Concerns raised 7 Failure to produce timely final reports and interim statements on investigation progress and safety issues View source Failure to recognise oxygen fires and immediately cut off the oxygen supply View source Uncertainty about the effectiveness of Halon fire extinguishers for onboard fires View source Failure to prevent cigarettes and related flammable items and materials in the cockpit View source Unavailability of protective equipment for cockpit fires View source Lack of evidence access for states entitled to participate in an investigation when excluded by the State of Occurrence View source Failure of risk analyses to account for overpressure in the oxygen distribution system View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Richard Mohamed Fekry Osman · 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
Richard Mohamed Fekry Osman was a passenger on flight MS804, which crashed into the Mediterranean Sea on 19 May 2016 after a fire broke out on the flight deck; there were no survivors. The inquest stated that the fire was caused by an ignition source of unknown origin, most likely associated with the first officer’s oxygen supply system. The substantive concerns included cockpit fire and smoke procedures, oxygen-system risks, fire-protection equipment and extinguishers, smoking regulations, and arrangements for participation in or transfer of aircraft accident investigations.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to produce timely final reports and interim statements on investigation progress and safety issues
Wider context from the report “(2) That a drafting committee be convened to consider amending Annex 13 of the Convention on International Civil Aviation signed at Chicago on 7 December 1944 to provide:
(a) a right for states entitled to participate in an investigation to have access to evidence to enable those participating states to release a statement in accordance with Chapter 6.6.1 in circumstances where they have been excluded from an investigation by the State of Occurrence;
(b) a right of states entitled to participate in an investigation to take over conduct of an investigation in circumstances where a State of Occurrence does not produce a Final Report within a reasonable timeframe and does not produce interim statements indicating the progress of the investigation and safety issues raised within a reasonable timeframe and has not otherwise consented to the delegation of the investigation in accordance with Chapter 5.1.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise oxygen fires and immediately cut off the oxygen supply
Wider context from the report “(1) That a full review of cockpit fire/smoke procedures be undertaken to include, but not limited to:
- the recognition of an oxygen fire (identifiable by a characteristic noise comparable to that of a blowtorch) and the immediate cutting off this oxygen supply.
- the installation or carrying of protective equipment to deal with any cockpit fires.
- a review of the effectiveness of Halon fire extinguishers to deal with onboard fires.
- a review of regulations (if required) to prevent the use of cigarettes in the cockpit and related flammable items and materials.
- the additional risk analyses to take into account the hypothesis of an overpressure in the oxygen distribution system.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Uncertainty about the effectiveness of Halon fire extinguishers for onboard fires
Wider context from the report “(1) That a full review of cockpit fire/smoke procedures be undertaken to include, but not limited to:
- the recognition of an oxygen fire (identifiable by a characteristic noise comparable to that of a blowtorch) and the immediate cutting off this oxygen supply.
- the installation or carrying of protective equipment to deal with any cockpit fires.
- a review of the effectiveness of Halon fire extinguishers to deal with onboard fires.
- a review of regulations (if required) to prevent the use of cigarettes in the cockpit and related flammable items and materials.
- the additional risk analyses to take into account the hypothesis of an overpressure in the oxygen distribution system.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent cigarettes and related flammable items and materials in the cockpit
Wider context from the report “(1) That a full review of cockpit fire/smoke procedures be undertaken to include, but not limited to:
- the recognition of an oxygen fire (identifiable by a characteristic noise comparable to that of a blowtorch) and the immediate cutting off this oxygen supply.
- the installation or carrying of protective equipment to deal with any cockpit fires.
- a review of the effectiveness of Halon fire extinguishers to deal with onboard fires.
- a review of regulations (if required) to prevent the use of cigarettes in the cockpit and related flammable items and materials.
- the additional risk analyses to take into account the hypothesis of an overpressure in the oxygen distribution system.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Unavailability of protective equipment for cockpit fires
Wider context from the report “(1) That a full review of cockpit fire/smoke procedures be undertaken to include, but not limited to:
- the recognition of an oxygen fire (identifiable by a characteristic noise comparable to that of a blowtorch) and the immediate cutting off this oxygen supply.
- the installation or carrying of protective equipment to deal with any cockpit fires.
- a review of the effectiveness of Halon fire extinguishers to deal with onboard fires.
- a review of regulations (if required) to prevent the use of cigarettes in the cockpit and related flammable items and materials.
- the additional risk analyses to take into account the hypothesis of an overpressure in the oxygen distribution system.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of evidence access for states entitled to participate in an investigation when excluded by the State of Occurrence
Wider context from the report “(2) That a drafting committee be convened to consider amending Annex 13 of the Convention on International Civil Aviation signed at Chicago on 7 December 1944 to provide:
(a) a right for states entitled to participate in an investigation to have access to evidence to enable those participating states to release a statement in accordance with Chapter 6.6.1 in circumstances where they have been excluded from an investigation by the State of Occurrence ;
(b) a right of states entitled to participate in an investigation to take over conduct of an investigation in circumstances where a State of Occurrence does not produce a Final Report within a reasonable timeframe and does not produce interim statements indicating the progress of the investigation and safety issues raised within a reasonable timeframe and has not otherwise consented to the delegation of the investigation in accordance with Chapter 5.1.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Failure of risk analyses to account for overpressure in the oxygen distribution system
Wider context from the report “(1) That a full review of cockpit fire/smoke procedures be undertaken to include, but not limited to:
- the recognition of an oxygen fire (identifiable by a characteristic noise comparable to that of a blowtorch) and the immediate cutting off this oxygen supply.
- the installation or carrying of protective equipment to deal with any cockpit fires.
- a review of the effectiveness of Halon fire extinguishers to deal with onboard fires.
- a review of regulations (if required) to prevent the use of cigarettes in the cockpit and related flammable items and materials.
- the additional risk analyses to take into account the hypothesis of an overpressure in the oxygen distribution system.
” Open source report
×
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 Continue monitoring safety data and future aviation safety investigation recommendations relating to fire risks.
Verbatim wording from the response “However, given the specific concerns identified by the Assistant Coroner, the CAA will continue to carefully monitor safety data and future aviation safety investigation recommendations related to fire risks with a view to taking appropriate action where necessary.” Source location Response from Civil Aviation Authority
Open published response
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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 CAA safety oversight and occurrence data do not indicate a smoking-related safety risk or gap requiring regulatory change.
Verbatim wording from the response “While there is no specific reference to smoking in the flight deck within these regulations, the CAA is not aware of any UK aircraft operators that allow smoking in any part of an aircraft, including the flight deck. Flight crew receive extensive training in safety and risk management, with a strong emphasis on maintaining a controlled and hazard-free operating environment onboard aircraft. In addition, all safety related occurrences must be reported to the CAA, which enables data to be collected and analysed over time. Following a review of the coroner’s request, the UK CAA Safety Intelligence Team have confirmed that there have been no reported UK incidents involving smoking or vaping in the flight deck in the past decade.¹¹” Source location Response from Civil Aviation Authority
Open published response
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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 The Department for Transport will respond separately to report aspects concerning aircraft accident investigation.
Verbatim wording from the response “The CAA understands that the Department for Transport (‘DfT’) will, therefore, respond separately to those aspects of the Report which relate to aircraft accident investigation. We can confirm that we have exchanged responses with the DfT prior to filing this response with the court.” Source location Response from Civil Aviation Authority
Open published response
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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 Aircraft accident and serious-incident investigation is outside the CAA’s responsibility and falls to the Air Accidents Investigation Branch.
Verbatim wording from the response “The CAA is not responsible for the investigation of aircraft accidents or serious incidents on behalf of the UK, which falls to the Air Accidents Investigation Branch (‘AAIB’), a body who report directly to the Secretary of State for Transport. Procedures for these investigations are laid down in international protocols, specifically the standards and recommended practices defined in Annex 13 to the Convention on International Civil Aviation, Aircraft Accident and Incident Investigation, and published by the International Civil Aviation Organization (‘ICAO’).” Source location Response from Civil Aviation Authority
Open published response
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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 Existing airworthiness, operational, certification and safety-management safeguards provide adequate mitigation, so no aviation safety regulatory changes are currently required.
Verbatim wording from the response “No new fires have been identified by the CAA as a result of this audit programme and the CAA remains satisfied that all known risks fall within existing design, certification and operational controls.” Source location Response from Civil Aviation Authority
Open published response
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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 The Department for Transport will respond separately to report aspects concerning aircraft accident investigation.
Verbatim wording from the response “The CAA understands that the Department for Transport (‘DfT’) will, therefore, respond separately to those aspects of the Report which relate to aircraft accident investigation. We confirm that we have exchanged responses with the DfT prior to filing this response with the court.” Source location Response from Civil Aviation Authority
Open published response
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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 CAA safety data does not indicate that onboard fire risks or flight-deck fire consequences require changes to existing rules.
Verbatim wording from the response “The CAA’s review of the Assistant Coroner’s recommendations has concluded that no change to the existing aviation safety regulatory framework is currently required. The CAA remains satisfied that the safeguards in place, which are underpinned by airworthiness and operational regulations, design and certification requirements and operator safety management systems provide adequate risk mitigation. As part of this review, subject matter experts have examined relevant safety data held by the CAA under the Mandatory Occurrence Reporting Scheme, which does not indicate there is a risk of fire onboard large commercial aircraft - or the consequences of a flight deck fire - necessitate changes to existing rules. The CAA is also mindful of international requirements directed by ICAO which do not support change to existing fire safety controls at the present time.” Source location Response from Civil Aviation Authority
Open published response
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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 Existing airworthiness, operational, certification and safety-management controls provide adequate mitigation, so no regulatory framework change is currently required.
Verbatim wording from the response “The CAA’s review of the Assistant Coroner’s recommendations has concluded that no change to the existing aviation safety regulatory framework is currently required. The CAA remains satisfied that the safeguards in place, which are underpinned by airworthiness and operational regulations, design and certification requirements and operator safety management systems provide adequate risk mitigation. As part of this review, subject matter experts have examined relevant safety data held by the CAA under the Mandatory Occurrence Reporting Scheme, which does not indicate there is a risk of fire onboard large commercial aircraft - or the consequences of a flight deck fire - necessitate changes to existing rules. The CAA is also mindful of international requirements directed by ICAO which do not support change to existing fire safety controls at the present time.” Source location Response from Civil Aviation Authority
Open published response
×
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 Aircraft accident investigation is outside the CAA’s responsibility and falls to the Air Accidents Investigation Branch.
Verbatim wording from the response “The CAA is not responsible for the investigation of aircraft accidents or serious incidents on behalf of the UK, which falls to the Air Accidents Investigation Branch (‘AAIB’), a body who report directly to the Secretary of State for Transport. Procedures for these investigations are laid down in international protocols, specifically the standards and recommended practices defined in Annex 13 to the Convention on International Civil Aviation, Aircraft Accident and Incident Investigation, and published by the International Civil Aviation Organization (‘ICAO’).” Source location Response from Civil Aviation Authority
Open published response
Concerns raised 6 Failure to require provision of system and flight-testing data to specialist suppliers of critical parts View source Lack of defined and controlled life limits for non-structural critical parts in aircraft designs already in service View source Failure to require system-level failure modes analysis for potentially catastrophic failure modes View source Failure to address rolling contact fatigue failure in critical-part bearing certification requirements View source Lack of comprehensive and uniform standards for calculating design load spectrums for non-structural critical parts View source Unavailability of comprehensive post-removal assessment programmes for critical parts in in-service helicopters View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Eric Swaffer and 4 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 27 October 2018, a helicopter crashed shortly after departing Leicester's King Power Stadium, killing pilots Eric Swaffer and Izabela Lechowicz and passengers Vichai Srivaddhanaprabha, Nusara Suknamai and Kaveporn Punpare. The report states that Ms Lechowicz died from head and chest injuries, while the other four died from inhaling combustion products. The principal concerns relate to EASA's handling of recommendations about helicopter component design, certification, life limits, post-service assessment, load-spectrum standards and system-level failure analysis.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to require provision of system and flight-testing data to specialist suppliers of critical parts
Wider context from the report “In these circumstances, I am concerned by EASA’s rejection of the AAIB safety recommendation , which would appear to propose a meaningful improvement to requirements for aircraft design work.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of defined and controlled life limits for non-structural critical parts in aircraft designs already in service
Wider context from the report “In these circumstances, I am concerned that EASA has not implemented the recommendation in relation to designs already in service . Although ████████ said that EASA had explained that it considered that issues with non-structural critical parts would be picked up as part of continued airworthiness review, that does not strike me as a response which meets the recommendation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to require system-level failure modes analysis for potentially catastrophic failure modes
Wider context from the report “I am concerned that the AAIB’s apparently sensible suggestion of requiring failure modes analysis to be conducted at a system level continues to be rejected .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to address rolling contact fatigue failure in critical-part bearing certification requirements
Wider context from the report “I am concerned that an issue raised by the AAIB to the effect that CS-29 and/or AMC may be improved to address risks of rolling contact fatigue failure in critical part bearings has not been addressed by EASA by a time over 18 months after the AAIB report on this crash was issued.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of comprehensive and uniform standards for calculating design load spectrums for non-structural critical parts
Wider context from the report “I am concerned that EASA has responded to this AAIB recommendation by citing action it has taken which does not appear to meet the AAIB’s concerns .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Unavailability of comprehensive post-removal assessment programmes for critical parts in in-service helicopters
Wider context from the report “I am concerned that EASA does not intend making changes which would allow in-service helicopters to benefit from the proposed new CIVP requirements .
” Open source 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 Share the Certification Memorandum with EASA for discussion.
Verbatim wording from the response “c. is developing a Certification Memorandum (“CM”) which will clarify that applicable data from the supplier of critical bearings (including installation and operating limitations, bearing design specification, and applicable best practice) should be recorded and assessed by the TCH of the aircraft prior to certification. This CM will apply to all critical bearings, including both metallic and hybrid designs. The CAA will share this CM with EASA for discussion;” Source location Response from Civil Aviation Authority
Open published response
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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 Advance rulemaking extending required safety assessments of rotor and rotor-drive systems to reduce component-failure hazard severity.
Verbatim wording from the response “b. has initiated rulemaking projects to update the UK regulatory framework to:” Source location Response from Civil Aviation Authority
Open published response
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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 Advance rulemaking to clarify critical-part airworthiness status and life-limit definitions and publication for aircraft operators.
Verbatim wording from the response “b. has initiated rulemaking projects to update the UK regulatory framework to:” Source location Response from Civil Aviation Authority
Open published response
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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 Adopt updates to Acceptable Means of Compliance addressing rolling contact fatigue in critical bearings classified as Principal Structural Elements.
Verbatim wording from the response “a. has adopted updates to Acceptable Means of Compliance to CS-27 and CS-29 relating to rolling contact fatigue in critical bearings classified as Principal Structural Elements;” Source location Response from Civil Aviation Authority
Open published response
×
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 Advance rulemaking requiring defective critical parts to be removed from service and returned to type certificate holders for analysis.
Verbatim wording from the response “b. has initiated rulemaking projects to update the UK regulatory framework to:” Source location Response from Civil Aviation Authority
Open published response
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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 Consider EASA’s final Continued Integrity Verification Programme proposals and reflect them in equivalent UK provisions where appropriate.
Verbatim wording from the response “d. will consider EASA’s final proposals in relation to the Continued Integrity Verification Programme (CIVP) once they are issued and will reflect those provisions in the equivalent UK regulatory provisions if appropriate to do so;” Source location Response from Civil Aviation Authority
Open published response
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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 a Certification Memorandum requiring applicable critical-bearing supplier data to be recorded and assessed before aircraft certification.
Verbatim wording from the response “c. is developing a Certification Memorandum (“CM”) which will clarify that applicable data from the supplier of critical bearings (including installation and operating limitations, bearing design specification, and applicable best practice) should be recorded and assessed by the TCH of the aircraft prior to certification. This CM will apply to all critical bearings, including both metallic and hybrid designs. The CAA will share this CM with EASA for discussion;” Source location Response from Civil Aviation Authority
Open published response
Concerns raised 2 Inadequacy of Peer Support for pilots with severe mental health difficulties and suicidal thoughts View source Insufficient industry support for pilots whose problems escalate beyond usual job stresses and pressures View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
John Peter MCLOUGHLIN · 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
John Peter McLoughlin, a pilot employed by West Atlantic UK, died by suicide in a Brighton hotel bathroom on 19 July 2023 while attending a stressful and highly pressured training course. The report raised concerns that peer support from trained mental health first aiders was inadequate for pilots experiencing severe mental health difficulties and suicidal thoughts, and that wider industry support was insufficient when problems escalated.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Inadequacy of Peer Support for pilots with severe mental health difficulties and suicidal thoughts
Wider context from the report “John was an experienced Pilot. He was on a training course run by Quadrant which he found stressful and with which he struggled. On the course, mental health issues were discussed. The support offered was through Peer Support who allow pilots to talk to another pilot who is a trained mental health first aider, but they are not medically trained . Although HM Coroner is of the view that there is great merit in talking through difficulties with those in the same industry, I have concerns that Peer Support is not adequate support for those who are suffering severe mental health difficulties and suicidal thoughts. It appears that there is not enough support in the industry as a whole for pilots whose problems escalate beyond the usual stresses and pressures of the job.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Insufficient industry support for pilots whose problems escalate beyond usual job stresses and pressures
Wider context from the report “John was an experienced Pilot. He was on a training course run by Quadrant which he found stressful and with which he struggled. On the course, mental health issues were discussed. The support offered was through Peer Support who allow pilots to talk to another pilot who is a trained mental health first aider, but they are not medically trained. Although HM Coroner is of the view that there is great merit in talking through difficulties with those in the same industry, I have concerns that Peer Support is not adequate support for those who are suffering severe mental health difficulties and suicidal thoughts. It appears that there is not enough support in the industry as a whole for pilots whose problems escalate beyond the usual stresses and pressures of the job .
” Open source 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 Launch and run a dedicated Pilot Peer training course providing delegates with skills, knowledge and behaviours to deliver pilot peer assistance.
Verbatim wording from the response “To support organisations with pilot peer assistance, the CAA launched a dedicated Pilot Peer training course through its subsidiary, CAA International. The course provides delegates with the skills, knowledge and behaviours, as a peer, to become confident in delivering pilot peer assistance to flight crew under an operator’s support programme. The course has been run annually since 2023 and can be run on a bespoke, ad-hoc basis when requested. More information about this course can be found here.” Source location Response from Civil Aviation Authority
Open published response
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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 Instruct inspectors to encourage escalation of pilots’ significant mental-health concerns to mental-health professionals, including trained expert intervention.
Verbatim wording from the response “The CAA will therefore instruct Flight Operations and Approved Training Organisation Inspectors, through its programme of audit activity, to encourage operators and Approved Training Organisations to continue improving their mental health support to pilots by:” Source location Response from Civil Aviation Authority
Open published response
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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 Instruct inspectors to encourage operators and training organisations to improve peer supporters’ practical suicide-awareness and intervention knowledge.
Verbatim wording from the response “The CAA will therefore instruct Flight Operations and Approved Training Organisation Inspectors, through its programme of audit activity, to encourage operators and Approved Training Organisations to continue improving their mental health support to pilots by:” Source location Response from Civil Aviation Authority
Open published response
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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 Direct inspectors to encourage operators and training organisations to highlight pilots’ mental-health importance and available support resources, particularly during stressful training and examinations.
Verbatim wording from the response “Further, the CAA will, on an ongoing basis, direct its inspectors to encourage operators and Approved Training Organisations to highlight to pilots the importance of their mental health and to ensure they are aware of the resources that are available to them, particularly during times of stress, such as during flight training and examinations. These measures will make these organisations fully aware of the roles they play in supporting pilots at risk.” Source location Response from Civil Aviation Authority
Open published response
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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 Existing aviation regulations, pilot medical assessments and CAA guidance already mitigate some identified mental-health concerns.
Verbatim wording from the response “The CAA does consider there is already an aviation safety regulation structure in place that is designed to mitigate some of the concerns identified by the Assistant Coroner. This structure, which includes direct regulation of operational peer support programmes for pilots in accordance with the requirements in the Ops Regulation and mental health assessments for pilots under the Aircrew Regulation, is enhanced by the publication of information and guidance by the CAA which is focussed on operators and aero-medical examiners recognising mental health concerns for pilots, those who are in training and those who are actively engaged in flight operations, and how to deal with them.” Source location Response from Civil Aviation Authority
Open published response
2 Aug 2024 Peter GREGORY · Prevention of Future Deaths report Worcestershire
View report summary
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
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 7
Action
Establish and use a ballooning subject-matter-expert working group to develop competition-flying safety guidance.
Stated completedThe respondent said that this action was complete when they made their response on 9 August 2024. View source
Action
Develop and publish web guidance on the design, testing and inspection of amateur-built balloons.
Stated in progressThe respondent said that this action was in progress when they made their response on 9 August 2024. View source
Action
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.
Stated in progressThe respondent said that this action was in progress when they made their response on 9 August 2024. View source
Action
Issue a Safety Notice addressing amateur-built balloon design, construction, testing and continued non-regulation, with links to supporting guidance.
Stated plannedThe respondent said that this action was planned when they made their response on 9 August 2024. View source
Action
Publish safety guidance for competition balloon events, working with the BBAC to address risks for competitors and organisers.
Stated plannedThe respondent said that this action was planned when they made their response on 9 August 2024. View source
Action
Publish guidance on the design, testing and inspection of amateur-built balloons, working with the BBAC.
Stated plannedThe respondent said that this action was planned when they made their response on 9 August 2024. View source
Action
Continue reviewing UK balloon-flying regulation, including possible regulation of amateur-built balloon design, construction, inspection, testing and competition flying.
Stated in progressThe respondent said that this action was in progress when they made their response on 9 August 2024. View source See 4 more actions
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AI-generated summary
Peter GREGORY · 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 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.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
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;
” Open source 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
Open published response
×
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
Open published response
×
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
Open published response
×
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
Open published response
×
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
Open published response
×
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
Open published response
×
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 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
Open published response
×
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
Open published response
2 Feb 2024 Shaun CROSSFIELD · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 2 Lack of licensing for use and registration of class BGD Luna 2 paragliders View source Lack of regulatory quality and airworthiness control for class BGD Luna 2 paragliders View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Shaun CROSSFIELD · 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
Shaun Crossfield died on 9 August 2022 after his paramotor became uncontrollable during flight and descended in a spiral before impacting the ground. The report raises concerns about damage and repairs to the propeller and control mechanisms, and about the absence of regulatory inspection, certification, licensing and registration for the aircraft type.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of licensing for use and registration of class BGD Luna 2 paragliders
Wider context from the report “It appears to be the case that no regulatory authority is available to control the quality or airworthiness of the class BGD Luna 2 Paraglider flown by the deceased.
The absence of such quality control and licensing for use and registration of such aircraft does provide the opportunity for future deaths to occur.
Had a mandatory inspection and certification of fitness been carried out and imposed by qualified inspectors, in all likelihood such a death as suffered by the deceased may not have occurred.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of regulatory quality and airworthiness control for class BGD Luna 2 paragliders
Wider context from the report “It appears to be the case that no regulatory authority is available to control the quality or airworthiness of the class BGD Luna 2 Paraglider flown by the deceased.
The absence of such quality control and licensing for use and registration of such aircraft does provide the opportunity for future deaths to occur.
Had a mandatory inspection and certification of fitness been carried out and imposed by qualified inspectors , in all likelihood such a death as suffered by the deceased may not have occurred.
” Open source report
×
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 Revise, publish and distribute Paramotor Code guidance on maintaining SPHG aircraft airworthiness.
Verbatim wording from the response “The CAA therefore considers that it would be appropriate for it to publish new safety guidance on the importance of maintaining the airworthiness of all operational SPHG aircraft to a high standard.” Source location Response from Civil Aviation Authority
Open published response
×
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 Mandatory airworthiness requirements for SPHG aircraft are not proportionate because accident rates and risks to third parties remain low.
Verbatim wording from the response “Given the available safety data, it is the opinion of the CAA that the probability of an SPHG accident having unintended consequences for uninvolved third parties remains low. The consequences of such an occurrence, given the lightweight profile of these aircraft, are also considered to be low, when compared to more complex aviation activities that create greater risks to the public, including private transport, flight training and commercial operations.” Source location Response from Civil Aviation Authority
Open published response
5 Dec 2023 Jonathan Neal Goldstein and 2 others · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 4 Failure to restrict untrained PPL(A) licence holders from conducting mountain flying View source Lack of compulsory specific mountain flying training in theoretical and practical PPL training View source Failure to require flying schools to provide specific mountain flying advice to PPL(A) candidates View source Failure to provide currently qualified pilots with guidance on the risks of navigating through mountain passes View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jonathan Neal Goldstein and 2 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
Jonathan Neal Goldstein, Hannah Louise Goldstein and Saskia Lucia Goldstein died when a light aircraft crossing the Swiss Alps stalled at low altitude and collided with the ground on 25 August 2019. The principal concerns were the lack of compulsory specific mountain-flying training for PPL(A) pilots and the lack of UK guidance on the risks of navigating mountain passes.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to restrict untrained PPL(A) licence holders from conducting mountain flying
Wider context from the report “Specifically, I am concerned that:
1) There is no compulsory specific mountain flying training element to either the theoretical or practical parts of PPL training, and once qualified, there is no restriction on the right of pilots with PPL(A) licences to conduct mountain flying without having had such training ;
2) Nor, in the absence of any formal requirement, does the CAA request or require flying schools to provide specific mountain flying advice for PPL(A) candidates; and
3) Despite the safety advice given by the STSIB, guidance has not been given in the UK by any organisation to currently qualified pilots, highlighting the specific risks of navigating through mountain passes, and offering either guidance, or the location where guidance can be found.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of compulsory specific mountain flying training in theoretical and practical PPL training
Wider context from the report “Specifically, I am concerned that:
1) There is no compulsory specific mountain flying training element to either the theoretical or practical parts of PPL training , and once qualified, there is no restriction on the right of pilots with PPL(A) licences to conduct mountain flying without having had such training;
2) Nor, in the absence of any formal requirement, does the CAA request or require flying schools to provide specific mountain flying advice for PPL(A) candidates; and
3) Despite the safety advice given by the STSIB, guidance has not been given in the UK by any organisation to currently qualified pilots, highlighting the specific risks of navigating through mountain passes, and offering either guidance, or the location where guidance can be found.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to require flying schools to provide specific mountain flying advice to PPL(A) candidates
Wider context from the report “Specifically, I am concerned that:
1) There is no compulsory specific mountain flying training element to either the theoretical or practical parts of PPL training, and once qualified, there is no restriction on the right of pilots with PPL(A) licences to conduct mountain flying without having had such training;
2) Nor, in the absence of any formal requirement, does the CAA request or require flying schools to provide specific mountain flying advice for PPL(A) candidates ; and
3) Despite the safety advice given by the STSIB, guidance has not been given in the UK by any organisation to currently qualified pilots, highlighting the specific risks of navigating through mountain passes, and offering either guidance, or the location where guidance can be found.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to provide currently qualified pilots with guidance on the risks of navigating through mountain passes
Wider context from the report “Specifically, I am concerned that:
1) There is no compulsory specific mountain flying training element to either the theoretical or practical parts of PPL training, and once qualified, there is no restriction on the right of pilots with PPL(A) licences to conduct mountain flying without having had such training;
2) Nor, in the absence of any formal requirement, does the CAA request or require flying schools to provide specific mountain flying advice for PPL(A) candidates; and
3) Despite the safety advice given by the STSIB, guidance has not been given in the UK by any organisation to currently qualified pilots , highlighting the specific risks of navigating through mountain passes , and offering either guidance, or the location where guidance can be found .
” Open source report
×
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 Disseminate the new webpage and guidance through SkyWise, training organisations and GA representative organisations.
Verbatim wording from the response “The CAA will use a number of platforms to share the new webpage and guidance widely among the GA stakeholder community, including SkyWise, a free subscription service providing regular updates on items such as safety guidance, regulations and more to approximately 12,000 members of the UK GA community. The CAA will especially ensure that all Approved and Declared Training Organisations in the UK are made aware of the guidance. The CAA will also bring the new webpage and guidance to the attention of GA representative organisations (including, for example, members of the General Aviation Partnership) for them to promote among their members.” Source location Response from UK Civil Aviation Authority
Open published response
×
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 Create and maintain a dedicated webpage publishing relevant international guidance on the risks and challenges of high-mountain flying.
Verbatim wording from the response “The CAA has therefore decided to create a webpage on its website dedicated to the risks of flying in high mountain terrain. The CAA considers that the most appropriate guidance is that produced by National Aviation Authorities (“NAAs”) of states which do have high mountain terrain because those states have the necessary expertise to provide such guidance. The CAA will therefore provide links to relevant international guidance given on mountain flying and publish it within the Safety Topics section of its GA webpages to ensure the information can be easily located. The links will be regularly checked and updated to ensure the guidance remains current and relevant.” Source location Response from UK Civil Aviation Authority
Open published response
×
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 Safety Sense Leaflet providing mountain-flying safety information and guidance to pilots.
Verbatim wording from the response “The CAA has also decided to develop a Safety Sense Leaflet on mountain flying. Safety Sense Leaflets are an additional form of information and guidance to pilots covering specific safety topics. For example, safety guidance and information from the CAA exists for UK GA pilots flying under VFR conditions in the form of the Safety Sense Leaflet: Flight under VFR - Visual Flight Rules.¹” Source location Response from UK Civil Aviation Authority
Open published response
×
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 Consider whether to implement regulatory-framework changes in light of relevant safety data and international developments, following required consultation and impact assessment processes.
Verbatim wording from the response “The CAA will continue to review UK aviation safety data relevant to the concerns raised by the Assistant Coroner and will monitor any future developments in the international aviation context in this area. Where appropriate, the CAA will consider whether to implement a change to the regulatory framework to reflect those developments. Any decision to take mandatory action in respect of changes to the requirements associated with obtaining a PPL(A) must follow the CAA’s aviation safety legislation and policy development process, including public stakeholder consultation and impact assessment, where necessary.” Source location Response from UK Civil Aviation Authority
Open published response
×
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 New guidance and existing private pilot licensing requirements provide necessary knowledge, information and skills for safe mountainous VFR flight.
Verbatim wording from the response “The new webpage and guidance, together with the requirements for private pilot licensing in the UK, mean that the CAA is satisfied PPL(A) holders will have access to the necessary knowledge, information and skills to safely operate an aircraft in a variety of environments, including planning and executing a safe transit along a VFR route in mountainous terrain in good weather. The CAA has summarised the requirements applicable to a PPL(A) below.” Source location Response from UK Civil Aviation Authority
Open published response
×
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 Detailed mountain-flying guidance is most appropriately produced by national aviation authorities with high-mountain expertise.
Verbatim wording from the response “The CAA has therefore decided to create a webpage on its website dedicated to the risks of flying in high mountain terrain. The CAA considers that the most appropriate guidance is that produced by National Aviation Authorities (“NAAs”) of states which do have high mountain terrain because those states have the necessary expertise to provide such guidance. The CAA will therefore provide links to relevant international guidance given on mountain flying and publish it within the Safety Topics section of its GA webpages to ensure the information can be easily located. The links will be regularly checked and updated to ensure the guidance remains current and relevant.” Source location Response from UK Civil Aviation Authority
Open published response
24 Aug 2023 Jonathan Paul Bost Mann and Margaret Jean Costa · Prevention of Future Deaths report Somerset
View report summary
Concerns raised 5 Failure to obtain critical information about the pilot’s capabilities View source Failure to maintain accurate shared understanding and communication between the D&D Cell and Exeter Air Traffic Control View source Failure to obtain critical information about the plane’s capabilities View source Failure to use checklists and aide memoires for ground-based assistance View source Failure to obtain critical weather information about the selected diversion aerodrome View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Jonathan Paul Bost Mann and Margaret Jean Costa · 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 12 August 2021, Jonathan Paul Bost Mann and Margaret Jean Costa were involved in a plane crash after weather conditions deteriorated while Mr Mann was flying above cloud, which he was not qualified to do. Both suffered catastrophic injuries incompatible with life. The principal concerns were that the Distress and Diversion Cell did not obtain or share critical information about the pilot, aircraft and weather, and that incorrect assumptions, misunderstandings and miscommunications with Exeter Air Traffic Control limited the assistance provided.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain critical information about the pilot’s capabilities
Wider context from the report “The D&D cell did not request or receive any critical information about
(i) the pilot’s capabilities (i.e that he could not instrument fly and/or fly in cloud);
(ii) the plane’s capabilities (i.e. that it was not equipped to allow the pilot to instrument fly)
(iii) the weather conditions at the selected diversion aerodrome (to ensure that the weather was more favourable to the conditions at the home aerodrome).
Checklists and aide memoires were not used by those on the ground and, consequently, there was a lack of knowledge and/or appreciation of the unsuitability of the selected airport (Exeter) as a viable diversion destination; despite it being the closest in geographic proximity. There was no immediate requirement for urgent assistance as the pilot had fuel for a further 1.5hours of flying time and so there was sufficient time for key information to be obtained, analysed and shared between the D&D Cell and Exeter ATC.
The incorrect assumptions, misunderstandings and miscommunications between the D&D Cell and Exeter Air Traffic Control limited the ability of those on the ground to provide adequate assistance to a pilot in distress.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accurate shared understanding and communication between the D&D Cell and Exeter Air Traffic Control
Wider context from the report “The D&D cell did not request or receive any critical information about
(i) the pilot’s capabilities (i.e that he could not instrument fly and/or fly in cloud);
(ii) the plane’s capabilities (i.e. that it was not equipped to allow the pilot to instrument fly)
(iii) the weather conditions at the selected diversion aerodrome (to ensure that the weather was more favourable to the conditions at the home aerodrome).
Checklists and aide memoires were not used by those on the ground and, consequently, there was a lack of knowledge and/or appreciation of the unsuitability of the selected airport (Exeter) as a viable diversion destination; despite it being the closest in geographic proximity. There was no immediate requirement for urgent assistance as the pilot had fuel for a further 1.5hours of flying time and so there was sufficient time for key information to be obtained, analysed and shared between the D&D Cell and Exeter ATC.
The incorrect assumptions, misunderstandings and miscommunications between the D&D Cell and Exeter Air Traffic Control limited the ability of those on the ground to provide adequate assistance to a pilot in distress.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain critical information about the plane’s capabilities
Wider context from the report “The D&D cell did not request or receive any critical information about
(i) the pilot’s capabilities (i.e that he could not instrument fly and/or fly in cloud);
(ii) the plane’s capabilities (i.e. that it was not equipped to allow the pilot to instrument fly)
(iii) the weather conditions at the selected diversion aerodrome (to ensure that the weather was more favourable to the conditions at the home aerodrome).
Checklists and aide memoires were not used by those on the ground and, consequently, there was a lack of knowledge and/or appreciation of the unsuitability of the selected airport (Exeter) as a viable diversion destination; despite it being the closest in geographic proximity. There was no immediate requirement for urgent assistance as the pilot had fuel for a further 1.5hours of flying time and so there was sufficient time for key information to be obtained, analysed and shared between the D&D Cell and Exeter ATC.
The incorrect assumptions, misunderstandings and miscommunications between the D&D Cell and Exeter Air Traffic Control limited the ability of those on the ground to provide adequate assistance to a pilot in distress.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to use checklists and aide memoires for ground-based assistance
Wider context from the report “The D&D cell did not request or receive any critical information about
(i) the pilot’s capabilities (i.e that he could not instrument fly and/or fly in cloud);
(ii) the plane’s capabilities (i.e. that it was not equipped to allow the pilot to instrument fly)
(iii) the weather conditions at the selected diversion aerodrome (to ensure that the weather was more favourable to the conditions at the home aerodrome).
Checklists and aide memoires were not used by those on the ground and, consequently, there was a lack of knowledge and/or appreciation of the unsuitability of the selected airport (Exeter) as a viable diversion destination; despite it being the closest in geographic proximity. There was no immediate requirement for urgent assistance as the pilot had fuel for a further 1.5hours of flying time and so there was sufficient time for key information to be obtained, analysed and shared between the D&D Cell and Exeter ATC.
The incorrect assumptions, misunderstandings and miscommunications between the D&D Cell and Exeter Air Traffic Control limited the ability of those on the ground to provide adequate assistance to a pilot in distress.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain critical weather information about the selected diversion aerodrome
Wider context from the report “The D&D cell did not request or receive any critical information about
(i) the pilot’s capabilities (i.e that he could not instrument fly and/or fly in cloud);
(ii) the plane’s capabilities (i.e. that it was not equipped to allow the pilot to instrument fly)
(iii) the weather conditions at the selected diversion aerodrome (to ensure that the weather was more favourable to the conditions at the home aerodrome).
Checklists and aide memoires were not used by those on the ground and, consequently, there was a lack of knowledge and/or appreciation of the unsuitability of the selected airport (Exeter) as a viable diversion destination; despite it being the closest in geographic proximity. There was no immediate requirement for urgent assistance as the pilot had fuel for a further 1.5hours of flying time and so there was sufficient time for key information to be obtained, analysed and shared between the D&D Cell and Exeter ATC.
The incorrect assumptions, misunderstandings and miscommunications between the D&D Cell and Exeter Air Traffic Control limited the ability of those on the ground to provide adequate assistance to a pilot in distress.
” Open source report
18 Nov 2021 Rebecca Dobson and 4 others · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 2 Lack of a central register recording crash-resistant fuel system fitment View source Failure to mandate retrofit of crash-resistant fuel systems on rotorcraft View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Rebecca Dobson and 4 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 10 February 2018, a helicopter crashed over the Grand Canyon and caught fire. Rebecca Dobson, Jason Hill, Stuart Hill, Eleanor Udall and Jonathan Udall survived the crash but died from thermal injuries and smoke inhalation caused by the ensuing fire. The principal concerns were that helicopters without crash-resistant fuel systems remained in operation, that retrofit installation was not mandatory, and that the absence of a central register prevented passengers from knowing whether an aircraft had such a system.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of a central register recording crash-resistant fuel system fitment
Wider context from the report “5. For the public there does not appear to be any way of knowing whether a particular aircraft has been fitted with the CRFS as there is no central register which records this . The public cannot therefore make an informed decision as to whether to fly on that aircraft.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to mandate retrofit of crash-resistant fuel systems on rotorcraft
Wider context from the report “4. There is nothing in place to mandate the fitting of CRFS as a retrofit and so the risk of post-crash fire in non-CRFS fitted helicopters remains very high with the likelihood of loss of life
” Open source report
×
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 Conduct detailed analysis of risks affecting UK-registered rotorcraft and assess the impacts of subsequent rule-change and safety-guidance proposals.
Verbatim wording from the response “The CAA will continue to work with international and domestic aviation stakeholders to mitigate the risks to public safety in accordance with the concerns highlighted in the Senior Coroner’s Regulation 28 report. The CAA will conduct further detailed analysis of those risks, insofar as they relate to UK registered rotorcraft, together with an assessment of the impact of any subsequent proposals for rule changes and amendments to safety guidance. The CAA will be informed by analysis of UK aviation safety data, the progress of EASA RMT.0710 and work undertaken by the FAA arising from the ROPWG.” Source location 2021-0392-Response-from-Civil-Aviation-Authority
Open published response
×
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 Consider whether UK aviation safety requirements require rule changes, following technical evaluation of applicable crash-resistant fuel systems and structures.
Verbatim wording from the response “The CAA will then consider whether rule changes are required to align UK aviation safety requirements, where appropriate. Any decision reached to take mandatory action must follow extensive technical evaluation including, but not limited to, testing CRFS and CRSS to ensure compliance with design and certification requirements for each applicable aircraft type.” Source location 2021-0392-Response-from-Civil-Aviation-Authority
Open published response
×
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 Contact the FAA to understand the rationale for rotorcraft crash-resistant fuel bladder retrofit recommendations.
Verbatim wording from the response “The CAA will continue to review UK aviation safety data relevant to the concerns raised by the Senior Coroner and monitor related developments arising from EASA RMT.0710. The CAA will also contact the FAA to understand the rationale for recommendations from” Source location 2021-0392-Response-from-Civil-Aviation-Authority
Open published response
×
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 operate a national aviation safety rule-making programme covering rotorcraft design and certification requirements.
Verbatim wording from the response “With effect from 1 January 2021 the CAA has established a national rule making programme, working with the Department for Transport, for managing proposed changes to the existing regulatory framework for aviation safety in the UK. This programme is designed to align, where appropriate, with technical specifications, known as Standards and Recommended Practices (‘SARP’s) adopted by the Council of ICAO and separate global rule making, including that directed by EASA and the US Federal Aviation Authority (‘FAA’).” Source location 2021-0392-Response-from-Civil-Aviation-Authority
Open published response
×
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 Undertake consultation with owners and operators as part of the wider impact assessment for proposed retrospective rotorcraft requirements.
Verbatim wording from the response “These proposals will be retrospective and targeted into Part 26 for existing type designed Rotorcraft,² and will require the CAA to undertake a period of consultation with owners and operators as part a wider impact assessment.” Source location Response from Civil Aviation Authority
Open published response
×
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 Consider safety proposals for existing UK-registered rotorcraft within the aviation legislation and policy rulemaking programme.
Verbatim wording from the response “Based on the work carried out to date, including a preliminary assessment of the impact on owners and operators, the CAA is considering safety proposals for existing Rotorcraft on the UK register to be incorporated into the aviation legislation and policy rulemaking programme.” Source location Response from Civil Aviation Authority
Open published response
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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 Monitor UK rotorcraft safety following the Senior Coroner’s recommendations.
Verbatim wording from the response “In the meantime, the CAA will continue to carefully monitor Rotorcraft safety in the U.K. following the recommendations issued by the Senior Coroner and encourage owners and operators of Rotorcraft in the U.K., particularly those performing commercial air transport operations to consider enhancing safety by voluntarily fitting CRFS design provisions, including, tear resistant bladder inserts to fuel tanks pending any future mandatory rule changes.” Source location Response from Civil Aviation Authority
Open published response
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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 Implement targeted safety promotion for the rotorcraft community, including collaboration with industry and operators to encourage best practice and voluntary CRFS fitting.
Verbatim wording from the response “The CAA has already held meetings with representatives of both EASA and the FAA to ensure that it is working collaboratively with European and U.S. policy teams on this issue. In addition, the CAA intends to work with U.K. industry and operators to raise public awareness and encourage best practice.” Source location Response from Civil Aviation Authority
Open published response
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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 UK accident data does not indicate an imminent safety risk requiring immediate changes to rotorcraft certification requirements or a UK-wide safety directive.
Verbatim wording from the response “The CAA reviewed the UK Rotorcraft accident data relevant to the specific concerns raised by the Senior Coroner. The accident data relevant to operations in the UK does not highlight an imminent safety risk to passengers who are travelling in previously certified Rotorcraft without CRFS provisions fitted, or to the general public, such that an unsafe condition exists requiring an immediate change to the design and certification requirements or a U.K. wide safety directive.” Source location Response from Civil Aviation Authority
Open published response
3 Nov 2021 Steven Phillip Evans · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 1 Failure to use effective radio communication between ground crew and glider pilots during launch and flight View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Steven Phillip Evans · 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
Steven Phillip Evans was preparing to fly a glider when its tail plane became dislodged during launch, causing it to crash. He sustained serious injuries and died on 1 August 2019. The principal concern was that ineffective communication between ground crew and aircraft pilots failed to alert those involved to problems with the glider before launch; the report noted that radios may not be in use at other clubs and could put lives at risk in the future.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to use effective radio communication between ground crew and glider pilots during launch and flight
Wider context from the report “1. Mandatory radio communication between ground crew and aircraft pilots.
During the course of the inquest the jury heard that problems with Steven’s glider were observed before the glider was launched however the system of communication did not alert either the tug plane operator or Steven Evans to the problems prior to his launch . In the circumstances I consider this constituted a failure to adopt an effective communication system at launch , a finding endorsed by the Air Accident Investigation Branch. However, there was insufficient information to determine that this contributed to Steven’s death as the glider crashed within seconds of the fault being identified.
In evidence it became clear that the CAA do not mandate the use of radios in the relevant aircraft and by the ground crew and whilst this was previously recommended by the BGA it was not usual practice at South Wales Gliding Club until after Steven’s death .
Whilst it was not determined that the failure to have radio communication contributed to Steven’s death it appears that radios may still not be in use in other clubs and therefore lives may be put at risk in the future. I consider that further consideration should be given by the CAA to require effective radio communication not only at launch but throughout the glider flight and that the BGA further strengthen the current guidelines that radios are strongly recommended.
” Open source 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 Coordinate with the BGA to promote launch-signalling safety information at the start of the 2022 gliding season.
Verbatim wording from the response “1. The CAA will coordinate with the BGA to promote the relevant safety information regarding launch signalling to coincide with the start of the 2022 gliding season.” Source location 2021-0372-Response-from-Civil-Aviation-Authority
Open published response
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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 Continue monitoring launch-related occurrence data with the BGA to assess whether further action is required.
Verbatim wording from the response “The Regulation 28 Report from the Senior Coroner, states that there was insufficient information to determine whether the failure to adopt an effective communication system contributed to Mr Evans’ death. The CAA recognises that radios are one possible means of effective communication between aircraft and groundcrews involved in glider launching, they are not however, the only means. In its updated guidance on this topic, the BGA has outlined the various recognised methods of effective launch signalling, including the associated limitations of each. The CAA has reviewed the updated BGA guidance on launch signalling and is content that the revision is adequate. The CAA will, however, continue to work closely with the BGA and monitor occurrence data for launch-related incidents to determine whether further action is required.” Source location 2021-0372-Response-from-Civil-Aviation-Authority
Open published response
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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 Review the BGA’s updated launch-signalling guidance and confirm that its revision is adequate.
Verbatim wording from the response “The Regulation 28 Report from the Senior Coroner, states that there was insufficient information to determine whether the failure to adopt an effective communication system contributed to Mr Evans’ death. The CAA recognises that radios are one possible means of effective communication between aircraft and groundcrews involved in glider launching, they are not however, the only means. In its updated guidance on this topic, the BGA has outlined the various recognised methods of effective launch signalling, including the associated limitations of each. The CAA has reviewed the updated BGA guidance on launch signalling and is content that the revision is adequate. The CAA will, however, continue to work closely with the BGA and monitor occurrence data for launch-related incidents to determine whether further action is required.” Source location 2021-0372-Response-from-Civil-Aviation-Authority
Open published response
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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 Updated BGA launch-signalling guidance is considered adequate, so further action will depend on monitoring whether occurrence data indicates it is required.
Verbatim wording from the response “The Regulation 28 Report from the Senior Coroner, states that there was insufficient information to determine whether the failure to adopt an effective communication system contributed to Mr Evans’ death. The CAA recognises that radios are one possible means of effective communication between aircraft and groundcrews involved in glider launching, they are not however, the only means. In its updated guidance on this topic, the BGA has outlined the various recognised methods of effective launch signalling, including the associated limitations of each. The CAA has reviewed the updated BGA guidance on launch signalling and is content that the revision is adequate. The CAA will, however, continue to work closely with the BGA and monitor occurrence data for launch-related incidents to determine whether further action is required.” Source location 2021-0372-Response-from-Civil-Aviation-Authority
Open published response
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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 Radios are not required in relevant airspace or ground operations and are not the only effective launch-signalling method.
Verbatim wording from the response “The Air Navigation Order 2016 and the Standardised European Rules of the Air specify which classes of airspace radios are required to be used and in which context. The Air Accidents Investigation Branch (“AAIB”) correctly note in their report for G-DDGX, published 28 May 2020[1], that aircraft operating under visual flight rules within Class G[2] airspace, which has not been declared a Radio Mandatory Zone (“RMZ”)[3] are not required to use a radio whilst airborne. Additionally, in the context of this operational environment, there is no existing requirement for radios to be used during ground operations.” Source location 2021-0372-Response-from-Civil-Aviation-Authority
Open published response
Concerns raised 2 Lack of training for airline and ground staff on vulnerability of lone passengers when disembarked overseas View source Lack of safeguarding procedures for vulnerable passengers disembarked overseas View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Andrew Paul WESTLAKE · 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
Andrew Paul WESTLAKE was disembarked from a flight in Turkey while appearing frightened, confused and mentally unwell, and later fell 10.2 metres from the second floor of Dalaman Airport, dying in hospital from his injuries on 29 May 2018. The concerns centred on the lack of airline procedures and staff training for safeguarding vulnerable passengers who are disembarked overseas, particularly those travelling alone and experiencing a mental health crisis.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of training for airline and ground staff on vulnerability of lone passengers when disembarked overseas
Wider context from the report “1. Mr WESTLAKE appears on the evidence to have been mentally unwell when he was disembarked. He was not aggressive, violent or abusive - toxicological evidence showed he had not consumed alcohol or any drugs prescribed or illicit. He was travelling alone. He had no possessions, money, mobile telephone, this was his first trip outside the UK as an adult and he could not speak Turkish.
2. A witness for JET2.Com confirmed no policy or procedure exists for disembarking a passenger other than for a disruptive passenger. She could not recall any training on this situation or in relation to passengers that may be vulnerable through mental illness.
3. A number of witnesses gave evidence on the distress and confusion of Mr WESTLAKE within the terminal, aircraft and air bridge.
Mr WESTLAKE was disembarked from the aircraft. He found himself without support in a foreign country and it would appear, was in some form of mental health crisis.
My concerns centre on;
• Training for airline and ground staff (employed by UK Airlines) on vulnerability of lone passengers when disembarked overseas.
• Procedures for safeguarding vulnerable passengers such as Mr WESTLAKE.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of safeguarding procedures for vulnerable passengers disembarked overseas
Wider context from the report “1. Mr WESTLAKE appears on the evidence to have been mentally unwell when he was disembarked. He was not aggressive, violent or abusive - toxicological evidence showed he had not consumed alcohol or any drugs prescribed or illicit. He was travelling alone. He had no possessions, money, mobile telephone, this was his first trip outside the UK as an adult and he could not speak Turkish.
2. A witness for JET2.Com confirmed no policy or procedure exists for disembarking a passenger other than for a disruptive passenger. She could not recall any training on this situation or in relation to passengers that may be vulnerable through mental illness.
3. A number of witnesses gave evidence on the distress and confusion of Mr WESTLAKE within the terminal, aircraft and air bridge.
Mr WESTLAKE was disembarked from the aircraft. He found himself without support in a foreign country and it would appear, was in some form of mental health crisis.
My concerns centre on;
• Training for airline and ground staff (employed by UK Airlines) on vulnerability of lone passengers when disembarked overseas.
• Procedures for safeguarding vulnerable passengers such as Mr WESTLAKE.
” Open source report
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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 No regulations enable the CAA to mandate changes to UK airline procedures and training for disembarking vulnerable lone passengers overseas.
Verbatim wording from the response “There are no regulations that would enable the CAA to mandate changes to UK airline procedures and training for the disembarkation of vulnerable lone passengers overseas. We will however continue our work to support the UK aviation industry make improvements to the treatment of vulnerable consumers. The CAA is actively taking steps to increase our engagement with UK aviation stakeholders including airline operators, to enhance the” Source location 2020-0268-Response-from-CAA-Redacted
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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 The CAA has no direct regulatory oversight of UK airlines’ overseas disembarkation training and procedures or specific authority to intervene in safeguarding vulnerable passengers.
Verbatim wording from the response “The CAA has no direct regulatory oversight of UK airline operators’ overseas passenger disembarkation training and procedures. There is no specific aviation legislation that supports the CAA’s formal intervention concerning safeguarding vulnerable passengers. Nevertheless, the CAA does recognise the significance of its role regulating to safety and consumer protection in UK aviation, including the statutory requirement to have due regard to further certain societal objectives relating to equality when carrying out its functions.¹” Source location 2020-0268-Response-from-CAA-Redacted
Open published response
17 May 2019 Jaspal Singh BAHRA and 3 others · Prevention of Future Deaths report Buckinghamshire
View report summary
Concerns raised 4 Risk of Carbon Monoxide exposure in light aircraft from undetected exhaust or heating-system defects View source Reliance on “See and Avoid” procedures that cannot reliably detect craft concealed by blind spots View source Lack of mandatory carriage of Carbon Monoxide monitors or warning devices in light aircraft View source Lack of universal carriage of inter-craft electronic proximity warning or collision avoidance devices View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Jaspal Singh BAHRA 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
Jaspal Singh Bahra, Saavan Singh Mundae, Michael Leonard Green and Thanh Trung Nguyen died at the scene after the aircraft they were flying collided over Wilderness Wood in Buckinghamshire on 17 November 2017. The report raised concerns about reliance on the “See and Avoid” procedure in unregulated airspace without universal electronic proximity warning or collision-avoidance devices, and about the lack of mandatory carbon monoxide monitors or warning devices in light aircraft.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Risk of Carbon Monoxide exposure in light aircraft from undetected exhaust or heating-system defects
Wider context from the report “(2) Although it could not be demonstrated that exposure to Carbon Monoxide prior to or during flight played a part in the implementation of “See and Avoid” or the collision, evidence demonstrated that it is not mandatory for light aircraft such as were involved in this collision to carry any Carbon Monoxide monitors or warning devices, notwithstanding their potential availability.
Given the regular service requirements for such craft and the possible limitations in identifying airline cracks or hidden defects in aircraft exhaust and heating systems , there remains a risk that pilots and passengers may be exposed to Carbon Monoxide in such craft which might directly put them at risk of death or might put the craft at risk of collision or accident carrying with that the inherent risk of death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Reliance on “See and Avoid” procedures that cannot reliably detect craft concealed by blind spots
Wider context from the report “(1) It was clear from the evidence of The Air Accidents Investigation Branch (AAIB) and The Civil Aviation Authority (CAA) that aircraft such as the two involved in this collision operate in unregulated Class G airspace such as exists in the area of this collision without the requirement to carry any inter-craft electronic proximity warning or collision avoidance devices and are primarily kept safe by operating under the “See and Avoid” procedure which remains the same today as it was on 17th November 2017 (when the collision occurred). It appears this has also been the case for many years before that. This procedure is entirely reliant upon pilots seeing other craft and undertaking periodic clearing turns to try to bring craft into view which might be concealed by a blind spot particular to that craft. It was the view of the AAIB that the “See and Avoid” procedure was central to the cause of this collision.
Although evidence was given by CAA about movement towards the introduction of electronic devices, it was clear that, without universal application, small craft would remain at risk and that timescales for implementation are unclear, leaving “See and Avoid” as the continuing process by which these types of craft avoid collisions .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory carriage of Carbon Monoxide monitors or warning devices in light aircraft
Wider context from the report “(2) Although it could not be demonstrated that exposure to Carbon Monoxide prior to or during flight played a part in the implementation of “See and Avoid” or the collision, evidence demonstrated that it is not mandatory for light aircraft such as were involved in this collision to carry any Carbon Monoxide monitors or warning devices , notwithstanding their potential availability.
Given the regular service requirements for such craft and the possible limitations in identifying airline cracks or hidden defects in aircraft exhaust and heating systems, there remains a risk that pilots and passengers may be exposed to Carbon Monoxide in such craft which might directly put them at risk of death or might put the craft at risk of collision or accident carrying with that the inherent risk of death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of universal carriage of inter-craft electronic proximity warning or collision avoidance devices
Wider context from the report “(1) It was clear from the evidence of The Air Accidents Investigation Branch (AAIB) and The Civil Aviation Authority (CAA) that aircraft such as the two involved in this collision operate in unregulated Class G airspace such as exists in the area of this collision without the requirement to carry any inter-craft electronic proximity warning or collision avoidance devices and are primarily kept safe by operating under the “See and Avoid” procedure which remains the same today as it was on 17th November 2017 (when the collision occurred). It appears this has also been the case for many years before that. This procedure is entirely reliant upon pilots seeing other craft and undertaking periodic clearing turns to try to bring craft into view which might be concealed by a blind spot particular to that craft. It was the view of the AAIB that the “See and Avoid” procedure was central to the cause of this collision.
Although evidence was given by CAA about movement towards the introduction of electronic devices, it was clear that, without universal application, small craft would remain at risk and that timescales for implementation are unclear, leaving “See and Avoid” as the continuing process by which these types of craft avoid collisions.
” Open source 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 Review airprox reports and analyse UK Airprox Board findings to identify causal factors, lessons and potential safety action.
Verbatim wording from the response “However, pending such further advancement and subsequent adoption, the CAA continues to address the associated risk by ensuring that pilots are cognisant of the limitations of ‘see and avoid’; reviewing reports of airprox incidents identifying causal or contributory factors; collaborating with industry stakeholders through the Mid-Air Collision Programme and recommending or acting where appropriate to mitigate the risk of such incidents occurring.” Source location 2019-0160-Response-by-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 Consult the AOPA Maintenance Working Group, consider the merits of a carbon monoxide Safety Notice and decide whether to publish it.
Verbatim wording from the response “The Regulation 28 report to prevent future deaths has provided an opportunity to review available material on CO contamination avoidance. Notwithstanding the measures already in place and those expected in the near future, the CAA will consider the merits of an additional information on best practice CO contamination avoidance, in a ‘Safety Notice’ publication. To this end, the CAA will consult with members of the relevant stakeholder forum, the AOPA Maintenance Working Group, in making this decision by the end of the third quarter of 2019. If a decision be made to publish a Safety Notice, this is expected to take place by the end of 2019.” Source location 2019-0160-Response-by-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 Publish and maintain guidance on carbon monoxide contamination, including maintenance expectations, inspection importance and testing methods.
Verbatim wording from the response “CAA Publication (CAP) 562 ‘Civil Aircraft Airworthiness Information and Procedures’” Source location 2019-0160-Response-by-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 Ensure pilots understand the limitations of see-and-avoid techniques through training and safety guidance.
Verbatim wording from the response “However, pending such further advancement and subsequent adoption, the CAA continues to address the associated risk by ensuring that pilots are cognisant of the limitations of ‘see and avoid’; reviewing reports of airprox incidents identifying causal or contributory factors; collaborating with industry stakeholders through the Mid-Air Collision Programme and recommending or acting where appropriate to mitigate the risk of such incidents occurring.” Source location 2019-0160-Response-by-Civil-Aviation-Authority
Open published response
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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 Manage mid-air collision data and use evidence to steer mitigation strategies collaboratively with industry.
Verbatim wording from the response “Among other measures, the MAC Programme will continue to:” Source location 2019-0160-Response-by-Civil-Aviation-Authority
Open published response
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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 Continue investing resources in developing electronic conspicuity devices to mitigate mid-air collision risk in uncontrolled airspace.
Verbatim wording from the response “The CAA anticipates that the further development and deployment of universally-compatible electronic conspicuity devices will aid in mitigation the risk of future mid-air collisions occurring in Class G (uncontrolled) airspace. As such, this is an area in which the CAA has invested and will continue to invest significant resources.” Source location 2019-0160-Response-by-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 Contribute to updating and improving accessibility of the Skyway Code as guidance on airmanship and collision prevention.
Verbatim wording from the response “The importance of maintaining an effective visual lookout is reinforced through CAA publications. In May 2019, the CAA published the second edition of the ‘Skyway Code’,² which is intended to provide pilots involved in non-commercial and flight training operations with practical guidance on the operational, safety and regulatory issues relevant to their flying. Its primary focus is safe aircraft operations and the safe use of airspace. It is oriented towards Visual Flight Rules (VFR) flight and provides guidance on the rules for the prevention of collisions; precautionary measures that pilots can take; techniques for effective visual scanning; the limitations of ‘see and avoid’ and available means of ensuring electronic visual conspicuity. The CAA intends that the Skyway Code will be reviewed annually to ensure it reflects the latest regulatory requirements and best aviation practice.” Source location 2019-0160-Response-by-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 Encourage development and deployment of interoperable, practical and affordable electronic conspicuity devices.
Verbatim wording from the response “Among other measures, the MAC Programme will continue to:” Source location 2019-0160-Response-by-Civil-Aviation-Authority
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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 CO detectors are not mandated because aircraft certification requirements are considered sufficient to minimise contamination risk; installation remains at pilot or owner discretion.
Verbatim wording from the response “CO detectors may be fitted to UK-registered aircraft as ‘standard changes’ under the provisions of CS-STAN (for EASA aircraft) and CAP 1419 (for non-EASA aircraft). This removes the need for direct authority involvement, allowing equipment to be installed without the associated time and costs.” Source location 2019-0160-Response-by-Civil-Aviation-Authority
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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 Changes to aircraft design requirements, including CO detector requirements, would need to be made by EASA.
Verbatim wording from the response “The European Aviation Safety Agency (EASA) has oversight of the design of the aircraft involved in this accident. EASA promulgates design requirements (‘codes’) CS-23 for ‘Small Light Aeroplanes’ and CS-VLR for ‘Very Light Rotorcraft’, which contain specific requirements on cockpit contamination preventative measures. Any change to those requirements would need to be brought about by EASA. The codes address the required levels of ventilation, the maximum acceptable CO content in the cockpit and the design of heating systems (notably exhaust-related heat exchangers) with a view to preventing CO contamination in the cockpit. The codes do not require CO detectors to be fitted as part of the design. Similar design requirements exist in the United States, which is the primary source of general aviation aircraft types.” Source location 2019-0160-Response-by-Civil-Aviation-Authority
Open published response
2 Jan 2019 Flt. Lt. Alexandre Jay Parr · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 3 Failure to communicate the emergency fuel-primer-pump cycle rate to YAK pilots View source Failure to apply a 20-year engine-overhaul limit to all piston engines View source Failure of the emergency fuel-primer-pump instructions to specify the required cycle rate View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Flt. Lt. Alexandre Jay Parr · 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
Flt. Lt. Alexandre Jay Parr died after fuel starvation caused loss of engine power during a training flight in a Yak 52 aircraft, followed by a forced landing and crash on 8 July 2016. The report identified concerns about engine-overhaul limits, aircraft safety harnesses, and communicating the appropriate emergency use cycle rate for the fuel primer pump to Yak pilots.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate the emergency fuel-primer-pump cycle rate to YAK pilots
Wider context from the report “c) THE USE OF THE FUEL PRIMER PUMP IN AN EMERGENCY.
Whilst the primer pump may not have originally been specifically designed for use in an emergency I understand from the AAIB investigators that the manufacturer's state in their manual that the pump can be used in an emergency, for example should the fuel pump fail. Regrettably, I also understand that the manufacturer's manual gives no indication as regards the cycle rate for the use of the primer pump in these emergency circumstances. When G-YAKB experienced a loss of engine power and Alex sitting in the front cockpit used the primer pump he was pumping at a rate of 1 cycle every 3 to 4 seconds. This was found to be insufficient to provide sufficient fuel to the engine in order to regain power. When the AAIB investigators attempted to ascertain a sufficient cycle rate they found that a significantly higher rate was required in order to provide sufficient fuel to the engine. That rate was 1.3 cycles per second. I am unclear, aside from the findings of the AAIB report, as to how this potentially important piece of information can be communicated to the YAK user population in the United Kingdom. It seems to me that this information is important and may be unknown to many YAK pilots and I am concerned that if the intention is that YAK 52 pilots are required to read this AAIB Report concerning this incident, then this particular piece of information may be missed if a pilot does not research this particular incident . I would respectfully ask you to consider how best to communicate this information to the wider YAK pilot community in the United Kingdom.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to apply a 20-year engine-overhaul limit to all piston engines
Wider context from the report “a) OVERHAUL OF ENGINE.
This particular aircraft G-YAKB a YAK 52 was manufactured in 1992 and had an initial manufacturer's life span of 20 years. The life span was extended in 2013 for a period of 10 years following an overhaul carried out in accordance with CAA Regulations. The manufacturer's specification was that an overhaul of the engine was required at 750 hours. At the time of the crash even though the aircraft was approximately 24 years old the original piston engine had only logged 516 hours. I understand having heard Mr. Hawkins that currently there is a CAA leaflet number 70/80 that requires a 20-year calendar limit in relation to an engine overhaul irrespective as to whether or not the manufacturer's specified number of hours usage has been reached however leaflet 70/80 only applies to engine with more than 400 horsepower . I understand from the AAIB investigators that your organisation is conducting a review as to whether or not this should be extended to all piston engines. Whilst accepting the evidence of the AAIB that there was not an issue with this particular engine this observation made by the AAIB investigators may lend sense to me from a safety perspective and I would be grateful if you could please advise me as regards the state of this review and ultimately notify me as to whether leaflet 70/80 is to be extended or how the issue is to be resolved through other means. If there is to be no change then please indicate why and how you reached that decision.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Failure of the emergency fuel-primer-pump instructions to specify the required cycle rate
Wider context from the report “c) THE USE OF THE FUEL PRIMER PUMP IN AN EMERGENCY.
Whilst the primer pump may not have originally been specifically designed for use in an emergency I understand from the AAIB investigators that the manufacturer's state in their manual that the pump can be used in an emergency, for example should the fuel pump fail. Regrettably, I also understand that the manufacturer's manual gives no indication as regards the cycle rate for the use of the primer pump in these emergency circumstances . When G-YAKB experienced a loss of engine power and Alex sitting in the front cockpit used the primer pump he was pumping at a rate of 1 cycle every 3 to 4 seconds. This was found to be insufficient to provide sufficient fuel to the engine in order to regain power. When the AAIB investigators attempted to ascertain a sufficient cycle rate they found that a significantly higher rate was required in order to provide sufficient fuel to the engine. That rate was 1.3 cycles per second. I am unclear, aside from the findings of the AAIB report, as to how this potentially important piece of information can be communicated to the YAK user population in the United Kingdom. It seems to me that this information is important and may be unknown to many YAK pilots and I am concerned that if the intention is that YAK 52 pilots are required to read this AAIB Report concerning this incident, then this particular piece of information may be missed if a pilot does not research this particular incident. I would respectfully ask you to consider how best to communicate this information to the wider YAK pilot community in the United Kingdom.
” Open source 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 Discuss YAK fuel-primer-pump use during power loss at the next CAA-led YAK and Nanchang Continuing Airworthiness Forum and consider whether additional UK guidance would be useful and effective.
Verbatim wording from the response “manufacturer to specify a rate. The use of the YAK Fuel Primer Pump in the event of a loss of power, will be included for discussion at the next CAA led YAK & Nanchang ‘Continuing Airworthiness Forum’ due to be held by the end of the second quarter of 2019 and attended by key owners and maintainers of the affected types. The Group will consider whether additional guidance to UK users would be useful and effective.” Source location 2019-0001-Response-by-CAA
Open published response
×
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 Replace the YAK-52 engine life directive with requirements reinforcing the 2,250-hour limit and informing owners of a maximum calendar life.
Verbatim wording from the response “Additionally, Mandatory Permit Directive, MPD 1998-001R2, which limits the life of the YAK-52 engine to 2250 flying hours has been superseded by a new MPD 2019-002 which reinforces the replacement lifespan of this engine and now also ensures owner/operators are aware of the need for a maximum calendar life, even if engine utilisation (flying hours) is low.” Source location 2019-0001-Response-by-CAA
Open published response
×
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 Require calendar-based engine overhaul periods for low-utilisation National Permit to Fly aircraft alongside or instead of flying-hour maintenance tasks.
Verbatim wording from the response “The CAA’s requirements for all National Permit to fly Aircraft[1] now includes an expectation that appropriate calendar periods for engine overhaul should complement or replace flying hour-related maintenance tasks in the aircraft maintenance programme for individual aircraft in the case of low utilisation. Any such calendar period(s) for engine overhaul are expected to be determined by consideration of manufacturers recommendations, usage, environmental conditions (e.g. hangarage) and type of operation (safety risk).” Source location 2019-0001-Response-by-CAA
Open published response
×
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 Requesting the manufacturer to specify a fuel-primer-pump rate is not appropriate because technical and human factors may make use counterproductive.
Verbatim wording from the response “The CAA has established there are a number of different technical and human factors that would have an impact on the effectiveness of utilisation of the Fuel Primer Pump, particularly in emergency situations where it’s use may, in certain circumstances be counter-productive. For this reason, the CAA has concluded it would not be appropriate for CAA to request the” Source location 2019-0001-Response-by-CAA
Open published response
×
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 The applicability of Leaflet 70-80 does not need extending following the review of YAK-52 engine-failure data and overhaul findings.
Verbatim wording from the response “As a consequence of the review conducted by the CAA and the findings set out above, the applicability of Leaflet 70-80 does not need to be extended.” Source location 2019-0001-Response-by-CAA
Open published response
×
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 UK YAK-52 engine-failure reports did not identify engine age or inadequate maintenance as contributory factors; conventional wear drives replacement.
Verbatim wording from the response “The CAA has reviewed the UK accident safety data related to engine failure on YAK-52 aircraft and confirmed that none of the reports (five in total between January 2003–January 2019) cited engine age or lack of maintenance as a contributory factor. Additionally, the CAA has reviewed recent overhaul data from a specialist Approved Organisation in Hungary which is responsible for the maintenance overhaul of 40-50 of this engine type per year. This review concluded that conventional (flight hour-related) component wear is the main reason for replacement at overhaul, rather than age.” Source location 2019-0001-Response-by-CAA
Open published response
Concerns raised 3 Limitations of visual collision avoidance in certain weather conditions View source Absence of air traffic control over an airfield with multiple aircraft in the vicinity View source Lack of effective, compatible and mandatory aircraft collision-position and warning systems View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
John Christopher Armstrong · 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
John Christopher Armstrong, a 70-year-old glider pilot, died on 4 December 2016 after his glider collided mid-air with a Cessna aircraft near Husbands Bosworth Airfield. The concerns included the limitations of visual “see and avoid” collision prevention, the lack of compatible or mandatory electronic conspicuity systems, and the absence of air traffic control at the airfield despite multiple aircraft being nearby.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Limitations of visual collision avoidance in certain weather conditions
Wider context from the report “(1) A ‘see and avoid’ principle of avoiding collisions is subject to limitations of the human eye and may be a significant problem in certain weather conditions (as in this case, a low sun eye) :
2) There is no effective way of one aircraft ascertaining another aircraft’s position in flight or have any warning of an impending collision. Some aircraft have alarms and/or anti-collision devices but (a) they are not necessarily compatible with other systems that are used and (b) they are not mandatory;
(2) There was no Air Traffic control over Husbands Bosworth airfield even though there is a gliding club at the airfield and therefore, one would assume, a higher usage of airspace and likelihood of a collision. There were seven aircraft in the vicinity at the time of the accident (including the two aircraft involved in the accident) but no-one controlling the position of the aircraft.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Absence of air traffic control over an airfield with multiple aircraft in the vicinity
Wider context from the report “(1) A ‘see and avoid’ principle of avoiding collisions is subject to limitations of the human eye and may be a significant problem in certain weather conditions (as in this case, a low sun eye):
2) There is no effective way of one aircraft ascertaining another aircraft’s position in flight or have any warning of an impending collision. Some aircraft have alarms and/or anti-collision devices but (a) they are not necessarily compatible with other systems that are used and (b) they are not mandatory;
(2) There was no Air Traffic control over Husbands Bosworth airfield even though there is a gliding club at the airfield and therefore, one would assume, a higher usage of airspace and likelihood of a collision. There were seven aircraft in the vicinity at the time of the accident (including the two aircraft involved in the accident) but no-one controlling the position of the aircraft .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of effective, compatible and mandatory aircraft collision-position and warning systems
Wider context from the report “(1) A ‘see and avoid’ principle of avoiding collisions is subject to limitations of the human eye and may be a significant problem in certain weather conditions (as in this case, a low sun eye):
2) There is no effective way of one aircraft ascertaining another aircraft’s position in flight or have any warning of an impending collision . Some aircraft have alarms and/or anti-collision devices but (a) they are not necessarily compatible with other systems that are used and (b) they are not mandatory ;
(2) There was no Air Traffic control over Husbands Bosworth airfield even though there is a gliding club at the airfield and therefore, one would assume, a higher usage of airspace and likelihood of a collision. There were seven aircraft in the vicinity at the time of the accident (including the two aircraft involved in the accident) but no-one controlling the position of the aircraft.
” Open source report
×
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 CAP1391 specifications and requirements for electronic conspicuity devices.
Verbatim wording from the response “7. You also mention in your letter that the CAA has published CAP1391. This document is the result of many years of work of the Electronic Conspicuity Working Group (ECWG), that has striven to overcome the challenges of the need for low power consumption, portability and affordability to encourage the wider use of electronic conspicuity devices. The CAA, alongside the ECWG, has provided specifications to industry for such devices and is actively encouraging the licensing and equipage of such equipment, to minimise the incidents of mid-air conflict. There are several trials currently being run in the UK airspace to examine the efficacy of this equipment.” Source location 2018-0008-Response-by-CAA
Open published response
×
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 Encourage licensing and carriage of compatible electronic conspicuity equipment to reduce mid-air conflicts.
Verbatim wording from the response “7. You also mention in your letter that the CAA has published CAP1391. This document is the result of many years of work of the Electronic Conspicuity Working Group (ECWG), that has striven to overcome the challenges of the need for low power consumption, portability and affordability to encourage the wider use of electronic conspicuity devices. The CAA, alongside the ECWG, has provided specifications to industry for such devices and is actively encouraging the licensing and equipage of such equipment, to minimise the incidents of mid-air conflict. There are several trials currently being run in the UK airspace to examine the efficacy of this equipment.” Source location 2018-0008-Response-by-CAA
Open published response
×
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 Drive the plan for operators to become electronically conspicuous through the MAC programme’s continuing collaborative safety improvements.
Verbatim wording from the response “12. The CAA will continue to drive forward the plan to ensure operators are ‘electronically conspicuous’ which will help to reduce the incidence of such events as those at Husbands Bosworth and others more recently. The risk of mid-air collision is a complex and long-term challenge and as such the CAA’s MAC programme aims to reduce the risk of mid-air collision by pursuing targeted and continuous improvements in systems, cultures, processes and capability. The MAC programme works closely and collaboratively with the UK Airprox Board, UK Flight Safety Committee, Military Aviation Authority and industry stakeholders to understand and assess risk and identify effective and collaborative mitigations. This programme also meets the European Plan for Aviation Safety (EPAS) requirement for Member States to address MAC in their safety plans.” Source location 2018-0008-Response-by-CAA
Open published response
×
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 Strobe lighting is not a realistic conspicuity solution because glider weight and power-consumption constraints prevent its wider use.
Verbatim wording from the response “use of stripes and bands of colour, but the key contributor to visual acuity is the use of strobe lighting and, due to weight and power consumption constraints, this has not proven to be a realistic solution. Some modern, high-end gliders are fitted with powerful batteries and in some cases even, a small engine to help sustain flight, but this is in a very small section of the gliding community.” Source location 2018-0008-Response-by-CAA
Open published response
7 Jul 2017 Christopher Bell and 29 others · Prevention of Future Deaths report London (West)
View report summary
Concerns raised 2 Lack of board-level security advisors in travel companies View source Failure by holiday and travel sellers to prominently display Travel Aware information and links View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Christopher Bell and 29 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
Thirty British nationals were killed in a terrorist attack at the Imperial Mahaba Hotel in Sousse, Tunisia, on the morning of 26 June 2015. The concerns identified were whether travel companies had board-level security expertise and whether holiday and travel websites provided sufficiently prominent information about terrorist risks through the Government’s Travel Aware programme.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of board-level security advisors in travel companies
Wider context from the report “(1) I heard evidence that prior to the attack neither TUI nor other travel companies had security advisors on their boards . The evidence of a TUI witness was that “security was a matter for the accommodation hoteliers and providers”. I am informed that TUI now have such an advisor. However I remain concerned that if other companies do not have similar security advisors at board level then hotels which they use will not be adequately protected.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Failure by holiday and travel sellers to prominently display Travel Aware information and links
Wider context from the report “(2) I heard evidence that prior to the attack, TUI's websites for Thomson and First Choice did not prominently display logos and links to the Government’s Travel Aware programme , which provides detailed travel advice for every country on the Foreign and Commonwealth Office website. I heard evidence that TUI have taken steps to change their website and promote literature to make these logos and links more prominent. I remain concerned that other companies which sell holidays, or sell flights and hotel accommodation separately, may not have taken such steps , as a result of which members of the public receive insufficient information about the risks of terrorist attacks in destination countries .
” Open source report
2 Feb 2016 Carl Alan Dickerson and 3 others · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 1 Lack of equivalent regulation for non-commercial departures from unlicensed aerodromes in limited visibility View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
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.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
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.
” Open source report
×
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 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
Open published response
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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 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
Open published response
×
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 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
Open published response
×
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 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
Open published response
2 Feb 2016 Carl Alan Dickerson and 3 others · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 1 Lack of equivalent regulation for departures from non-commercial ventures and unlicensed aerodromes View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
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 died after an Augusta Westland AW139 helicopter impacted the ground near Gillingham, Norfolk, shortly after take-off in dark and foggy conditions. The principal concern was that regulations restricting take-off in such conditions did not apply because the flight was non-commercial and departed from an unlicensed aerodrome.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of equivalent regulation for departures from non-commercial ventures and unlicensed aerodromes
Wider context from the report “(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 .
” Open source report
2 Feb 2016 Carl Alan Dickerson and 3 others · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 1 Lack of equivalent regulation covering non-commercial departures from unlicensed aerodromes View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
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 aboard a helicopter that impacted the ground near Gillingham, Norfolk, shortly after take-off in dark and foggy conditions; all four died from their injuries. The principal concern was that regulations restricting take-off in such conditions did not apply because the flight was non-commercial and departed from an unlicensed aerodrome, despite a previous accident in similar circumstances and concerns about the regulatory gap.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of equivalent regulation covering non-commercial departures from unlicensed aerodromes
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 outside 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 .
” Open source report
4 Jan 2016 Peter Barnes and Matthew Wood · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 5 Failure to ensure in-depth consultation between the Heliport and planning authorities about developments affecting air-service safety View source Failure to enable pre-permission CAA assessment of new en route obstacles View source Failure to ensure safe and sufficiently clear flying rules for helicopter route H4 View source Failure to establish adequate Heliport safeguarding arrangements View source Failure to adequately consider Heliport and Thames helicopter aviation safety in tall-building planning processes View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Peter Barnes and Matthew Wood · 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
A helicopter crashed into a crane at St George’s Wharf, causing non-survivable injuries to the pilot and non-survivable burns to a pedestrian after falling debris and fuel ignited. The report raised concerns about the safety of helicopter routes along the Thames, the planning and safeguarding of tall buildings near the heliport, and the lack of implementation of AAIB Safety Recommendation 2014-30.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure in-depth consultation between the Heliport and planning authorities about developments affecting air-service safety
Wider context from the report “Despite a good safety record, it would seem that the relevant bodies in relation to aviation safety along the Thames need to expedite a specific review of H4 and consider any need to alter flying rules, to assure the public of ongoing safety given the current concerns of pilots about the difficulties of flying along the Thames. It is not clear that helicopter aviation considerations for the Heliport or more widely for flights along the Thames are adequately considered in the planning processes for tall buildings. It appears that little or no progress has been made in considering the need to safeguard the heliport or implement AAIB Recommendation 2014-30, which the court heard would potentially save future lives.
1. London Tall Buildings Policy, implemented after planning permission for St George’s Wharf was approved, required reporting of any buildings over 1000 ft, which is the appropriate consideration for Heathrow and City Airport flight paths. In a previous application to development on the site the CAA responded that 575ft would not impact on integrated airspace management and advised consultation with the Heliport. There is no equivalent policy of reporting considering the flight paths to the Heliport.
2. The Head of Safety at Department of Transport advised that aerodrome licence holders should conduct an in depth consultation with local planning authorities about any proposed developments that may affect the safety of air services. No in depth consultation did take place between the Heliport and planning authority about the construction of St George’s Tower, to which was attached the crane. A retired official from the Civil Aviation Authority had expressed the view that the London Heliport should be a safeguarded aerodrome. The Head of Safety in Department of Transport advised that in an official safeguarding regime one can be sure that such consultation takes place, which one cannot in an unofficial process, where it depends on the local system and players.
3. The Heliport manager was concerned that the erection of St George’s Wharf would affect passing air traffic on helicopter route H4. He stated that there was an apparent conflict between maintaining en route standard altitudes and complying with Rule 5, especially in reduced cloud base. He had some informal discussions with the CAA, but the local planning authority did not respond to his concerns. He did not take the matter further as the proposed building was just outside the area designated in the map of his local plan. It is not clear of whether this local plan or the local process is adequate to assure safety. He remained of the view that the tall building created a risk as it was more difficult to operate helicopters in poor visibility.
4. Captain ████████ who was called as an independent expert pilot, gave an opinion that establishing a minimum altitude would assist pilots and promote safety and that the H4 route required review, to make it safer, to reduce future deaths. Other pilots testified to the challenges of flying along the Thames with the proliferation of tall buildings in less good weather.
5. The Air Accident Investigation Branch of the Department of Transport (AAIB) made a Safety Recommendation 2014-30 in August 2014. It read:
It is recommended that the Department of Transport implement measures that enable the Civil Aviation Authority to assess, before planning permission is granted, the potential implications of new en route obstacles for airspace arrangements and procedures.
The Senior Inspector of Air Accidents (Operations) AAIB said that if this recommendation was not implemented lives would be put at risk. The Head of Airspace, Air Traffic Management and Procedures at the CAA supported this recommendation, saying it would be a safety back up. The Department of Transport has not implemented this recommendation, and reported in December 2014 that it was consulting, which was still the position a year later. This was explained by the Head of Aviation Safety Policy at the Department of Transport as initially due to lack of resources. He said that there was not an intention to implement this recommendation, in particular noting that it may be contrary to government proposals for the planning process.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to enable pre-permission CAA assessment of new en route obstacles
Wider context from the report “Despite a good safety record, it would seem that the relevant bodies in relation to aviation safety along the Thames need to expedite a specific review of H4 and consider any need to alter flying rules, to assure the public of ongoing safety given the current concerns of pilots about the difficulties of flying along the Thames. It is not clear that helicopter aviation considerations for the Heliport or more widely for flights along the Thames are adequately considered in the planning processes for tall buildings. It appears that little or no progress has been made in considering the need to safeguard the heliport or implement AAIB Recommendation 2014-30, which the court heard would potentially save future lives.
1. London Tall Buildings Policy, implemented after planning permission for St George’s Wharf was approved, required reporting of any buildings over 1000 ft, which is the appropriate consideration for Heathrow and City Airport flight paths. In a previous application to development on the site the CAA responded that 575ft would not impact on integrated airspace management and advised consultation with the Heliport. There is no equivalent policy of reporting considering the flight paths to the Heliport.
2. The Head of Safety at Department of Transport advised that aerodrome licence holders should conduct an in depth consultation with local planning authorities about any proposed developments that may affect the safety of air services. No in depth consultation did take place between the Heliport and planning authority about the construction of St George’s Tower, to which was attached the crane. A retired official from the Civil Aviation Authority had expressed the view that the London Heliport should be a safeguarded aerodrome. The Head of Safety in Department of Transport advised that in an official safeguarding regime one can be sure that such consultation takes place, which one cannot in an unofficial process, where it depends on the local system and players.
3. The Heliport manager was concerned that the erection of St George’s Wharf would affect passing air traffic on helicopter route H4. He stated that there was an apparent conflict between maintaining en route standard altitudes and complying with Rule 5, especially in reduced cloud base. He had some informal discussions with the CAA, but the local planning authority did not respond to his concerns. He did not take the matter further as the proposed building was just outside the area designated in the map of his local plan. It is not clear of whether this local plan or the local process is adequate to assure safety. He remained of the view that the tall building created a risk as it was more difficult to operate helicopters in poor visibility.
4. Captain ████████ who was called as an independent expert pilot, gave an opinion that establishing a minimum altitude would assist pilots and promote safety and that the H4 route required review, to make it safer, to reduce future deaths. Other pilots testified to the challenges of flying along the Thames with the proliferation of tall buildings in less good weather.
5. The Air Accident Investigation Branch of the Department of Transport (AAIB) made a Safety Recommendation 2014-30 in August 2014. It read:
It is recommended that the Department of Transport implement measures that enable the Civil Aviation Authority to assess, before planning permission is granted, the potential implications of new en route obstacles for airspace arrangements and procedures.
The Senior Inspector of Air Accidents (Operations) AAIB said that if this recommendation was not implemented lives would be put at risk. The Head of Airspace, Air Traffic Management and Procedures at the CAA supported this recommendation, saying it would be a safety back up. The Department of Transport has not implemented this recommendation , and reported in December 2014 that it was consulting, which was still the position a year later. This was explained by the Head of Aviation Safety Policy at the Department of Transport as initially due to lack of resources. He said that there was not an intention to implement this recommendation, in particular noting that it may be contrary to government proposals for the planning process.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure safe and sufficiently clear flying rules for helicopter route H4
Wider context from the report “Despite a good safety record, it would seem that the relevant bodies in relation to aviation safety along the Thames need to expedite a specific review of H4 and consider any need to alter flying rules , to assure the public of ongoing safety given the current concerns of pilots about the difficulties of flying along the Thames. It is not clear that helicopter aviation considerations for the Heliport or more widely for flights along the Thames are adequately considered in the planning processes for tall buildings. It appears that little or no progress has been made in considering the need to safeguard the heliport or implement AAIB Recommendation 2014-30, which the court heard would potentially save future lives.
1. London Tall Buildings Policy, implemented after planning permission for St George’s Wharf was approved, required reporting of any buildings over 1000 ft, which is the appropriate consideration for Heathrow and City Airport flight paths. In a previous application to development on the site the CAA responded that 575ft would not impact on integrated airspace management and advised consultation with the Heliport. There is no equivalent policy of reporting considering the flight paths to the Heliport.
2. The Head of Safety at Department of Transport advised that aerodrome licence holders should conduct an in depth consultation with local planning authorities about any proposed developments that may affect the safety of air services. No in depth consultation did take place between the Heliport and planning authority about the construction of St George’s Tower, to which was attached the crane. A retired official from the Civil Aviation Authority had expressed the view that the London Heliport should be a safeguarded aerodrome. The Head of Safety in Department of Transport advised that in an official safeguarding regime one can be sure that such consultation takes place, which one cannot in an unofficial process, where it depends on the local system and players.
3. The Heliport manager was concerned that the erection of St George’s Wharf would affect passing air traffic on helicopter route H4. He stated that there was an apparent conflict between maintaining en route standard altitudes and complying with Rule 5, especially in reduced cloud base. He had some informal discussions with the CAA, but the local planning authority did not respond to his concerns. He did not take the matter further as the proposed building was just outside the area designated in the map of his local plan. It is not clear of whether this local plan or the local process is adequate to assure safety. He remained of the view that the tall building created a risk as it was more difficult to operate helicopters in poor visibility.
4. Captain ████████ who was called as an independent expert pilot, gave an opinion that establishing a minimum altitude would assist pilots and promote safety and that the H4 route required review, to make it safer , to reduce future deaths. Other pilots testified to the challenges of flying along the Thames with the proliferation of tall buildings in less good weather.
5. The Air Accident Investigation Branch of the Department of Transport (AAIB) made a Safety Recommendation 2014-30 in August 2014. It read:
It is recommended that the Department of Transport implement measures that enable the Civil Aviation Authority to assess, before planning permission is granted, the potential implications of new en route obstacles for airspace arrangements and procedures.
The Senior Inspector of Air Accidents (Operations) AAIB said that if this recommendation was not implemented lives would be put at risk. The Head of Airspace, Air Traffic Management and Procedures at the CAA supported this recommendation, saying it would be a safety back up. The Department of Transport has not implemented this recommendation, and reported in December 2014 that it was consulting, which was still the position a year later. This was explained by the Head of Aviation Safety Policy at the Department of Transport as initially due to lack of resources. He said that there was not an intention to implement this recommendation, in particular noting that it may be contrary to government proposals for the planning process.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to establish adequate Heliport safeguarding arrangements
Wider context from the report “Despite a good safety record, it would seem that the relevant bodies in relation to aviation safety along the Thames need to expedite a specific review of H4 and consider any need to alter flying rules, to assure the public of ongoing safety given the current concerns of pilots about the difficulties of flying along the Thames. It is not clear that helicopter aviation considerations for the Heliport or more widely for flights along the Thames are adequately considered in the planning processes for tall buildings. It appears that little or no progress has been made in considering the need to safeguard the heliport or implement AAIB Recommendation 2014-30, which the court heard would potentially save future lives.
1. London Tall Buildings Policy, implemented after planning permission for St George’s Wharf was approved, required reporting of any buildings over 1000 ft, which is the appropriate consideration for Heathrow and City Airport flight paths. In a previous application to development on the site the CAA responded that 575ft would not impact on integrated airspace management and advised consultation with the Heliport. There is no equivalent policy of reporting considering the flight paths to the Heliport.
2. The Head of Safety at Department of Transport advised that aerodrome licence holders should conduct an in depth consultation with local planning authorities about any proposed developments that may affect the safety of air services. No in depth consultation did take place between the Heliport and planning authority about the construction of St George’s Tower, to which was attached the crane. A retired official from the Civil Aviation Authority had expressed the view that the London Heliport should be a safeguarded aerodrome. The Head of Safety in Department of Transport advised that in an official safeguarding regime one can be sure that such consultation takes place, which one cannot in an unofficial process, where it depends on the local system and players.
3. The Heliport manager was concerned that the erection of St George’s Wharf would affect passing air traffic on helicopter route H4. He stated that there was an apparent conflict between maintaining en route standard altitudes and complying with Rule 5, especially in reduced cloud base. He had some informal discussions with the CAA, but the local planning authority did not respond to his concerns. He did not take the matter further as the proposed building was just outside the area designated in the map of his local plan. It is not clear of whether this local plan or the local process is adequate to assure safety. He remained of the view that the tall building created a risk as it was more difficult to operate helicopters in poor visibility.
4. Captain ████████ who was called as an independent expert pilot, gave an opinion that establishing a minimum altitude would assist pilots and promote safety and that the H4 route required review, to make it safer, to reduce future deaths. Other pilots testified to the challenges of flying along the Thames with the proliferation of tall buildings in less good weather.
5. The Air Accident Investigation Branch of the Department of Transport (AAIB) made a Safety Recommendation 2014-30 in August 2014. It read:
It is recommended that the Department of Transport implement measures that enable the Civil Aviation Authority to assess, before planning permission is granted, the potential implications of new en route obstacles for airspace arrangements and procedures.
The Senior Inspector of Air Accidents (Operations) AAIB said that if this recommendation was not implemented lives would be put at risk. The Head of Airspace, Air Traffic Management and Procedures at the CAA supported this recommendation, saying it would be a safety back up. The Department of Transport has not implemented this recommendation, and reported in December 2014 that it was consulting, which was still the position a year later. This was explained by the Head of Aviation Safety Policy at the Department of Transport as initially due to lack of resources. He said that there was not an intention to implement this recommendation, in particular noting that it may be contrary to government proposals for the planning process.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately consider Heliport and Thames helicopter aviation safety in tall-building planning processes
Wider context from the report “Despite a good safety record, it would seem that the relevant bodies in relation to aviation safety along the Thames need to expedite a specific review of H4 and consider any need to alter flying rules, to assure the public of ongoing safety given the current concerns of pilots about the difficulties of flying along the Thames. It is not clear that helicopter aviation considerations for the Heliport or more widely for flights along the Thames are adequately considered in the planning processes for tall buildings. It appears that little or no progress has been made in considering the need to safeguard the heliport or implement AAIB Recommendation 2014-30, which the court heard would potentially save future lives.
1. London Tall Buildings Policy, implemented after planning permission for St George’s Wharf was approved, required reporting of any buildings over 1000 ft, which is the appropriate consideration for Heathrow and City Airport flight paths. In a previous application to development on the site the CAA responded that 575ft would not impact on integrated airspace management and advised consultation with the Heliport. There is no equivalent policy of reporting considering the flight paths to the Heliport.
2. The Head of Safety at Department of Transport advised that aerodrome licence holders should conduct an in depth consultation with local planning authorities about any proposed developments that may affect the safety of air services. No in depth consultation did take place between the Heliport and planning authority about the construction of St George’s Tower, to which was attached the crane. A retired official from the Civil Aviation Authority had expressed the view that the London Heliport should be a safeguarded aerodrome. The Head of Safety in Department of Transport advised that in an official safeguarding regime one can be sure that such consultation takes place, which one cannot in an unofficial process, where it depends on the local system and players.
3. The Heliport manager was concerned that the erection of St George’s Wharf would affect passing air traffic on helicopter route H4. He stated that there was an apparent conflict between maintaining en route standard altitudes and complying with Rule 5, especially in reduced cloud base. He had some informal discussions with the CAA, but the local planning authority did not respond to his concerns. He did not take the matter further as the proposed building was just outside the area designated in the map of his local plan. It is not clear of whether this local plan or the local process is adequate to assure safety. He remained of the view that the tall building created a risk as it was more difficult to operate helicopters in poor visibility.
4. Captain ████████ who was called as an independent expert pilot, gave an opinion that establishing a minimum altitude would assist pilots and promote safety and that the H4 route required review, to make it safer, to reduce future deaths. Other pilots testified to the challenges of flying along the Thames with the proliferation of tall buildings in less good weather.
5. The Air Accident Investigation Branch of the Department of Transport (AAIB) made a Safety Recommendation 2014-30 in August 2014. It read:
It is recommended that the Department of Transport implement measures that enable the Civil Aviation Authority to assess, before planning permission is granted, the potential implications of new en route obstacles for airspace arrangements and procedures.
The Senior Inspector of Air Accidents (Operations) AAIB said that if this recommendation was not implemented lives would be put at risk. The Head of Airspace, Air Traffic Management and Procedures at the CAA supported this recommendation, saying it would be a safety back up. The Department of Transport has not implemented this recommendation, and reported in December 2014 that it was consulting, which was still the position a year later. This was explained by the Head of Aviation Safety Policy at the Department of Transport as initially due to lack of resources. He said that there was not an intention to implement this recommendation, in particular noting that it may be contrary to government proposals for the planning process.
” Open source 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 Support preparation of an official safeguarding map for the London Heliport.
Verbatim wording from the response “2.2 The CAA supports the London Heliport’s application to the Department for Transport (“DfT”) to become officially safeguarded. The CAA is currently providing support to the DfT in order to assist with the preparation of an official safeguarding map for the Heliport.” Source location Peter-wood-Response
Open published response
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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 Engage with and support the Department for Transport and Department for Communities and Local Government to progress implementation of AAIB Recommendation 2014-030.
Verbatim wording from the response ““It is recommended that the Department for Transport implement measures that enable the Civil Aviation Authority to assess, before planning permission is granted, the potential implications of new en-route obstacles for airspace arrangements and procedures.”” Source location Peter-wood-Response
Open published response
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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 Conduct a UK-wide review of onshore helicopter safety, including London airspace, H4 and post-implementation review of SERA rules.
Verbatim wording from the response “1.2 As you know, the London airspace is highly regulated and has a good safety record. Nevertheless the CAA routinely conducts on-going regulatory oversight and, as part of this role, the Flight Operations team (“Flight Ops”) is in the process of conducting a review of the safety of onshore helicopter operations in the UK this year. This follows the recent review of offshore helicopter operations. The review will include a post implementation review of the Standardised European Rules of the Air (“SERA”) which came into force in the UK on 4 December 2014.” Source location Peter-wood-Response
Open published response
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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 Review whether an equivalent London Tall Buildings Policy is needed to maintain safe helicopter access routes.
Verbatim wording from the response “2.7 The CAA will keep under review, both when implementing the outcome of Recommendation 2014-030 and when considering, on a case by case basis, pre-planning applications and as part of the on-going review of onshore UK helicopter operations, whether it becomes necessary to implement an equivalent to the London Tall Buildings Policy in order to maintain safe access routes for helicopters approaching London aerodromes and for those transiting the London (City) and London (Heathrow) Control Zones.” Source location Peter-wood-Response
Open published response
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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 The Department for Transport, with the Department for Communities and Local Government, is responsible for implementing Recommendation 2014-030; the CAA will support them.
Verbatim wording from the response ““It is recommended that the Department for Transport implement measures that enable the Civil Aviation Authority to assess, before planning permission is granted, the potential implications of new en-route obstacles for airspace arrangements and procedures.”” Source location Peter-wood-Response
Open published response
3 Jul 2015 Davina Tavener · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 1 Lack of mandatory carriage of airway adjuncts, suction equipment, bag-valve-mask equipment and defibrillators on all aircraft View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Davina Tavener · 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
Davina Tavener died on 1 November 2014 after collapsing during a Ryanair flight from Manchester to Lanzarote. Cardiopulmonary resuscitation continued until the aircraft landed, but the aircraft did not carry airway adjuncts, suction equipment, a bag-valve-mask or a defibrillator. The report raised concerns that the absence of this equipment could contribute to future deaths and called for review of the requirements for medical equipment on aircraft.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory carriage of airway adjuncts, suction equipment, bag-valve-mask equipment and defibrillators on all aircraft
Wider context from the report “The Regulations do not require Aircraft to carry the equipment requested by ████████ and the minimum requirement is to carry the equipment carried by Ryanair on Flight FR2131. It was accepted that Ryanair was operating within the Regulations in relation to medical equipment on Flight FR2131.
iii. The evidence at the Inquest confirmed that some Airlines do carry the equipment requested by ████████, even though there is no Regulation for such equipment to be carried .
Evidence was given that the equipment is carried on some long haul flights as opposed to short haul flights but it was accepted that the differential is not relevant in view of the fact that a cardiac arrest can occur at any time whether the Aircraft is ten minutes into a flight or ten hours into a flight.
iv. ████████ gave evidence, supported by the Pathologist, that when someone has suffered a cardiac arrest, time is of the essence and the equipment requested by her could be critical in an attempt to save life.
████████ confirmed that a defibrillator would be critical to survival in cardiac events and a defibrillator would give someone the best chance of survival in a situation where there is a cardiac arrest. The evidence confirmed that for every one minute when activity in the heart has stopped the chance of survival reduces by ten percent and the availability of a defibrillator at the earliest time would increase the chance of survival.
Both ████████ and the Pathologist gave evidence that an airway adjunct, suction equipment, bag-valve-mask and a defibrillator should be carried on all Aircraft as a mandatory provision of medical equipment to assist in the treatment and resuscitation of a passenger on an Aircraft and to give a passenger the best chance of survival until the Aircraft can reach the nearest destination.
The provision of the aforementioned equipment would be used for the reasons explained in ████████ evidence and detailed in paragraph 4.4 of this report.
v. Evidence was given that all the above equipment is now available as relatively inexpensive portable equipment and, in particular, a defibrillator is very simple to operate in that the defibrillator will announce instructions in relation to use by the operator.
vi. It may be felt that cases of sudden cardiac arrest on Aircraft are very rare but Airlines carrying defibrillators have led to lives being saved and the saving of a single life would justify the availability of equipment on all Aircraft for use as and when a medical emergency arises.
The Federal Aviation Authority has required US Airlines to carry a defibrillator on flights since 1994.
vii. The evidence raised concerns that there is a risk that future deaths will occur unless action is taken to review the above issues.
” Open source report
16 Feb 2015 RICHARD MARK WESTGATE · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 5 Failure to account for genetic variation in susceptibility to exposure View source Lack of real-time monitoring for organo-phosphate compounds in cabin air View source Exposure of aircraft cabin occupants to organo-phosphate compounds causing health damage View source Health impairment of aircraft controllers endangering aircraft occupants View source Presence of organo-phosphate compounds in aircraft cabin air View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
RICHARD MARK WESTGATE · 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
Richard Mark Westgate was found deceased in his room at the Bastion Hotel in Bussum, Netherlands, on 12 December 2012. The report raised concerns about exposure to organophosphate compounds in aircraft cabin air, possible consequential health damage, risks posed by impaired aircraft controllers, lack of real-time monitoring, and genetic variation in susceptibility.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to account for genetic variation in susceptibility to exposure
Wider context from the report “(5) That no account is taken of genetic variation in the human species , such as would render individuals tolerant or intolerant of the exposure .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of real-time monitoring for organo-phosphate compounds in cabin air
Wider context from the report “(4) There is no real time monitoring to detect such compounds in cabin air .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Exposure of aircraft cabin occupants to organo-phosphate compounds causing health damage
Wider context from the report “(2) That the occupants of aircraft cabins are exposed to organo-phosphate compounds with consequential damage to their health .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Health impairment of aircraft controllers endangering aircraft occupants
Wider context from the report “(3) That impairment to the health of those controlling aircraft may lead to the death of occupants .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Civil Aviation Authority; that does not assign responsibility.
PFD Monitor interpretation Presence of organo-phosphate compounds in aircraft cabin air
Wider context from the report “(1) That organo-phosphate compounds are present in aircraft cabin air .
” Open source 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 Co-operate fully with EASA’s cabin air quality work.
Verbatim wording from the response “The CAA will co-operate fully with EASA’s work on cabin air quality and will review its position in due course with the benefit of the results of EASA’s study.” Source location 2015-0050-Response-by-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 Review its position on cabin air quality after receiving EASA’s study results.
Verbatim wording from the response “The CAA will co-operate fully with EASA’s work on cabin air quality and will review its position in due course with the benefit of the results of EASA’s study.” Source location 2015-0050-Response-by-Civil-Aviation-Authority
Open published response
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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 Expert studies found no positive evidence linking cabin-air contaminants with acute or long-term health effects, although a link cannot be excluded.
Verbatim wording from the response “The CAA takes its regulatory responsibilities regarding passenger and crew health very seriously. The subject of cabin air quality has been considered by several expert studies over the years as referred to in the annex to the CAA’s letter to you dated 23 March 2015, a copy of which we attach as an annex to this response. The overall conclusion of those studies is that there is no positive evidence of a link between exposure to contaminants in cabin air and possible acute and long-term health effects, although such a link cannot be excluded.” Source location 2015-0050-Response-by-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 Existing expert studies and EASA investigations constitute a proportionate, evidence-based response to cabin-air-quality health concerns.
Verbatim wording from the response “In our opinion the above studies represent a proportionate, evidence-based response to the concerns that have been raised about the health implications of cabin air quality for passenger and crew. They were not taken in response to the PFD Report but have been ongoing for several years.” Source location 2015-0050-Response-by-Civil-Aviation-Authority
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations