The inquest into the death of Coast Guard volunteer Caitríona Lucas has heard that "interpersonal issues" at the Kilkee Coast Guard station were detailed to senior Irish Rescue Coast Guard service (IRCG) managers, in the months prior to her death.
The 41-year-old died after the boat she was in capsized, during a search and rescue operation near Kilkee on 12 September 2016.
The Doolin Coast Guard volunteer was assisting colleagues from the Kilkee station, which had experienced a reduction in available personnel in the months before the tragedy.
The inquest, before Limerick Coroner John McMahon, has resumed at Kilmallock Courthouse.
Orla Hassett, a former Officer in Charge (OIC) at Kilkee Coast Guard was the first witness to give evidence today.
In March 2016, in her role as Deputy Officer in Charge, she said she informed senior management about "ongoing interpersonal issues" in Kilkee and sought intervention.
These requests culminated in a meeting with two managers on 9 September 2016, at which Ms Hassett was informed she would become acting OIC, on 12 September.
She told the court that personnel numbers had dwindled from 30 in 2010, to 12 by 2013, and that in the weeks prior to the accident in 2016, "four very experienced members" had left the station.
Ms Hassett said she understood that she would take over from the OIC Martony Vaughan, subject to a conference call that would formalise the appointment.
This call did not take place.
Ms Hassett met Mr Vaughan on 10 September, to discuss an ongoing search and rescue (SAR) operation in the area.
She said he was not satisfied with the arrangements regarding oversight of the station and that she undertook to take part in the search as Cox, on the basis of his instructions.
By 12 September, the procedures to allow for her to take over had still not been actioned and she attended for duty, on the understanding that Mr Vaughan was still OIC.
She gave evidence of being at the station when a Mayday call was issued following the capsize of the Rigid Inflatable Boat, on which Ms Lucas and two other colleagues had put to sea.
She said she immediately informed Martony Vaughan, who was outside the station, and told him there was a need to launch a D-Class vessel to assist in the operation.
She re-entered the base to get ready to crew the boat, but when she emerged minutes later, Mr Vaughan and another colleague, Lorraine Lynch, had departed.
"I didn't know what to do. I knew we had to get out to try and save our three colleagues," she said.
She said she was certain that the parameters to launch safely at that time were satisfied.
Had the D-Class been launched immediately on foot of the Mayday call, she said she had "no doubt in my mind that we could have effected a very good rescue attempt".
Ms Hassett did secure access to a leisure vessel with three locals, who agreed to take her to the scene of the accident.
"I was on a vessel, not aware of its capabilities and that didn't have equipment that would have been on a rescue boat."
On their arrival at the scene, Ms Hassett was able to rescue one of the three crew members, Jenny Carraway, from the water.
She told the inquest that had the leisure craft not been at her disposal "I can’t say Jenny Carraway would be alive today".
In subsequent evidence, the Director of the IRCG, Micheál O’Toole told the Court that Martony Vaughan was the OIC on the 12 September.
He said his recollection of the meeting he attended on 9 September was that Mr Vaughan was to take up a post in project management with the Coast Guard in Dublin, and that Orla Hassett would take over as OIC.
Because this would involve a change in appointed roles, various stakeholders, including the Valentia Marine Rescue Sub Centre would have to be informed in advance.
"I can’t give evidence to the effect that happened," he said.
Mr O’Toole was Costal Unit Sector Manager for the west and northwest at the time of the September 2016 incident.
Unit 'very effective'
He said a 2015 operational audit in Kilkee had found the unit was "very effective" in comparison to colleague units and had exceeded standards in a number of areas.
He said the crews had shown a "heightened awareness of risk, through local knowledge and comprehensive professional knowledge ... of their area."
Michael Kingston, who is representing the Lucas family, has repeatedly raised the findings of a Marine Casualty Investigation Board (MCIB) report into a previous incident off the Kerry coast, in which recommendations were made about surf zones and precautions the IRCG should make in this regard.
The inquest has heard that the area in which the tragedy occurred was one such zone.
Several crew members have given evidence saying they were never made aware of these recommendations or provided with additional training in that regard.
The assistant Director of the Coast Guard Eugene Cloonan, said the report from the MCIB had been actioned, after it was published in February 2015.
"We went through recommendations, we created a programme of work and split them into volunteer and management actions.
"There were regular meetings to assess how the work was progressing to "close out" the recommendations."
He said: "The report was not handed to individual members but actions were taken by the management team, it was entered into safety management," adding that measures were taken to ensure the recommendations were actioned.
"Boat teams are not allowed to operate in surf and they know that," said Mr Cloonan.
"It’s mentioned as you’re being trained, in the personal survival course.
"There is particular training to identify waves that are breaking, which is what surf is."
Mr Cloonan agreed the recommendations were of serious import and that it was a matter of concern that some members were not aware of them.
Health and Safety Authority Inspector Helen McCarthy has been giving evidence in relation to her investigation into the matter.
She told the inquest that the volunteers did not generally understand that the life jackets they were provided with would not self inflate in the water.
She said the RIB recovered from the scene had been retained by the HSA but that all other available evidence had been handed over to the Marine Casualty Investigation Board.
Her investigation determined that the manual self righting mechanism on the boat was not activated.
Ms McCarthy said some of the PPE worn by the three members on board the vessel was supplied by the coast guard. Some of it did not carry a CE mark.
Helmets were approaching the manufacturer's recommended lifespan.
The Delta RIB boat was owned and maintained by the coast guard. It was not CE marked and no information manual was available at the time of the incident.
The HSA inspector went on to outline the geographical traits of the cliff area, where the incident occurred.
She said it had an indented cave and that "peculiar waves" could produce unexpected conditions that would come as a surprise to seafarers not familiar with the area. Effectively mariners need to 'reverse’ safely into the sea there but at the time of the accident the boat was broadside and the ‘freak’ wave capsized it.
Ms McCarthy said a site specific risk assessment would have alerted the Cox to this. But she said training records for coast guard volunteers were at odds with personal accounts of training received.
The inquest heard yesterday that the radio on board the RIB had been disconnected due to interference issues.
Ms McCarthy said the only means of communication the three crew members had was via a hand-held VHF radio. It was programmed to only communicate via Channel 16, to the Kilkee Coast Guard station.
She said had the station not been manned at the time of the mayday call, there would have been further delays in responding to the emergency.
The HSA investigation also found that personal location devices failed to function.
The court heard a file was sent to the DPP after the completion of the Health and Safety Authority report but it was decided that no charges be brought against the coast guard in relation to the workplace death.
This was upheld, on appeal by the Lucas family, according to Ms McCarthy.
Inspector Helen McCarthy concluded her evidence by showing Caitriona Lucas' log book, in which she recorded her Coast Guard activities meticulously.
"It shows the person behind the inquest," she said, "someone so fastidious and so dedicated to the Coast Guard, with an incredible record of service".
The inquest will resume in the morning.
