The jury retired to consider their verdict on Wednesday evening and resumed Thursday morning.
In her summation of the evidence and guidance to the jury, North Mayo coroner Dr Eleanor Fitzgerald said a finding of accidental death would be akin to a straightforward drowning.
While a finding of death by misadventure was akin to a person swimming while intoxicated and then drowning.
The inquest heard harrowing evidence of R116’s final moments as the crew realised they were within 12 seconds of impacting Blackrock island.
All those on board the Rescue 116 helicopter lost their lives when the aircraft crashed into Blackrock Island at 00.46 on March 14, 2017, off the Mayo coast.
In the immediate aftermath of the tragedy, the body of Captain Dara Fitzpatrick was recovered from the sea, and 12 days later, the remains of Captain Mark Duffy were recovered from the cockpit of the submerged wreckage.
However, the bodies of winch operators Paul Ormsby and Ciarán Smith were never recovered, and their deaths have been recorded as lost at sea.
The inquest, which was overseen by the Coroner for North Mayo, Dr Eleanor Fitzgerald, heard from 23 witnesses, including the chief air accident investigator who found the tragedy occurred due to a myriad of both operation and human factors.
During the deliberations, the jury sought clarification from the Air Accident Report Investigator Paul Farrell about the conclusions and safety recommendations he found.
Last November, a 350-page Air Accident Investigation Unit (AAIU) report into the tragedy laid out the chain of events that led to the accident.
The report found several issues relating to the navigational aids used by the crew on the night of the accident.
The inquest also heard there were also human factors such as crew fatigue and poor lighting in the cockpit as potential issues which led to the tragedy.
The AAIU made a total of 42 safety recommendations. Nineteen of those were addressed to CHC Ireland; the company contracted to operate air search and rescue (SAR) operations in Ireland.
These included suggestions to carry out a review of navigation aids, enhanced crew training and improved monitoring of missions and decision making.
Other recommendations were made concerning the Department of Transport’s oversight of SAR and Coast Guard operations. The Aviation Authority and the European Commission also advised to take action on foot of the report.
One finding to emerge from the investigation was that R116’s initial intention was to refuel in Sligo rather than Blacksod due to concerns by Capt Fitzpatrick about weather conditions.
However, during the flight from their base in Dublin, Capt Fitzpatrick was assured by her colleagues in R118 that weather conditions in Blacksod were fine, and the aircraft switched course.
The first witness called in person was Mr Ian Scott, the station officer at Malin Head Coastguard station.
Mr Scott defended his decision to task R116 to provide top cover to R118 during a rescue of a fisherman who had amputated his thumb above the knuckle on a trawler 140 nautical miles off the west coast.
Top cover is where a second aircraft attends an incident at least 100 miles off the coast, observing the rescue operation and assisting if required.
The second aircraft also assists with communications between the vessel, rescue aircraft and the dispatcher.
Questions arose as to whether a medical evacuation by R118 of the injured fisherman was required in the first place.
Departing from his witness statement, Mr Ian Scott, a station officer at Malin Head Coast Guard, offered his condolences to the bereaved families.
Mr Scott said he had 42 years of experience and felt the thumb injury received by the fisherman on the trawler was life-threatening as he heard the words “bleeding out”, “blood spurting”, “severe pain”, and “amputation”.
“It is my opinion that man needed off that vessel,” he said.
“I would make the same decision now. I have to make decisions on the information I have.”
Coroner Dr Fitzgerald asked Mr Scott if he believed the injury to the fisherman, who caught his thumb while hauling in a fishing net, was “life and death”.
“It could well have been,” he replied.
Dr Fitzgerald asked if he still believed it was the right decision to evacuate the casualty “even in the middle of the night”?
Mr Scott said the person was bleeding and “If I had left him, he could have died”.
He added that before he tasked R116 to provide top cover, he initially tried the Air Corp and a British Nimrod fixed-wing maritime patrol aircraft, but neither were available.
Mr Scott said he was taken aback to hear subsequently that a doctor whom he consulted with on the night had said in a statement she did not recommend a medical evacuation of the casualty.
“At no time was I told she disagreed with that decision,” Mr Scott said
In her evidence, Dr Mai Nguyen, who was then an Emergency Department Registrar in Cork University Hospital, said when she spoke to Mr Scott, the rescue helicopter had already been dispatched.
Dr Nguyen said from her memory of the incident, she felt at the time the dispatch of the Sligo based R118 Coast Guard helicopter “was probably an excessive thing” but that it was not her call.
“I was a first-year resident, I did not have the power to stop a helicopter making that journey.
“I personally felt the injury was minor in nature and wouldn’t have sent the Coastguard out there because the thumb couldn’t have been saved.”
She told the inquest she provided medical advice on how to treat the injured fisherman but also said that given how far the vessel was out to sea, she did not think the thumb could be saved.
The Air Accident Investigation Unit (AAIU) report into the crash found that procedures governing the dispatching of a Coast Guard helicopter were not conducted in sequence.
Mr Scott detailed extensive efforts to contact R116 after he was informed by the lighthouse keeper at Blacksod lighthouse, Vincent Sweeney, that the helicopter did not arrive as scheduled to refuel.
Mr Scott said he was very alarmed to hear at 1.06am on March 14, R116 was missing and uncontactable.
The coroner heard both Mr Scott and Mr Sweeney made extensive efforts to make contact with the helicopter via radio and a satellite phone.
Mr Sweeney, the lighthouse keeper told Dr Fitzgerald he was on duty having been alerted to the injured fisherman at 9.55 pm on March 13, 2017.
He told the inquest that R118 first arrived to refuel and he was informed R116 would follow later in the night.
Mr Sweeney said at 00.26, he spoke with R116 and understood they would be landing shortly.
It was previously established that R116 disappeared from radar at 00.46 am.
Mr Sweeney said he went outside to wait for the helicopter but was unable to see or hear it approaching.
“The longer this went on, the more concerned I became,” he said.
Mr Sweeney also told the inquest that visibility deteriorated rapidly and what was initially “a mist” developed into “a deadly fog”.
“It happened in a matter of minutes,” he said.
Vincent Sweeney estimated visibility at 400-500ft earlier in the night on the night but minutes before R116 was due to land to refuel, visibility “dropped fast”, to the point that “you’d hardly see your arm in front of you”.
The inquest into the deaths opened in April 2018, when preliminary evidence was heard.
Proceedings were adjourned pending the completion of a number of investigations into the crash.
A Garda inquiry was finalised in 2019, resulting in a file being sent to the Director of Public Prosecutions (DPP), which directed no prosecutions.
During a break in the proceedings on Wednesday, Mr Ian Scott, who dispatched R116 on the night of tragedy, approached relatives of the crew, including Capt Dara Fitzpatrick’s mother and said he was so sorry for their loss and he thinks of the tragedy and their loved ones every day.
Mr Scott was warmly embraced by each of the bereaved family members.