"Caitríona Lucas could still live, if we had known what we should have known & # 39;

When Caitríona Lucas responded to a request of 12 September 2016 to help find a young man missing the north coast of Clare, she was not aware that she was going to sea.

The 41-year-old librarian, mother of two and very experienced volunteer at the Doolin unit of the Irish coastguard, expected that she would walk the coastline with fellow volunteers from Kilkee who had been looking for additional back-up. This is usually the norm when neighboring units help each other.

Little did she expect it to be her last call-out because of the lack of effective security and personnel management systems within the Irish Coast Guard and, in particular, the failure to implement full recommendations after a very similar incident in Dingle, Co. Kerry, two years earlier.

A concept of the official investigation into the death of Ms. Lucas by the Marine Casualty Investigation Board (MCIB), who continued The Irish Times, highlights a number of serious problems, including the absence of a safety system administrator recommended in April 2012 in a price-quality ratio. Since the draft report, a health and safety officer has been appointed.

With 10 years of experience to her credit, Caitríona Lucas was one of the most respected and competent volunteers at the Irish Coast Guard in Co Clare. The Doolin unit – with which her husband, Bernard, also serves – was recently led by Mattie Shannon who recently retired after 30 years of service. It has earned a reputation as one of the best Irish Coast Guard teams of its kind, due to the varied and challenging range of calls it has responded to for ships at sea, climbers and hikers in difficulty on nearby sea cliffs, or people reported that they are the Cliffs of Moher had missed.

The experience of Caitríona Lucas was supported by a series of qualifications, from control and navigation to climbing, first aid and response to emergency situations, together with training for suicide prevention. She was also national secretary and active member of the Search and Rescue Dog Association.


School inspector David McMahon from Lissycasey was missing most of a week when Mrs. Lucas traveled to Kilkee to help, convinced she would walk over the high cliffs and scan the coastline. Both the Civil Defense and the Kilkee Coast Guard were given the task of assisting through the maritime rescue center of the Irish Coast Guard in Valentia.

However, Kilkee Coast Guard experienced difficulties in collecting volunteers due to internal tensions dating back to its reconstruction in 2013, when a 30-year community marine rescue service, founded by Manuel di Lucia, was taken over by the Irish Coast Guard. The community had initially preferred the acquisition because it was difficult to raise funds, but the transition did not go smoothly.

The Doolin unit of the Irish Coast Guard had earned a reputation as one of the best Irish Coast Guard teams of its kind.

The Doolin unit of the Irish Coast Guard had earned a reputation as one of the best Irish Coast Guard teams of its kind.

As Independent Clare TD told Michael Harty de Dáil on February 15, 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 persons involved at Kilkee dropped from 26 to 12. This loss of valuable experience included qualified steermen.

The Irish Coast Guard had appointed an experienced member of the Doolin Coast Guard unit, Martony Vaughan, as officer officer (OIC) in Kilkee in 2013, initially for six months. It was felt that an experienced outsider could best deal with any problems that occurred during the transition. His style is expressed in an e-mail to all members of the Kilkee unit, to be seen in this newspaper of January 29, 2016.


On 24 March 2016, the sector manager of the Irish Coast Guard, Michael O & # 39; Toole, covering an area of ​​the west coast, was formally warned of problems when four members of Kilkee's unit sent him a copy of a communication with the Mr. Vaughan sent, dated March 23, 2016.

Communication problems

The memo refers to problems with communication, lack of clear definition of roles and responsibilities and adequate supervision of training. It also referred to "a sense of distrust" in relation to the use of CCTV to monitor people.

The memo noted that there was a need for training at the head office for new officer roles, along with disclosing policies, procedures and protocols, and said that there should be "no more one-on-one chats", and should be complete debriefs with all crew members in relation to incidents and events.

"Although we are well aware that we are an emergency service that requires a professional, safe and efficient response … the social aspect of the unit no longer exists", according to the memo, "suggesting" an active training plan and more openness within the whole team "would" help solve this problem ".

"Morale and enthusiasm are at a low point in the unit and there is a risk that a large number of people will leave the unit, which could seriously impede our ability to respond to assignments," the memo warned.

Sources near the Irish Coast Guard have confirmed that the OIC delegate of the Orla Hassett unit, who was one of the four signatories of the memo, contacted the unit manager at the end of March 2016. The Irish Coast Guard management held a meeting with volunteers in July 2016 to discuss discussed issues.

During a new meeting with the Irish Coast Guard management on Friday 9 September, Kilkee volunteers were told that Mr Vaughan "stepped aside" as and from 12 September 2016, and took up another position within the Irish Coast Guard and that Hassett would be appointed interim OIC to a permanent replacement. That same day a search for Mr. McMahon was started.

This series of events is confirmed in the draft MCIB report that says the transfer has been postponed to 12 September to keep the Valentia Coast Radio station and other relevant parties informed. It also refers to a loss of experienced masters "with local knowledge".

Mr McMahon launched several searches during the weekend of 10 and 11 September, which Mr Vaughan coordinated, and on the evening of the 11th he asked volunteers to be at the station early on Monday 12 September. Hassett had to take over that morning.

Shortage of boat personnel

Because of the continuing shortage of qualified crew available, Valentia Coast Radio was asked to request assistance from Doolin. Launching includes a "triple lock" system of approval by the rescue co-ordination center, such as in Valentia, the OIC and the cox.

Éireann had issued a warning for small vessels, but determined that the southern winds would reach 6 or 7 on the shores of Malin Head to Howth Head and to Roche's Point off Cork. However, the prediction from Roche's Point to Slyne Head, including the Clare coastline, was for a less severe western force three, with wind speeds declining further to force two to four in the afternoon.

It is understood that some comments from the Draft Report on weather have been contested by notified parties pointing out that the warning for small vessels to which the draft refers does not apply to the west coast.

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