"Every time people walk the shore, they're still looking out."

That observation, from retired Garda Superintendent Tony Healy, encapsulates how deeply the Rescue 116 tragedy still resonates among the community, living on the Erris Peninsula.

Giving evidence about the investigation into the helicopter crash at this week’s inquest, Mr Healy spoke about the outpouring of emotions that followed the events of 14 March 2017.

Amid all the sadness, support, effort, frustration, grief and loss, there was a burning desire to bring home the bodies of missing crew members, Paul Ormsby and Ciarán Smith.

Search team co-ordinators meeting enroute to Blackrock Island

In the months after their colleagues Dara Fitzpatrick and Mark Duffy were laid to rest, Mr Healy spoke about the "amalgam of agencies and locals involved in carrying out the search…to do everything to recover those lost at sea".

It's the common response in coastal communities when a tragedy like this occurs. Normal life is paused. Everything is given to the effort. And no matter how much time passes, there’s a sense of unfinished business, as long as the mission is unfulfilled.

But despite huge endeavours to locate the missing men, only hints as to their resting place have been given up by the ocean.

Search team co-ordinators meeting en route to Blackrock Island

In late September 2017, Ciarán Smith's helmet was washed ashore. Ten months later, in July 2018, Paul Ormsby’s helmet was found by a fisherman operating from Achill. Both discoveries triggered intensified searches. In both instances, they were fruitless.

Nonetheless, the search never stops. And while hope may fade, it always flickers. That’s why people are still "looking out".

Blackrock Island

Many of those involved in the huge search and recovery effort attended the inquests into the four deaths in Belmullet this week.

Relatives and legal representatives for the families of the deceased Coast Guard members gathered in the auditorium at Áras Inis Gluaire, for the latest part of the State response to the accident.

They were joined by Coast Guard personnel, investigators and interested observers, for the conclusion of the inquest process.

The proceedings, overseen with an understated diligence and respect by North Mayo Coroner, Dr Eleanor Fitzgerald, bookend a number of official inquiries that followed the crash.

In the hours after the accident, several investigations were launched.

All had to be completed before the inquests could be held.

Firstly, a garda inquiry into the circumstances surrounding the tragedy. That involved several different lines of inquiry, over more than two years. It finished in April 2019, when a file was sent to the Director of Public Prosecutions. The following month, a direction of 'no prosecution’ was received.

As the crew were at work when the helicopter crashed into Blackrock Island, their deaths had to be investigated by the Health and Safety Authority (HSA) too. It, eventually, determined that no prosecutions would be taken under the Safety, Health and Welfare Act.

Details of the HSA inquiry have not been made public. We heard a fleeting reference to it at this week’s inquest, intimating that it contained similarities to the main report into the accident, that conducted by the Air Accident Investigation Unit (AAIU).

Charged with examining the circumstances around all air related accidents, AAIU personnel were on the road to Blacksod, immediately after the helicopter crash. In the days and weeks that followed, each and every piece of debris that was recovered from the waters around Blackrock Island, and those that washed up elsewhere, were photographed, logged and securely stored.

The wreckage of the helicopter was removed from the seabed and taken away for analysis. Data recorders were located and checked for any information they would yield. In time, interviews were held with anybody identified as having been involved in the chain of events that led to the crash.

Investigators met with Coast Guard staff, reviewed minutes of countless meetings and examined thousands of pages of records, guidelines and regulations.

People gathered to pay their respects to Captain Mark Duffy when his remains were taken from Blacksod Pier

Ultimately, the most detailed inquiry ever conducted by the unit took over four and a half years to complete. Publication of the final report was delayed by months, following objections from one of the parties under investigation.

When it came, the 350 page document provided a forensic insight into all aspects of the accident, its aftermath and the events that preceded it.

The report concluded with a series of recommendations, aimed at ensuring everything was done to avoid a repeat of the events off Blacksod, here or elsewhere.

The attention now switches to the coming months, when we will get some indication about how different entities are prepared to respond and change, as a result of the Rescue 116 crash.

The remains of Captain Mark Duffy being taken from Blacksod Pier

The Air Accident Investigation Unit says it hopes to soon publish an update on the progress being made, to implement the 42 different recommendations it issued last year.

There are lots of questions outstanding. There are lots of actions to be taken.

What definitive medical criteria will be put in place to determine what constitutes an air Search and Rescue (SAR) mission? What supports will be given to those charged with making such calls? How will 'top cover’ be provided in future? What safeguards will be introduced to ensure maps and navigational aids are updated, verified and checked? How does an island nation properly plan for the long-term provision of air SAR?

How those questions are answered and how those actions are implemented will be the ultimate test of how the State values the work that the colleagues of Dara Fitzpatrick, Mark Duffy, Paul Ormsby and Ciarán Smith carry out, day in, day out. Night in, night out.

Verdicts of accidental death were returned by a jury at the inquests into the Rescue 116 helicopter crash

The deaths on Blackrock Island have shone a light on shortcomings, shortcuts and short-term planning. It is up to entities like the company with the contract to provide air SAR services, CHC Ireland; the Coast Guard Service; the Department of Transport and the Irish Aviation Authority to ensure those failings are addressed and never repeated.

Those who put their lives on the line - and the memory of those who gave their lives in service of others - deserve no less.

We all need to be "looking out", to ensure that a service any of us could someday rely on, is properly resourced, supported and respected.