A private jet was a minute away from crashing into a mountain after pilots became confused over flight instructions, air accident investigators have found.
The Florida-registered plane was carrying three passengers and two crew when it took off from Kerry Airport on June 16 2015 on its way to Gander in Newfoundland, Canada.
A quick-thinking air traffic controller in Shannon spotted the jet levelled off too low to cross the Slieve Mish mountains near the Dingle peninsula.
The jet was about 800 feet below the highest peak as it flew into clouds shortly after take-off.
Experts from the Air Accident Investigation Unit (AAIU), which classed the incident as serious, said the pilots stopped climbing contrary to advice given to them while on the runway in Kerry.
The inspectors also said the crew misinterpreted instructions for the early flight path and did not try to clarify it with air traffic controllers.
The 32-year-old captain with 4,000 flying hours told the AAIU that they were confused over what altitude they should level off at.
"As we began to climb we had some confusion as to what the altitude clearance limit was as we were unsure what level 200 meant. We levelled at 2,000 feet to ensure we didn't exceed any altitude limits," the commander told the inquiry.
As the BAe 125-800B jet, known nowadays as a Hawker, was flying over Castlemaine the pilots contacted low level operators in Shannon's air traffic control centre.
Within 30 seconds the controller had asked the pilots three times for their altitude and confirmed they were at the wrong height.
The controller warned them of the high ground ahead in the Slieve Mish mountains and ordered them to climb to 4,000 feet with disaster less than one minute away.
The AAIU investigation also revealed that special radar to closely track flights from the control tower in Kerry airport was due to be in place in mid-2014 but was still not operating a month after the incident.
It said the lack of such a monitoring system was not a factor in this incident.
But the inspectors warned that the radar was first recommended in 2010 after a previous incident out of Kerry and they had no certainty when it would be up and running.
The Irish Aviation Authority (IAA) said the monitoring systems have been operating for the last two months.
"The IAA is committed to ensuring the highest levels of safety across the entire aviation system and we will ensure that all safety recommendations are implemented as expeditiously as possible," a spokesman said.
The AAIU called on the IAA to review how it monitors progress on safety recommendations in accident reports.