2 Aug 2024 Peter GREGORY · Prevention of Future Deaths report Worcestershire
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Concerns raised 2
Failure of CAA oversight for competition balloon flying in the UK View source Lack of CAA guidance on the design, testing and inspection of amateur-built balloons View source
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
Civil Aviation Authority
Establish and use a ballooning subject-matter-expert working group to develop competition-flying safety guidance.
View source
Civil Aviation Authority
Develop and publish a CAP containing operational safety guidance for competition balloon flying, including ascent and descent rates, standardised briefings and event guidance, then disseminate it to the ballooning community.
View source
Civil Aviation Authority
Publish safety guidance for competition balloon events, working with the BBAC to address risks for competitors and organisers.
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Civil Aviation Authority
Continue reviewing UK balloon-flying regulation, including possible regulation of amateur-built balloon design, construction, inspection, testing and competition flying.
View source
Civil Aviation Authority
Develop and publish web guidance on the design, testing and inspection of amateur-built balloons.
View source
Civil Aviation Authority
Issue a Safety Notice addressing amateur-built balloon design, construction, testing and continued non-regulation, with links to supporting guidance.
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Civil Aviation Authority
Publish guidance on the design, testing and inspection of amateur-built balloons, working with the BBAC.
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AI-generated summary
Peter GREGORY · Prevention of Future Deaths report
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Report summary
On 25 June 2023, Peter Gregory was fatally injured when the home-built hot air balloon he was piloting suffered a parachute stall during a rapid ascent in a competition race and descended rapidly to the ground. Concerns related to the possible contribution of the balloon’s design to the stall, the absence of CAA guidance on amateur-built balloons, and the lack of CAA regulation or guidance for the safe oversight of competition balloon flying in the UK.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of CAA oversight for competition balloon flying in the UK
Wider context from the report “2) The inquest also heard evidence that the CAA currently neither regulates, nor publishes guidance for the safe oversight of competition balloon flying in the UK . Whilst there is guidance published by the British Balloon and Airship Club ( BBAC ), the BBAC is a sporting body and not a regulator , and therefore does not have the power, for example, to ground a balloon which does not conform to its published guidance.
” Source location Peter GREGORY · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of CAA guidance on the design, testing and inspection of amateur-built balloons
Wider context from the report “1) The inquest heard evidence from an investigator at the Air Accidents Investigation Branch ( AAIB ) that Mr. Gregory’s balloon was home-built, based on a design produced by a friend and fellow balloon pilot, and that the balloon’s design ( in particular, the location of the balloon parachute’s centralising lines, which determine its height within the balloon envelope ) may have played a part in the parachute stall which led to the balloon’s sudden and fatal descent. The inquest also heard that the AAIB has recommended that the Civil Aviation Authority ( CAA ) publishes guidance on the design, testing and inspection of amateur-built balloons to reduce the risk of accidents due to unsafe conditions such as parachute stall, but that it is up to the CAA whether or not to regulate the design and construction of amateur/home-built balloons;
” Source location Peter GREGORY · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish and use a ballooning subject-matter-expert working group to develop competition-flying safety guidance.
Verbatim wording from the response “The CAA is currently developing safety guidance for balloon events to ensure the risks associated with competition balloon flying are understood by competitors and managed by competition organisers. This will be in the form of a CAP [Civil Aviation Authority Publication] document.” Source location Supplemental Response from Civil Aviation Authority 25.03.2025
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and publish a CAP containing operational safety guidance for competition balloon flying, including ascent and descent rates, standardised briefings and event guidance, then disseminate it to the ballooning community.
Verbatim wording from the response “The CAA is currently developing safety guidance for balloon events to ensure the risks associated with competition balloon flying are understood by competitors and managed by competition organisers. This will be in the form of a CAP [Civil Aviation Authority Publication] document.” Source location Supplemental Response from Civil Aviation Authority 25.03.2025
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish safety guidance for competition balloon events, working with the BBAC to address risks for competitors and organisers.
Verbatim wording from the response “Following publication of the AAIB’s final report, the Senior Coroner will be aware that two safety recommendations were issued to the CAA. The CAA has accepted both recommendations and has committed to working with the BBAC to produce guidance in relation to the design, testing and inspection of amateur-built balloons (including those used in competition flying). Additionally, the CAA will collaborate with the BBAC to produce guidance for the safe oversight of balloon events. The AAIB has classified the CAA responses as ‘adequate-open’ and the recommendations will remain open until the CAA has delivered on its commitment. The AAIB recommendations and the CAA’s initial response are set out below:” Source location Response from Civil Aviation Authority
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue reviewing UK balloon-flying regulation, including possible regulation of amateur-built balloon design, construction, inspection, testing and competition flying.
Verbatim wording from the response “Further to the proposed actions set out above, the CAA will continue its review of the regulation of balloon flying in the UK with a particular emphasis on whether there should be regulation of the design, construction, inspection and testing of amateur or home-built balloons and of competition balloon flying. The CAA will continue to work with domestic aviation stakeholders to mitigate the risks to public safety in accordance with the concerns highlighted in the Senior Coroner’s Report.” Source location Response from Civil Aviation Authority
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and publish web guidance on the design, testing and inspection of amateur-built balloons.
Verbatim wording from the response “It is recommended that the Civil Aviation Authority publish guidance on the design, testing and inspection of amateur-built balloons to reduce the risk of accidents due to unsafe conditions such as parachute stall.” Source location Supplemental Response from Civil Aviation Authority 25.03.2025
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue a Safety Notice addressing amateur-built balloon design, construction, testing and continued non-regulation, with links to supporting guidance.
Verbatim wording from the response “The CAA has been liaising with the amateur built balloon community with a view to producing guidance in the form of webpages on the CAA website to provide best practice guidance on the design, testing and inspecting of amateur built balloons and it is hoped the BBAC will also provide guidance in this regard and our liaison with them continues. It is also our intention to issue a Safety Notice (SN) regarding our decision to continue to allow the amateur built balloons to be unregulated. The SN shall also direct to the CAA website guidance and our previous Safety Directive (SD) on volumetric and occupancy limitations which will endure on a non-expiring basis.” Source location Supplemental Response from Civil Aviation Authority 25.03.2025
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish guidance on the design, testing and inspection of amateur-built balloons, working with the BBAC.
Verbatim wording from the response “Following publication of the AAIB’s final report, the Senior Coroner will be aware that two safety recommendations were issued to the CAA. The CAA has accepted both recommendations and has committed to working with the BBAC to produce guidance in relation to the design, testing and inspection of amateur-built balloons (including those used in competition flying). Additionally, the CAA will collaborate with the BBAC to produce guidance for the safe oversight of balloon events. The AAIB has classified the CAA responses as ‘adequate-open’ and the recommendations will remain open until the CAA has delivered on its commitment. The AAIB recommendations and the CAA’s initial response are set out below:” Source location Response from Civil Aviation Authority
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Direct regulation of amateur-built balloon airworthiness is not considered necessary because safety will be enhanced through published measures and guidance.
Verbatim wording from the response “The CAA has determined that the airworthiness of amateur built balloons can remain free of direct regulation, but flight safety will be enhanced with the addition of newly published measures for better managing design integrity, construction, inspection and testing (and consequent in-service performance) that will be promulgated by the CAA in the SN and links to additional guidance available on the CAA website. The CAA has previously published a mandatory Safety Directive (SD) (SD-2021/004: Non-Part 21 Amateur-Built Balloon and Airship Operational Limitations | UK Civil Aviation Authority) for amateur or home-built balloon limiting volumetric size of balloon envelope and occupancy, in keeping with the intent that these aircraft are for recreational, rather than for commercial use.” Source location Supplemental Response from Civil Aviation Authority 25.03.2025
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18 Mar 2022 Emiliano Raul Sala · Prevention of Future Deaths report Dorset
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Concerns raised 1
Insufficient CAA powers for investigating and enforcing aviation regulation breaches View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Emiliano Raul Sala · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Emiliano Raul Sala was a passenger on a flight from Nantes to Cardiff on 21 January 2019 when the aircraft crashed into the sea. He died from fatal head and trunk injuries; the flight was an unauthorised commercial operation. The report raised concerns about illegal flights, their safety risks, and limitations on the Civil Aviation Authority’s investigative and enforcement powers.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient CAA powers for investigating and enforcing aviation regulation breaches
Wider context from the report “2. I have concerns with regard to the following:
i. There could be future deaths as a result of these illegal flights, and I request that the Secretary of State for Transport conducts a review of the powers available to the CAA in investigating breaches of aviation regulations . I request that the Secretary of State for Transport consider meeting with the CAA to establish what powers they would find of assistance in their investigative and enforcement role .
ii. I further request that a review is undertaken by the Secretary of State for Digital, Culture, Media and Sport of the guidance given to the general public, especially all those involved in the sporting and music worlds, about the illegality of these flights and the risks associated with them. I would again request that consideration be given to meeting with the CAA who can properly advise on the risks associated with these flights, especially of future deaths that can occur and what support may assist them in deterring people from using these flights.
iii. I would request that all the organisations identified at numbers 3-20 in the list at the beginning of this report, consider cascading to all their members, and anyone else they consider will benefit from the information, the illegality of these flights and the risks associated with them, especially of a future death, in order to discourage the use of these flights. I would again request that consideration be given to liaising with the CAA who can properly advise on the risks and what support would be of benefit to reduce the use of these flights and prevent future deaths.
” Source location Emiliano Raul Sala · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete a review with the CAA of powers available for investigating breaches of aviation regulations.
Verbatim wording from the response “1. In relation to your request that the Secretary of State conduct a review of the powers available to the CAA in investigating breaches of aviation regulations, I can confirm that such a review has now been carried out together with the CAA.” Source location Response from Department for Transport
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Meet with the CAA to establish which powers would assist its investigative and enforcement role.
Verbatim wording from the response “2. In relation to your request that the Secretary of State consider meeting with the CAA to establish what powers they would find of assistance in their investigative and enforcement role, I can confirm that such a meeting has taken place between officials in the course of conducting a review of the powers available to the CAA in investigating breaches of aviation regulations.” Source location Response from Department for Transport
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue considering policy and legal changes that could improve the CAA’s investigation of suspected illegal flight activity.
Verbatim wording from the response “(ii) In parallel with the ongoing work on cost sharing arrangements, the Department is continuing to consider in detail what meaningful changes might be able to be made, in both policy and legal terms and, perhaps, in other respects, in order that the CAA is able to investigate suspected illegal flight activity more effectively. As you will appreciate the aviation regulatory framework is extensive and any changes to the law require careful consideration and justification. This or any other form of action may well require discussions with and the cooperation of other government departments and the police, in addition to further public consultation.” Source location Response from Department for Transport
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Further action and its timetable cannot yet be specified because potential legal changes require careful consideration, justification, consultation and interdepartmental cooperation.
Verbatim wording from the response “(ii) In parallel with the ongoing work on cost sharing arrangements, the Department is continuing to consider in detail what meaningful changes might be able to be made, in both policy and legal terms and, perhaps, in other respects, in order that the CAA is able to investigate suspected illegal flight activity more effectively. As you will appreciate the aviation regulatory framework is extensive and any changes to the law require careful consideration and justification. This or any other form of action may well require discussions with and the cooperation of other government departments and the police, in addition to further public consultation.” Source location Response from Department for Transport
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Without the inquest evidence and expert advice, the respondent cannot comment on the CAA’s regulatory functions or investigative and prosecutorial powers.
Verbatim wording from the response “The FA does not have knowledge of the practice of illegal flights as described in your report and was not an interested party at the inquest. In the absence of being able to review all the evidence presented to the inquest (which would also require expert advice even if we did review the evidence) The FA is not in a position to comment upon the regulatory functions of the CAA or the extent to which any suggested lack of powers inhibits its function of investigating air accidents and prosecuting where the evidence supports a prosecution.” Source location Response from The Football Association Limited
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The CAA regulates aviation safety, while ministerial responsibility lies with the Department for Transport, not DCMS.
Verbatim wording from the response “With regard to your recommendation, the Civil Aviation Authority (CAA) is responsible for the regulation of aviation safety in the United Kingdom, and Ministerial responsibility lies with the Department for Transport (DfT). Therefore, it would not be appropriate for DCMS to conduct a review of aviation guidance. You will be aware that the DfT are currently reviewing the powers available to the CAA in investigating breaches of aviation regulations.” Source location Response from Department for Digital, Culture Media and Sports
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2 Feb 2016 Carl Alan Dickerson and 3 others · Prevention of Future Deaths report Norfolk
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Concerns raised 1
Lack of equivalent regulation for non-commercial departures from unlicensed aerodromes in limited visibility View source
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Civil Aviation Authority
Conduct a review of IFR rules for flights outside controlled airspace to identify shortcomings and inform necessary regulatory or guidance changes.
View source
Civil Aviation Authority
Review and reissue the IFR aerodrome operating minima Safety Notice with enhanced information and links to the Air Operations Regulation.
View source
Civil Aviation Authority
Update the flight-planning and safe-flight-execution Safety Notice to introduce additional risk assessments and safety strategies.
View source
Civil Aviation Authority
Conduct regulatory oversight of non-commercial complex-aircraft operators subject to the new declaration requirements.
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AI-generated summary
Carl Alan Dickerson and 3 others · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 13 March 2014, four men were travelling in an Augusta Westland AW139 helicopter when it impacted the ground near Gillingham, Norfolk, in dark and foggy conditions. All four died from their injuries. The principal concern was that regulations governing visibility and take-off conditions applied to commercial departures from licensed aerodromes but not to this non-commercial departure from an unlicensed aerodrome, despite a previous accident in similar circumstances.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of equivalent regulation for non-commercial departures from unlicensed aerodromes in limited visibility
Wider context from the report “(1) On the 13 March 2013 at the time of take-off, it was dark and there was fog. Visibility was therefore limited. There are Regulations in place which would have prevented a take-off in these conditions had this been a departure from a licensed aerodrome and had this been a commercial venture.
(2) Because this was a departure from a non-commercial venture and take-off was from an unlicensed aerodrome, the Regulations do not apply.
(3) It is understood there was an accident in the 1990s in similar circumstances and operating under private category rules, as a result of which the Irish Air Accident Investigation Unit (AAIU) published a report and noted that "The flight used a navigation approach procedure that would not meet the standards required by the UK Authorities for public transport operations. However, this was not illegal because the flight was operated under private category rules".
(4) The AAIU made recommendations including that “The UK CAA should consider the establishment of a special category for the operation of corporate aviation”. It is understood this recommendation was accepted but no special category was established. Guidance was provided but not regulation.
(5) New European aviation legislation affecting the non-commercial operation of aircraft will come into effect in the UK from 25 August 2016 which will introduce new regulations for the management and operation of this type of aircraft.
(6) It is understood the CAA has decided a broader and deeper review of Instrument Flight Rules suite controlled airspace in general is necessary and that a project plan is being developed to address the issues, develop recommendations and suggested courses of action. There is liaison with the European Aviation Safety Agency “in taking forward any such changes”.
(7) It is of concern that despite the previous accident in the 1990s and this accident, a departure from a non-commercial venture and an unlicensed aerodrome is not covered by the equivalent regulation as a departure from commercial and licensed premises.
” Source location Carl Alan Dickerson and 3 others · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct a review of IFR rules for flights outside controlled airspace to identify shortcomings and inform necessary regulatory or guidance changes.
Verbatim wording from the response “We have closely followed the circumstances surrounding this unfortunate accident and supported the Air Accidents Investigation Branch (AAIB) during their investigation. Their report was reviewed carefully and the findings are reflected in your concerns. In addition, and following other safety recommendations relating to both helicopter and aeroplane accidents, we have instigated a thorough review of the rules applicable to flights being performed under Instrument Flight Rules (IFR) outside controlled airspace through our Safety Review Committee. This will cover several of the issues raised in relation to this accident as well as the wider context of current and emerging practices and is scheduled to be completed by 30 September 2016.” Source location Response-by-CAA
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and reissue the IFR aerodrome operating minima Safety Notice with enhanced information and links to the Air Operations Regulation.
Verbatim wording from the response “Recognising that interpreting and fully assimilating these requirements from the ANO is not immediately straightforward and in an effort to address this, we published a Safety Notice SN-2014/006 – Private and Aerial Work Helicopter Operations - Guidance on Aerodrome Operating Minima for IFR Departures shortly after the accident. This document provides explanation and guidance for private operators to help them establish their AOM and better understand the requirements. Nevertheless, the onus remains firmly on the pilot to ensure that any flight can be conducted safely.” Source location Response-by-CAA
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the flight-planning and safe-flight-execution Safety Notice to introduce additional risk assessments and safety strategies.
Verbatim wording from the response “In advance of this change, we are reviewing the contents of the Safety Notice and will re-issue it by the end of March with enhanced information and links to the Air Operations Regulation. This provides operators with a more logical and standard form of meeting their obligations and help the transition to the new regulations. At the same time, we will also update another Safety Notice regarding “the Flight Planning and Safe Flight Execution” to introduce additional risk assessments and safety strategies.” Source location Response-by-CAA
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct regulatory oversight of non-commercial complex-aircraft operators subject to the new declaration requirements.
Verbatim wording from the response “From 25 August 2016, operators of non-commercial complex aircraft, such as G-LBAL, will be required to make a declaration to the national Competent Authority (CAA for the UK) declaring that their organisation meets all the relevant requirements in the Air Operations Regulation. This is the first time that such measures have been applied under law and will require operators to meet stringent standards including having an accountable manager, an effective management system and procedures properly documented in their own operations manual detailing how all flights are to be managed and flown. The CAA will be required to conduct oversight of these organisations to ensure that they are compliant with the regulations. This is a level of contact that has not hitherto been required but is expected to help identify and better manage the risks in this sector of aviation.” Source location Response-by-CAA
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Actions and positions describe what organisations say in published responses. Implementation is not independently verified.