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.
Missing
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.
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.
The decision in capital letters: "THIS DEVICE IS A TEAM EFFORT THAT DOES NOT TRAIN IN TRAINING AND PUT IT INTO THE SHORT MINIMUM IS UNACCEPTABLE AND IS NOT DRIED FOR NOW, THIS IS NOT A SOCIAL CLUB."
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.
The draft report states that a drone was available to perform a search, which was a recovery rather than a rescue.
There was an early launch and then a second at 10.30 am, with qualified Kilkee helmsmen James Lucey and Jenny Caraway who needed another crew. Mrs Lucas had the necessary qualifications and her colleagues from Doolin had taken her drysuit and helmet out of their station, just in case. Normally she would have taken her own personal floating body (PFD) or lifejacket if she had known she was on the water, but she got one at Kilkee.
Caitríona Lucas
The search plan of the Kilkee Delta RIB was aimed at heading towards Intrinsic Bay and then north of George's Head to Chimney Bay. It returned to the base at 13.06 when it reported that it was just behind the holes in the Pollak and "would do one search under the shelter and we went there".
The Delta RIB entered a small bay northeast of the Foohagh point – a shallow area and a potential "surfing zone" that created dangers. In the draft report, local knowledge is mentioned that the seabed rises in "sharp rock faces" instead of gradual stretches, and this can cause a "sudden rebellion in certain sea conditions and large waves may appear, as if out of nowhere".
The Delta RIB was 20 meters from the shoreline when a large breaking wave struck directly to starboard, and tipped it before turning itself off from the Knockroe point. All three crew members were thrown overboard.
Ms. Caraway had the only functioning radio, her personal portable VHF, and gave a "Mayday" call on channel 16. It was not picked up by Valentia because of transmission difficulties with handheld devices. A member of the audience, however, witnessed what had happened and called station Kilkee, which in turn contacted Valentia.
The response from the shore was "immediate", according to the draft report, with the Shannon-based Rescue 115 helicopter, the RNLI Aran island lifeboat, the civil protection and the local fire brigade to assist.
GPS coordinates
The draft report states that three different GPS coordinates were registered for the hairdressing location, all within the general area, but the most accurate was recorded by an eyewitness. The Delta RIB was not equipped with an emergency position indicating the radio beacon (EPIRB), which could have indicated a location if activated.
The report says that Mr. Vaughan arrived at Kilkee Coast Guard Station some time after noon. "There is contradictory evidence whether he was informed about the current search or had called to return equipment," the report states.
He said that he had arrived at the station between 12.30 and 12.50. and took charge of the incident, contact with other agencies and with the Irish Coast Guard helicopter.
Keeper Hassett, who was officially in charge of the station, recognized an "immediate threat to life" and asked the local Garda to hire a RIB in private ownership. This RIB then saved the second mate Ms Caraway, who had managed to swim offshore, but had swallowed a lot of water and was taken to the hospital.
Caitríona Lucas stayed with the Kilkee Delta RIB, as she was trained to do; but as with her two other crew members, she lost her helmet in the crash. The draft report says it was not able to "definitively" determine how the helmets came off, but says that their safety depends on being correctly fitted / inflated and secured according to the supplier's instructions.
A post-mortem identified a trauma on the side of Ms. Lucas's head at a point where she should have been protected by her helmet. She had "put a lot of effort into holding the boat, would have taken water," says the report, and probably had an impact on her head when she was under water.
Lost her grip
Civil Defense drone video recordings have held her to the port arc section of the RIB, but repeatedly washed off by waves. After three minutes she lost her grip and was then seen with her face down in the water. Her life jacket was not inflated.
In the draft report, it is noted that two of the three PFDs or lifejackets examined were inflated and found that the three crew members had problems with finding the activation button or decided not to use it. "A fully inflated life jacket can reduce swimming and maneuverability and may have played a role," it says. Volunteers also know that it is virtually impossible to go to sea without the help of a RIB if you are wearing a fully inflated life jacket.
Back in Doolin volunteers had been commissioned by Valentia Coast Radio Station to respond to an & # 39; incident & # 39; at Kilkee. Davy Spillane and Bernard Lucas were on board with Conor McGrath. The first indication that there was something else about this call-out came in one of several broadcasts on VHF radio channel 67 to the Doolin RIB, which sent it to Kilkee, instead of to the incident. Gardaí waited on the slope of the Kilkee.
At that stage, Caitríona Lucas had been on board the Shannon-based Irish Coast Guard helicopter and had flown to a cliff where she was accompanied by paramedics. Bernard Lucas was escorted to her in a Garda car and flew with her to the Limerick University Hospital.
The Doolin RIB with Mr. McGrath and Mr. Spillane on board were transferred to the incident where the RNLI Aran lifeboat was located. Kilkee helmsman James Lucey was stuck at the back of an entrance to a cave, which was not accessible to both the lifeboat and the helicopter. Several jet ski teams tried to approach him, and one out of two of a Lahinch team made several very risky attempts to swim to the cave.
In the end, a combination of Doolin Coast Guard and Kilrush firefighting teams managed to get a line to Mr. Lucey and was subsequently taken out by the Waterford-based Rescue 117 helicopter at 5:25 pm, after a four-hour ordeal.
Declared dead
At this stage it was clear from VHF's reports that Caitríona Lucas was critical and might not make it. She was declared dead in hospital at 16.05 hours. On his way back to Doolin it was observed that the Doolin RIB stopped underneath the Cliffs of Moher and lifted one of his engines, suggesting that he was in trouble.
The Irish Coast Guard crews hold debriefs immediately after a call to mitigate the impact of trauma and identify potential problems. There was no direct debriefing for the Doolin crew after the Kilkee mission of September 12, 2016. However, there was a critical incident-stress briefing for both the Kilkee and Doolin crews, who were being held by a trained independent person. Sources near the volunteers say that no joint effort has been made to provide continuous counseling for all involved, including the Lucas family.
The Irish Coast Guard said an offer of counseling in February & # 39; personally & # 39; was done to a person in Co Clare. It states that counseling can be done by volunteers, what is paid for it and a confidential number for a counseling company is available at every station.
Very shortly after the death of Mrs. Lucas, regular training with the Doolin unit involved a survival exercise from the pier. A dry suit or survival suit, worn by one of the volunteers, began to fill with water and the volunteer returned to the station to discover that the neck seal on the suit had failed.
He was not aware that there was a problem with the neck seal on another drysuit worn by the second mate on the Kilkee crew Jenny Caraway. Fortunately, this was noticed by one of her colleagues during the time before she went out on September 12, but it indicated that there was a bigger problem with the equipment.
& # 39; Critical shortcomings & # 39;
The MCIB draft report notes that new safety helmets and dry suits for the sea were delivered to both the Doolin and Kilkee Coast Guard units prior to 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 essential to keep a helmet in place and provide maximum protection.
It notes that there was no evidence of any effective management in Kilkee with "associated supervision". It found that the Delta RIB was used outside of the Irish Coast Guard's own operational limits, and that there were "critical shortcomings" with the communication and navigation equipment of the boat.
It also notes that there was no registration of any risk assessment prior to the launch when Kilkee's second vessel, the D-class ship, was launched, although this was in response to the Mayday from the Delta.
The draft report states that the Delta RIB was not licensed or certified for the activities with which the RIB was charged – such as in a passenger boat license – for which regular surveys were required and for which there was no license for a ship's radio station. It notes that the helmsman of the boat James Lucey "had followed all relevant training" for his role at the Irish Coast Guard, but had no driver's license for passenger ships.
However, an Irish Coast Guard spokesman told The Irish Times that rescue boats were not passenger ships, were not available for hire and that it was an "effective boat traffic system that was regularly checked and assessed".
Most striking is that the Irish Coast Guard does not have an effective safety management system based on accident reports and other "non-compliance" to review the procedures and to constantly look for improvements. The draft report highlights an example of this – the capsize of a Delta RIB in Dingle on 25 August 2014, which, as he notes, & # 39; similar attributes & # 39; has with the Kilkee case.
Surf zone operations
A February 2015 internal investigation into that incident in Dingle reported that the Irish Coast Guard RIB was capsizing when it tried to surpass a breaking wave in a "surf zone" or shallow area. Surf zone operations are excluded by the policy of the Irish Coast Guard because of the security risks, and the first of the 20 recommendations of the internal investigation required a revision of the procedures in this respect.
The concept report from the Kilkee incident says: "It is clear that not all recommendations [arising from Dingle] were implemented ".
The Kilkee Delta RIB has capsized in a surf zone. The shallow bay was deemed unsafe by other coachmen. Although volunteers say they heard about the Dingle incident in August 2014, they did not receive a formal memo from the Irish Coast Guard or the internal report that was never published.
"If we had known everything we should have known about Dingle, Caitríona Lucas could still live," sources in the vicinity of volunteers have told this newspaper.
The sources believe that there are still many unanswered questions that may fall outside the scope of the research, including not addressing a particular management culture.
Operational issues related to the management of more than 900 volunteers do not fall within the scope, according to the draft report, but allude to extra responsibility on coxswains as a result of additional training requirements from 2013. Volunteers, who give their time during rigorous training of five can take a year and will take a very minimal cash reimbursement of € 12.70 for training and activities based on stations and an allowance of € 10.16 for the first hour of a call-out and € 3, 81 for every following hour.
Kilkee Coast Guard has not been able to return to the high seas since September 2016, and Minister of Transport Shane Ross told the Dáil in February 2018 that this "should give time for the training of new crews and that existing members again to be certified "to a sufficient standard".
complaints
A number of complaints have been filed by Kilkee members to the management of the Irish Coast Guard, and there are four lawsuits against the state about posttraumatic stress going on. There is also a separate investigation into the health and safety authority (HSA). After the death of Ms. Lucas, the Irish Coast Guard asked for an assessment by the British maritime coast guard that has not yet been published.
The former OIC of Kilkee Martony Vaughan is back with Doolin Coast Guard, where he spent so much time since 2000. The Irish TimesMr Vaughan said he did not want to comment on the draft report or on other issues raised.
The Irish Coast Guard said that a merger of teams in Kilkee under his responsibility was "complicated", but the situation was "assessed" as ready for "local management" and the meeting of September 9, 2016 was to formalize this, with Mr Vaughan as having been reassigned to project work on remote-controlled aircraft for search and rescue.
It said that the tensions after the death of Ms. Lucas & naturally came back up & # 39; in Kilkee, that some members temporarily left or stopped, and that a number of members creaked each other & # 39 ;. It said that it had appointed an independent company to manage the complaints & # 39; holistically & # 39 ;, by mediation and & # 39; if necessary & # 39; research. Apart from that, Kilkee's unit is trained by an expert in teambuilding and personal communication.
The Irish coastguard has said that it will not comment on operational and safety systems while the investigations are being continued, but said that it has used a health and safety officer, together with the services of a "competent company" to create a "gap". analysis "that was" in progress ".
It has said that there are "comprehensive" formal training in the field of boat management, proper use of dry suits and helmets, and dry suits and life jackets are maintained annually and neck seals are routinely replaced.
In January 2018, a safety notice was issued on boat operations, he added, repeating key safety and risk management requirements, dynamic risk assessments, buddy checks and surf / breaking waves and other safety and survival checks and procedures.
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