THE FAMILY of Irish Coast Guard advanced coxswain Caitrona Lucas has criticised the Coast Guard for safety systems failures, after a jury at an inquest into her death returned a unanimous verdict of misadventure.
By Lorna Siggins
The jury of four men and three women at the inquest before Limerick coroner John McNamara also issued seven recommendations for the Irish Coast Guard relating to safety, equipment, management and training.
Ms Lucas (41), an experienced member of Doolin Coast Guard and mother of two, died after a rigid inflatable boat (RIB) capsized off the Clare coast on September 12th, 2016.
The librarian from Ballyvaughan and living in Liscannor was the first Irish Coast Guard volunteer to lose her life during a tasking.
She had been assisting the neighbouring Kilkee unit in a search for a missing man when the incident occurred.
Mr McNamara heard from two survivors of the capsize, among some 28 depositions taken over four days at Kilmallock Court, Co Limerick.
Attending were Ms Lucas’s husband, Bernard, son Ben and daughter Emma, father Tom Deely, and siblings Padraig and Bríd, along with long-time friend and former Doolin Coast Guard member Davy Spillane.
The inquest heard evidence that a recommendation for a safety systems manager at the Irish Coast Guard in 2012 was not implemented till 2018.
It heard that “interpersonal issues”, which had been reported to Irish Coast Guard management the previous March (2016), had led to a loss of experienced volunteers at the Kilkee unit – which meant “flanking stations”, including Doolin which Ms Lucas was a member of, were asked to help out.
It heard Ms Lucas was conscious in the water for 17 minutes after the Kilkee Delta RIB was hit by a wave and capsized in a shallow surf zone at Lookout Bay off Kilkee, and that a second RIB owned by the Kilkee unit could have reached the area to effect a rescue of all three on board within 10 minutes.
However, after Kilkee deputy officer-in-charge Orla Hassett called for that D-class rib to be launched, two of her colleagues left the station. She had to requisition a privately owned vessel which rescued one of the three, Kilkee volunteer Jenny Carway.
In a statement given to the inquest on Thursday (Nov 30), Kilkee volunteer Lorraine Lynch, who had been at the station with Ms Hassett when a “Mayday” alert was relayed, said that she was “told” by Martony Vaughan as officer-in-charge (OIC) “to come with him in the jeep to the cliff walk”.
Kilkee Delta RIB coxswain James Lucey, was rescued some hours later by the Shannon Coast Guard helicopter.
The helicopter had also airlifted Ms Lucas on board earlier and flew her to Limerick University Hospital where she was pronounced dead.
The jury heard evidence that her drysuit – which was not made available to the HSA for examination and was disposed of by the Coast Guard – was filled with water.
The inquest heard that the cause of Ms Lucas’s death was due to drowning, but a head injury which could have caused temporary loss of consciousness was a contributory factor.
Two State investigations have already taken place into Ms Lucas’s death, and three years ago the Director of Public Prosecutions (DPP) directed that no criminal charges would be brought arising from an HSA inquiry.
A separate MCIB report was critical of the Irish Coast Guard’s safety management system and outlined a number of systems and equipment failures in relation to the Kilkee unit.
HSA inspector Helen McCarthy told the jury on Wednesday that she had examined Ms Lucas’s Coast Guard logbook, and described her logkeeping as fastidious and said she was so dedicated. “I have never seen anything quite so meticulous,” she told the coroner..
Simon Mills SC said Ms Lucas was “an absolutely fantastic member of the Coast Guard”.
In his closing submission on the final day of the inquest on November 30th, marine expert Michael Kingston for the Lucas family, said the 2012 recommendation in a consultancy report by Fisher Associates for the Coast Guard was not implemented until after the death of Ms Lucas in 2016, and loss of four Coast Guard air crew in the Rescue 116 crash off north Mayo in March, 2017.
Mr Kingston referred to personnel shortages at Kilkee Coast Guard station and ongoing “hierarchical issues”, which had been discussed in detail with senior Coast Guard managers in the months before.
Mr Kingston proposed the jury should consider a verdict of unlawful killing.
However, Simon Mills, senior counsel for the Department of Transport/Irish Coast Guard, said that a narrative verdict, or death by misadventure or accident were the options that should be considered by the jury under the legislation.
Mr Mills said that all three crew members on board the rib that capsized were in satisfactory safety gear, but were “blindsided” by a wave.
He said that none of them meant to be in an area where they would be at risk from the conditions that unfolded.
Mr Mills said there was no dispute that the Kilkee D-Class rescue boat had not been launched at the earliest possible opportunity, but said that it could not have one into the area where Ms Lucas was located and would have had to stand off the surf zone where she was in difficulty.
Summing up for the jury at the inquest on Thursday evening, Mr McNamara said it appeared there was a “brain drain” in relation to the Kilkee unit and some “confusion” about the command structure of the unit.
Mr McNamara said that Ms Hassett had put it “quite succinctly” that this was not relevant when three people were available to launch a second RIB to effect a rescue.
He recalled that evidence had been heard about previous recommendations, including those in an appendix to the Marine Casualty Investigation Board (MCIB) inquiry into Ms Lucas’s death relating to a previous incident in a surf zone off Inch, Co Kerry, in 2014.
He said that the Kilkee unit was not aware of those Inch recommendations, and he noted evidence from HSA inspector Helen McCarthy that there was no site specific risk assessment of the area where the capsize occurred and no map of hazardous areas at the Kilkee station.
Mr McNamara recalled evidence being heard that the radar system on the RIB was not operational, one of its seats was not in commission, and the radio was not working.
He noted that British marine safety expert Nick Bailey had confirmed the equipment was suitable for use in Irish coastal areas, but there was an issue for the Irish Coast Guard with helmets coming off on impact.
Earlier, Mr Bailey said in evidence that the loss of helmets by all three Coast Guard crew after the Kilkee Delta RIB capsized “should raise concerns” with the Coast Guard in relation to their design and whether they were being worn correctly.
Mr Bailey confirmed that Ms Lucas’s drysuit was not available for his inspection.
Mr Bailey told the inquest that he had examined Coast Guard safety equipment, including lifejackets, helmets and drysuits, at the Health and Safety Authority (HSA) on June 12th, 2017, nine months after the incident in which Ms Lucas lost her life.
The inquest had already heard that the HSA was unable to start its investigation until then, when it could establish it had a legal right to do so, and was only given access to one piece of Ms Lucas’s safety gear – as in her drysuit, which it was allowed to photograph only, and which was then disposed of in a skip.
Mr Bailey said that in his assessment the drysuit and thermal clothing used by the Irish Coast Guard was “appropriate” for the type of work it was doing in Irish waters.
He said that while the type of lifejacket he had examined was a “reasonable compromise” between support and free movement, it would not necessarily keep an unconscious person upturned with a clear airway.
The inquest heard that this Mullion design of lifejackets has since been withdrawn by the Irish Coast Guard.
In his summing up, Mr McNamara said that “it is clear that if Ms Lucas’s helmet had remained on, it may have avoided the head injury that she sustained”.
Mr McNamara said it was “unfortunate” that her drysuit, which had filled with water, was not available for inspection by the HSA or its experts.
The coroner said that “we don’t know what the outcome would have been” if the Kilkee D-class RIB had been launched, but Mr Kingston had established from drone footage that there was a window of 17 minutes.
“Ms Hassett, an experienced volunteer, felt they could have attempted a successful rescue,” he said, and he paid tribute to her presence of mind and that of Garda sergeant John Moloney in requisitioning a civilian vessel which rescued Ms Carway.
“This occurred within an emergency situation, with a lot of pressure on everyone involved,” he said. He also commended those who had recorded the drone footage.
In a statement afterwards on behalf of the Lucas family, her son Ben said that “the Irish Coast Guard’s failure to have proper safety systems caused my mother’s death”, and “the minister in charge of the transport department in 2012 should be held to account”.
Mr Lucas said there were “critical lessons to be learned”, and the jury had made recommendations that should have been made seven years ago “to protect life”.
Mr Lucas criticised the delay in holding the inquest, and said that “the preservation and production of evidence has been appalling”.
“Irish Coast Guard management, the Attorney General’s office and the Department of Transport did not act on a critical report in 2012 that instructed them to put in place a senior safety systems manager in the Irish Coast Guard that never happened, and my mother went to help others but was let down so terribly,” Mr Lucas said.
Condolences were expressed to the Lucas family by the coroner, Gardai, legal representatives for both parties, and the HSA.
The Irish Coast Guard says it accepts the findings made in the inquest into the death of advanced coxswain Caitriona Lucas of its Doolin unit off the Clare coast in September 2016.
A statement by the Irish Coast Guard said it would “now take time to reflect on the recommendations” and described Ms Lucas as “a very highly regarded and valued member of the Doolin Unit of the Irish Coast Guard who tragically lost her life in the course of duty”.
“We would like to extend our condolences to Ms. Lucas’s family and friends on their enormous loss,” it said.
“We will now take time to reflect on the recommendations that have been made,”it stated, and said that it was working to implement recommendations arising from two previous investigations into her death.
The Irish Coast Guard said its “priority at all times is the safety of our volunteers who save the lives of others”.
“Following Ms Lucas’s death, both the HSA and the Marine Casualty Investigation Board have conducted reviews into the incident and the Irish Coast Guard has worked to implement the recommendations stemming from both of these reports,”it said.
“The Irish Coast Guard is committed to operating at the highest possible maritime safety standards so that we support and protect our volunteers as they work to serve communities all around Ireland,”it said.
It thanked Mr McNamara and the jury “for the work and time they have dedicated to this inquest”.