The final report into the marine tragedy in which Doolin-based volunteer coastguard crew member Caitríona Lucas died in 2016 is critical of safety aspects of the operation.
It concluded that the Delta Rigid Inflatable Boat that capsized was launched in conditions that were outside the operational limits of the vessel and that there were deficiencies with its communications and navigational equipment.
Ms Lucas, a 41-year-old mother-of-two living in Liscannor in Co Clare, was searching for a missing man with two other volunteers when their rib overturned near cliffs at Kilkee on 12 September 2016.
A rescue operation was launched to assist them, but Ms Lucas died shortly after she was airlifted from the water by the Shannon rescue helicopter.
A report into the incident by the Marine Casualty Investigations Board is critical of aspects of the operation that day and the management of some of the safety systems operated by the Irish Coast Guard.
It says the Irish Coast Guard does not have an effective safety management system as demonstrated by recent events and about which some recommendations remain outstanding.
The criteria for determining the response to recovery operations as opposed to search and rescue operations are not clearly defined.
There is also criticism of the Delta rib used in the recovery operation that day.
The report states that it was not licenced or certified in accordance with the statutory requirements for the activities in which it was engaged and was launched in conditions that were outside the operational limits of the vessel.
The reports adds that insufficient consideration was given to the necessity and effectiveness of the boat operation and that there were critical deficiencies with the boat's communication and navigation equipment.
It did not hold the required ship radio station licence and the rib's cox did not hold the required statutory operators' licence, which is a mandatory qualification.
The report is also critical of Kilkee rescue station and questions its pre-determined operational readiness and the absence of any effective management system in place with associated oversight.
The report recommends that the Minister for Transport should review the Irish National Search and Rescue Framework to ensure the criteria for determining the response to recovery operations as opposed to search and rescue operations is clearly defined and that the criteria for tasking and launching coastguard boats is reviewed and clearly documented.
The report calls on the Irish Coast Guard itself to implement a comprehensive safety management system and address all aspects of the management of the service, including the management of volunteers, their appointment and training.
It should also undertake regular audits and governance of that management.
In an appendix included in the report, the Irish Coast Guard says it is flawed in its presentation of the evidence and requires a substantial reappraisal of the analysis on which its conclusions are based.
In particular, it says the weather intelligence available to key decision makers on the day was incorrect and this distorts the overall analysis.
It says the weather forecast was well within the weather limits for the rib and that the warning of a heavy swell was "nil".
But the report warns that this "nil" heading should not be interpreted to mean there is no swell expected.
In a statement, Minister for Transport Shane Ross expressed his sympathy to the Lucas family and said Ms Lucas was an "extraordinary woman - brave, committed, supremely generous - and her death was an appalling tragedy".
He welcomed the report's recommendations and said he would ensure they are all implemented.