadened the national SAR Framework review, whose group under the independent chairmanship of Sir Alan Massey, former CEO of the Maritime and Coastguard Agency in the UK, met on Wednesday, to encompass the relevant recommendations arising from the MCIB report.

He said he has also instructed the Coast Guard to accelerate its work in developing an independently accredited ISO safety management system that will be robust and fit for purpose.

He said the work is already underway and significant effort and investment has taken place over the last two years.

But he said he will now require the Coast Guard and the Marine Survey Office to take the “necessary and pragmatic steps” to ensure that any issues which could impact on vessel or crew safety are addressed as a matter of urgency.