Report into tragic Caitríona details her last moments
Marine board strongly critical of Irish Coast Guard
THE TRAGIC last moments of the first Irish Coast Guard volunteer to die in the course of their duties were detailed yesterday in a critical report into her death.
Catríona Lucas, who was posthumously awarded the Gold Medal Award for Bravery, died when her rigid inflatable boat (RIB) capsized during an operation to recover the body of a missing man off the Clare coast.
The Marine Casualty Investigation Board report into the September 12, 2016 incident, which is very critical of the Irish Coast Guard (IRCG), contains a detailed chronology of her last moments. But it also details safety-related deficiencies it believes existed at the time.
And it would appear, from what it says, some factors could have saved the 41-year-old librarian, who was part of the Co. Clarebased Doolin Coast Guard.
She had joined what had started as an effort by nearby Kilkee Coast Guard to rescue school inspector David McMasacrifice hon, who had fallen from cliffs into the sea off the north Clare coast. The MCIB also said that – in its opinion – the Irish Coast Guard does not have an effective safety-management system.
Last night, Transport Minister Shane Ross said: ‘I have instructed the IRCG to accelerate its work in developing an independently accredited safety management system that will be robust and fit for purpose.
‘This work is already under way, and significant effort and investment has taken place over the last two years. That said, I am requiring the IRCG to take the necessary steps to ensure that any issues which could impact on crew safety are addressed as a matter of urgency.’
He also paid tribute to Ms Lucas, saying: ‘I wish to again express my deepest condolences to the family and loved ones of Caitríona, who lost her life so tragically, doing the volunteer work she loved.
‘Caitríona was a talented, hardworking and deeply committed member of the Doolin Coast Guard Unit.
‘She was a selfless member of a unique group of people, those men and women who dedicate themselves to the protection of others at great risk to themselves.
‘Caitríona made the ultimate and her loss has been enormous.’
Among the most crucial items the investigating board picked up on was the helmet Ms Lucas – a widely respected search and rescue veteran – was wearing at the time her RIB capsized.
The rescue craft she was on was capsized by a large breaking wave striking it and all three crew members were thrown clear of the vessel and lost their helmets.
They found themselves in heavy seas which righted the boat again.
The boat’s cox – the person in charge of the vessel – was washed inshore and he clung to rocks until he was winched off by an Irish Coast Guard search and rescue helicopter.
The second cox swam offshore and was rescued by boat.
She had ingested water and required medical attention once brought ashore.
However, Ms Lucas, who is referred in the report as ‘the casualty’, was washed inshore with the boat onto a rock ledge that was awash under the cliffs.
‘She clung to the grab line on the port bow of the boat, but was repeatedly washed off and went under water,’ the report noted.
‘After three minutes she was washed off and did not swim back to the boat. Video footage showed her face down with her [lifejacket] uninflated.
‘The casualty expended energy holding on to the boat, would have ingested water and probacause
‘Safety-related deficiencies’ ‘No evidence of instruction’
bly received the impact to the head during one of the periods when she was submerged.’
It then concluded that a helicopter ‘winched the casualty out of the water and landed on an adjacent cliff top where paramedics attended to her’.
They brought her to Limerick University Hospital where she was pronounced dead.
Her post mortem report of September 13, 2016 indicated the of death was drowning.
However, the report noted, ‘the skull injury might have been a contributory factor but, on its own, this injury would not have been fatal’.
It further added: ‘The three crew members lost their helmets during the capsize.
‘The investigation was unable to establish definitively how the helmets were lost.
‘The security of the helmet in use depends entirely on it being properly fitted/inflated and secured according to the manufacturer’s instructions.
‘The post mortem on the casualty [Ms Lucas] identified a trauma to the side of the head in a position which should have been protected by the helmet.’
In a general but damning conclusion, the report stated: ‘The IRCG needs to implement an effective and functioning safety-management system.’
It made this comment after pointing out that while recommendations had been made after a major safety-related incident in 2014, with ‘many attributes similar to the present case’, not all of the recommendations had been implemented.
The report also pointed out: ‘In 2013, new helmets and drysuits were provided to both Doolin and Kilkee CGUs.
‘There was no evidence of formal instruction or training in the use of this equipment.’
In addition, the report noted: ‘The Irish National Search and Rescue Framework does not provide adequate clarity in relation to search and recovery operations as to when a search and rescue operation becomes a search and recovery operation or at any of the intermediate stages.’
It also stated: ‘Additional factors which do not appear to have been considered included the operational status of the vessel and functioning of all equipment.’