The father of Rescue 116 Pilot Captain Dara Fitzpatrick has said many things about the helicopter crash which claimed the life of his daughter and three colleagues are clearer after the inquest.
John Fitzpatrick was speaking on Prime Time after verdicts of accidental death were returned by a jury at the inquests into the Rescue 116 helicopter crash five years ago.
All four crew members on board the aircraft died when it crashed into Blackrock Island, off the Mayo coast, on 14 March 2017.
Mr Fitzpatrick said: "I learned from the beginning, how the whole thing started with the skipper, from the fishing vessel ringing into Malin Head and then the helicopters being tasked. And then the top cover, which I had never heard of before. And then the doctor in the hospital, all of that sort of stuff was an awful lot clearer in the inquest."
He said he was shocked and saddened after an earlier Air Accident Investigation Unit (AAIU) report.
"I just couldn't fathom that there wasn't systems and rules in place, which governed a lot of what happened. And that became a lot clearer, I thought, during the inquest," he said.
Mr Fitzpatrick said the families had received "unbelievable" support from the people of the areas around the crash and paid tribute to the other crews of coast guard helicopters.
"Even still, they would ring you and that, and it was a terrible thing for them. I mean, they were shattered by it, their colleagues, four of them gone just like that," he said.
He also said the inquest jury had been "extraordinary".
"There was an application to adjourn last night or not to carry on and finish. And they said 'no, we want to look at this overnight'.
"And they came back, they studied everything. They obviously read [the AAIU] report. They came back and asked a question which [the author] then had to answer. They seemed to know all about search and rescue and the importance of the way that these rescue services in general are run. They did an amazing job in it."
The bodies of Captain Mark Duffy and Captain Dara Fitzpatrick were recovered in the aftermath of the tragedy. But the remains of their colleagues, Winchman Ciarán Smith and Winch Operator Paul Ormsby, remain lost at sea.
At the conclusion of evidence at Belmullet Coroner's Court last evening, the jury retired to consider its verdicts.
Soon afterwards, proceedings were adjourned for the night and deliberations resumed at 11am.
After considering the evidence for over an hour-and-a-half today, the jury delivered verdicts of accidental death in respect of each of the four fatalities.
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The jury also issued a number of recommendations, following its deliberations.
Firstly, jurors endorsed the 42 recommendations contained in last November's Air Accident Investigation Unit report. They said there was a need for "definitive medical criteria" to inform decisions around the tasking of air search and rescue (SAR) operations. The jury said there should be "no ambiguity" in future, regarding the decision making process.
A further recommendation advises that "reliable" top cover be in place, at all times. This is the term used to describe the back-up, or support role, that a second aircraft performs on long distance SAR missions. The jury said that, ideally, this cover would not be provided by other SAR aircraft.
Jurors also drew attention to errors in mapping and navigational systems, which contributed to the fatal crash. They said there must be "cohesive oversight" to rectify this.
The recommendations were followed by a statement, in which the jury recognised the efforts of the myriad agencies involved in the search operation in the aftermath of the tragedy.
The North Mayo Coroner, Dr Eleanor Fitzgerald, said a "multiplicity of factors" had caused the crash. She expressed sympathy to the bereaved families, at the conclusion of today’s proceedings.
Afterwards, Captain Dara Fitzpatrick’s father said the inquest process had been difficult for the families of the crew members. But John Fitzpatrick said it had helped him to further process the loss of his daughter and he thanked those involved for the work they carried out in recent days.
Inquest heard detailed discussion about the events leading to the crash
At an earlier sitting, Coroner Dr Eleanor Fitzgerald accepted evidence from those involved in the massive search that followed the crash, which allowed her to pronounce both missing men dead.
The initial sitting also heard that Cpt Fitzpatrick died as a result of drowning, with Cpt Duffy sustaining fatal injuries as a result of the crash.
The inquest heard detailed discussion about the events leading to the crash in the early hours of 14 March 2017.
Central to the proceedings was evidence about the decision to task the Sligo based Rescue 118 helicopter, to evacuate an injured fisherman from a vessel in the Atlantic. John James Strachan had severed his thumb when hauling nets on the night of 13 March 2017.
His skipper, William Buchan, called Malin Head Marine Rescue Sub Centre, to seek assistance.
Radio operator Ian Scott, who took the call, told Mr Buchan that he would send the helicopter to airlift the casualty to hospital.
Mr Scott told the inquest he made the decision based on the information provided to him and the experience he had garnered over more than four decades in the search and rescue sphere.
He said that he had tried to get the Air Corps to provide top cover (a support role) for the Sligo helicopter. When it was not in a position to do this, the Dublin-based Rescue 116 crew were tasked to perform this role.
But the sequence for such tasking was not adhered to. Instead of being consulted about the merits of airlifting the injured fisherman, Dr Mai Nguyen told the inquest that the decision was presented to her as a fait accompli.
A tape recording of a three way call between the ship captain, Malin Head MRSC and Dr Nguyen confirmed this. The medic is heard asking: "Is he going to be 'medevaced'", to which Mr Scott replied: "Yes, he is going to be 'medevaced’"; the term used to describe a medical evacuation of a patient.
In her evidence, Dr Nguyen said she did not think the injury warranted such an intervention and that she would not have sent the Coast Guard to the vessel, some 140 nautical miles west of Eagle Island.
But she told the inquest: "I didn’t have the power to stop the helicopter making that journey".
Rescue 116 was en route to Blacksod to refuel for its top cover mission, when the helicopter crashed into Blackrock Island.
Previous inquiries have identified issues with the on board navigational aids the crew was using, some of which did not list Blackrock. The inquest also heard how visibility deteriorated dramatically in the time preceding the crash.
Lighthouse Attendant Vincent Sweeney, who was on duty at Blacksod, said conditions worsened significantly in the minutes before he expected R116 to land there.
At the same time, the crew was approaching Blackrock Island, unaware of the obstacle ahead of them, until just seconds before the crash.