Operators were warned life jackets not fit for purpose five years before R116 crash

In the five years before Rescue 116 crashed, the company that runs the search and rescue helicopter service, CHC Ireland, received repeated warnings that the life jackets they supplied to their pilots were not fit for purpose.

The helicopter crashed into Blackrock Island, off the Co Mayo coast in March, claiming the lives of all four people on board - writes rte.ie.

The bodies of Captain Dara Fitzpatrick and Captain Mark Duffy have been recovered but two others, winch operator Paul Ormsby and winch man Ciarán Smith, remain lost at sea.

Pilots had warned management that the personal locator beacons on the life jackets were not installed according to the beacon manufacturer’s guidelines and would not work.

One pilot warned that unless the life jackets were modified to address this fault "pilots are wholly exposed in the event of a ditching".

The beacon manufacturer advised that the beacon should be located at least 30cm apart from the GPS antenna. However, in the pilots' life jackets both elements were in the same pouch.

A safety report filed by a crew member in 2014 stated: "Effectively this means that the beacon could produce absolutely zero receivable transmissions."

The Air Accident Investigation Unit issued a preliminary report four weeks after the crash , which identified this crucial issue and issued a safety recommendation to the life jacket manufacturer to review the installation of this equipment.

A report to be broadcast on RTÉ’s Prime Time tonight reveals internal documents that show that the operator CHC was aware of this fault for at least five years before the accident.

When Rescue 116 crashed, none of the personal locator beacons worn by the four crew members activated.

While the installation fault only applies for the pilots' life jackets, Prime Time also has documents that show there had previously been ongoing issues with the beacons on the life jackets supplied to winch crew.

The life jackets were tested eight weeks after the crash. The type of life jacket worn by the winch crews passed the test.

However, the life jacket that pilots had been wearing failed to activate. CHC Ireland immediately withdrew those life jackets from service.

In a statement CHC Ireland said: "Given that the Rescue 116 accident continues to be the subject of a formal investigation ... it would be inappropriate for us to respond to specific questions of a technical nature.

"CHC is subject to oversight and regular independent audit by the Irish Aviation Authority, as well as audits undertaken on behalf of the customer - the Irish Coastguard."

The life jacket manufacturer Beaufort Ltd said it was "aware of the findings of the AAIU report, which are at this stage preliminary".

"'Investigations are continuing and we are liaising closely both with the AAIU and the Irish Coast Guard. We cannot make any further comment until the final outcome of the investigation."

Tonight's Prime Time report will also reveal that Coast Guard helicopter crews repeatedly raised concerns about the quality and accuracy of the maps on board their helicopters.

Since the Rescue 116 crash, it has become known that that the island the helicopter crashed into was not in the database of a key safety system .

The Enhanced Ground Proximity Warning system is designed to warn pilots if they get too close to terrain or an obstacle.

It has also been reported that CHC management had been told that this was missing from that database three years previously.

Safety issues with search and rescue services

Prime Time’s Katie Hannon will report on the series of safety issues concerning the search and rescue service, including maps and survival equipment.

One of those issues related to life jackets?

Yes, or more specifically the way that personal locator beacons were fitted on the life jackets supplied to coast guard pilots.

Every coast guard life jacket is fitted with a personal locator beacon and a GPS antennae, which is a key safety system to ensure that crew members can be quickly located in the water in the event of an accident.

The beacons are designed to activate automatically. Once they hit water they send a distress signal that is picked up by an international search and rescue satellite system. The GPS antenna ensures that rescuers get an exact location for the distress call.

When Rescue 116 crashed, the search and rescue satellite received no distress signals. This delayed the recovery of the pilots Dara Fitzpatrick and Mark Duffy, and of course the winch crew, Ciaran Smith and Paul Ormsby, have not yet been recovered. This failure sent shockwaves through the search and rescue service.

Was this mentioned in the AAIUpreliminary report into the crash?

Yes, the preliminary report issued by the Air Accident Investigation Unit four weeks after the crash identified a crucial issue in relation to this that may explain why the locator beacons on the pilots' life jackets at least did not activate.

It pointed out that the company that manufactures the beacons recommends that in a lifejacket the beacon and the GPS antenna should be at least 30cmapart.

But on the lifejackets worn by Dara Fitzpatrick and Mark Duffy, and all other Irish Coast Guard pilots, this was not the case. In fact, the beacon and the antenna were located together in the same pouch.

The AAIU issued a safety recommendation about this and said the life jacket manufacturer should review the viability of this installation on these life jackets.

Should this have come as a surprise?

What Prime Time will show tonight is that CHC Ireland - the company that provides the search and rescue service - had been repeatedly warned about this exact problem by their own crew in formal safety hazard reports going back five years before the crash.

These reports went into huge detail about this issue and clearly stated the implications.

In one report, a pilot warned "I would suggest that pilots are wholly exposed in the event of a ditching" until the life jackets are modified. That report stated that the CHC Design Office was looking into it.

Crews were told in 2012 that life jacket manufacturer was reviewing the installation of this equipment. But for whatever reason these life jackets were never modified and hazard reports continued to be filed about them over the following years.

There were also hazards reported with the winch crew life jackets, which were designed differently to allow them to do their job. There were a number of reports about wires being broken on these jackets and other complaints about their beacons not being armed or switched on for operations.

The CHC employee spoken to by Prime Time explained what they had expected to happen once a safety concern was flagged.

They said: "Obviously if you highlight a concern or something that may be related to safety or a hazard identification, management look at that and they see if they can improve it, but again, how a report from 2011 onwards could slip through cracks and be closed out as fixed is just ... no-one can comprehend that."

In the weeks after the preliminary report into the crash was issued, pilots became concerned that they were still being asked to fly wearing these life jackets.

"All the crews spoke to management directly and stated that they weren't going to operate over water with defective jackets that may or may not work," they said.

"It wasn't right for ... there's a duty of care to us as employees. What we were more amazed at is that when the preliminary report came out that the aviation authority didn't come in and step in and just go 'hang on, you can't operate like this'. No-one seemed concerned that they actually didn't work."

The pilot and winch crew life jackets were eventually tested weeks after the crash. The MK 15 life jackets worn by winch crew passed the test. Their beacons worked when put into salt water.

However, the beacons on the MK44 life jackets worn by pilots failed to emit a signal. Those life jackets were immediately withdrawn from service.

What does CHC have to say about this?

CHC Ireland said: "Given that the Rescue 116 accident continues to be the subject of a formal investigation ... it would be inappropriate for us to respond to specific questions of a technical nature.

"CHC is subject to oversight and regular independent audit by the Irish Aviation Authority, as well as audits undertaken on behalf of the customer - the Irish Coastguard."

The life jacket manufacturer Beaufort said it was aware of the findings of the preliminary AAIU report. It said "Investigations are continuing" and it is liaising closely with the AAIU and the Irish Coast Guard.

"'We cannot make any further comment until the final outcome of the investigation," it said.

Read also more news of Dublin on our site.

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