Over six months after Rescue 116 crashed into Blackrock Island off the coast of Co Mayo, a number of safety concerns still exists for Ireland’s rescue helicopter services.
One of the safety issues highlighted was known five years before the R116 crash.
The rescue helicopter crash claimed the lives of all four people on board.
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.
RTÉ’s Prime Time has reported that new maps published by the Irish Aviation Authority contain errors which the authority was alerted to.
Nine days after the R116 crashed into Blackrock Island, the IAA was informed that Sceilg Mhichíl was depicted on their maps. Last July, the IAA told Prime Time that after the discovery of the error, a "review of all other coastal islands was conducted and their data verified.
"No further anomalies of substance were found."
However, there were other substantial anomalies on the maps.
Achill Island was depicted in the official aeronautical quarter inch map with no contours or tinting to indicate high ground. In fact Achill Island has two peaks that are over 2200ft high.
A recreational pilots' association contacted the IAA to outline the error and a number of other inaccuracies last May, saying pilots should be urgently warned about the potential hazards.
The authority's Director of Safety Regulation responded that their inspectors had evaluated all of the specific details that were outlined and they had determined that "none of these issues affect the safety of any VFR operations."
However, the new maps that were published by the IAA since then contain the errors highlighted, as well as a number of new errors.
The most westerly of the Blasket Islands off the cost of Kerry, Inishtarraght, appears on the chart to have a highest point of 276ft. It is 660ft at its highest point.
On Rathlin Island, the map shows a lighthouse with an elevation of 243ft. There is no tinting or contours or any spot height to show the island has a highest point of 440ft.
There is no spot height on the map referring to the 1,400ft mountain peak near Malin Beg.
Bull Rock Lighthouse is no longer on Bull Rock Island on the new map, while Fastnet Rock has been moved further out to sea than its actual location.
The map shows Mine Head Lighthouse as an offshore lighthouse whereas it is actually located on the Waterford coast.
The IAA, which has responsibility for the production of these maps, declined to comment due to an ongoing investigation by the Air Accident Investigation Unit into the R116 crash.
A spokesperson for Minster for Transport Shane Ross said that it was inappropriate to comment at this time.
Helicopter moving maps 'blurred and unreadable'
RTÉ’s Prime Time programme also revealed that on the night of the R116 crash, the moving map that was on board the helicopter was blurred at some settings.
Also, when the map was zoomed in to a close range, the height of the island was hidden behind the location code.
Cpt Fitzpatrick planned her final flight at the Dublin Base office using the Skydeamonflight planning tool, which showed Black Rock Island as a dot. The planning tool had no information to indicate that the island was that of a significant height.
RTÉ’s Prime Time also reported that a few weeks before the R116 crash, Coast Guard pilots began testing a new electronic mapping system which was uploaded on to a mini iPad and strapped to the pilots' knee boards.
Both pilots on R116 took these iPads on board on the night of the crash off the Co Mayo coast. The map that was used was not approved for use as a navigation tool as it was still on trial.
It showed Black Rock Island at 46ft, however, it is 282ft at its highest point.
RTÉ’s Prime Time has learned that the search and rescue teams had been complaining about poor quality maps and navigation equipment for months before the crash.
In September 2016, a flight safety meeting attended by R116 winch man Paul Ormsby, discussed feedback on their new Operations Manual.
The manual warned that the moving map system on board the helicopters should not be used for primary navigation "as it provides insufficient detail and is not kept up to date".
One crew member asked "why is this map not kept up to date ... Some of the map images in aircraft are completely blurred and unreadable. For reasons of safety this system needs to be updated and of a quality that is usable for our current operations."
A month after this safety meeting, the issue was raised again at another flight safety meeting attended by Cpt Fitzpatrick and winch man Ciarán Smith.
This meeting was told that on a recent mission to London Heathrow "the moving map system was practically useless to the crew due to poor image quality and blurry detail when zoomed in.
"Crews are becoming frustrated by the lack of feedback or action. This important safety issue has been ongoing for several months now'.
An employee with CHC Ireland, a company that runs the search and rescue helicopter service, spoke anonymously to Prime Time and said that CHC Coast Guard pilots are still flying with blurred maps.
Operators warned about life jackets before R116 crash
In the five years before the R116 crash, CHC Ireland received repeated warnings that the life jackets they supplied to their pilots were not fit for purpose.
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.
RTÉ’s Prime Time revealed internal documents that show that the operator CHC was aware of this fault for at least five years before the accident.
When R116 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."
Confusion over responsibility for search and rescue helicopter safety oversight
In 2010, an audit by the International Civil Aviation Organization of the oversight of the Search and Rescue service found wanting.
The ICAO identified a gap and told the Department of Transport that it must establish a Search and Rescue inspectorate "comprised of a sufficient number of qualified staff".
The department has said that it dealt with this gap in 2013 by engaging an official from the UK Maritime and Coastguard Agency to carry out safety oversight "as required on an ongoing basis."
The Department of Transport initially told RTÉ’s Prime Time that the Irish Aviation Authority was responsible for safety oversight of the Search and Rescue helicopter service.
However, the IAA’s own State Safety Plan states that 'Search and Rescue is ... outside the remit of the IAA'.
Prime Time asked the IAA to explain how it was engaged in auditing an operation that was officially outside if its remit.
It told Prime Time that it was not in a position to comment on this issue due to the ongoing investigation into the Rescue 116 crash.
The Department of Transport also declined to comment in this apparent conflict.
Following the Prime Time programme, a spokesperson from the Department of Transport issued a statement saying that it will not be making any comment while an investigation is under way.
The statement said: "As there is an ongoing investigation by the Air Accident Investigation Unit, and it is reasonable to assume that as part of that investigation into the incident involving a CHC/Coast Guard Rescue helicopter (R116), it may well explore a wide range of issues, including established procedures, practices and any other issues that it decides are pertinent to its ongoing investigation.
"The Department is strongly of the view that the investigation must be allowed carry out its function free of speculation and/or pre-emptive assumptions.
"Therefore it is particularly important that the Department and the Minister avoid any suggestion that it is commenting on or drawing conclusions about an active and independent investigative process."