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.
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
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.
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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 European Union Aviation Safety Agency; 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 European Union Aviation Safety Agency; 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 European Union Aviation Safety Agency; 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 European Union Aviation Safety Agency; 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 European Union Aviation Safety Agency; 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 European Union Aviation Safety Agency; 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 European Union Aviation Safety Agency; 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
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.
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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.
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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 European Union Aviation Safety Agency; 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 European Union Aviation Safety Agency; 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 European Union Aviation Safety Agency; 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 European Union Aviation Safety Agency; 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 European Union Aviation Safety Agency; 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 European Union Aviation Safety Agency; 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 Review whether to clarify AMC1 29.571 and AMC1 27.571 so critical bearings are always considered.
Verbatim wording from the response “Acceptable Means of Compliance AMC1 29.571 (introduced with Amendment 11 of CS-29) addresses Rolling Contact Fatigue (RCF) which should be included, when applicable, in the fatigue tolerance evaluation of Principle Structure Elements (PSE). This AMC describes possible steps to be taken to minimise the risk of crack initiation due to RCF on PSEs and in particular for integrated bearing races. A fail-safe approach is recommended wherever possible, such that cracking of the affected structural element(s) is detected prior to its residual strength capability falling below the required levels prescribed in CS 29.571(f). In addition to following a fail-safe approach, inspection and retirement times may be needed in order to ensure that the assumptions supporting the fail-safety and detection of failure remain valid throughout the operational life of the component.” Source location Response from European Union Aviation Safety 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 Include a proposed CS-27 and CS-29 amendment in the next rulemaking notice under RMT.0128.
Verbatim wording from the response “EASA is however reviewing the opportunity to clarify the scope of application of AMC1 29.571, and similarly of AMC1 27.571, to ensure that critical bearings are always considered. A proposed amendment of CS-27 and CS-29 is planned to be included in the next Notice of Proposed Amendment under rulemaking task RMT.0128 ‘Regular update of the Certification Specifications for Very Light Rotorcraft (CS-VLR), Small Rotorcraft (CS-27), and Large Rotorcraft (CS-29)’.”” Source location Response from European Union Aviation Safety 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 introducing new AMC to CS 29.927(a) addressing certification testing, inspection intervals and retirement times.
Verbatim wording from the response “(ii) evaluated for the need of dedicated certification testing to demonstrate adequate performance and suitable intervals. EASA is currently considering the possibility of introducing new AMC to CS 29.927(a) (Additional tests) to address this aspect. This would clarify the need to support inspection intervals and retirement times with appropriate directly applicable data.” Source location Response from European Union Aviation Safety 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 Issue and publish certification guidance addressing compliance demonstrations for rotorcraft hybrid bearings.
Verbatim wording from the response “However, as lessons learned from this accident, EASA considers that future approvals of hybrid bearing with ceramic balls will deserve more attention as regards to the failure mechanics and the sensitivity of the bearing to its working conditions (including abnormal conditions originated by e.g. manufacturing defects, degraded lubrication, improper maintenance, etc..) in order to better cope with a wider range of scenarios.” Source location Response from European Union Aviation Safety 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 claimed non-conservative loads calculation is not accepted as the sole cause of bearing failure, and existing methodology does not require complete reconsideration.
Verbatim wording from the response ““The accident investigation report mentions a non-conservative loads calculation at the time of certification as a root cause of the bearing failure.” Source location Response from European Union Aviation Safety 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 existing regulatory framework adequately requires applicants to provide relevant testing information, so new prescriptive requirements are not needed.
Verbatim wording from the response ““Pursuant to point 21.A.20 of Annex I (Part 21) to Regulation (EU) No 748/2012, the applicant for aircraft type certification is responsible for the demonstration of compliance with the type certification basis (that includes certification specifications), and to record justifications of compliance within the compliance documents as referred to in the certification programme. This implies ensuring that parts and systems reach minimum performance and reliability targets.” Source location Response from European Union Aviation Safety 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 type-certificate-holder reporting and analysis obligations adequately address critical-part reliability, so no retrospective post-removal assessment programme is needed.
Verbatim wording from the response ““Point 21.A.3A of Annex I (Part 21) to Regulation (EU) No 748/2012 defines the obligations applicable to the Type Certificate Holders (TCHs) to establish and maintain a system for collecting, investigating and analysing occurrence reports. This includes, as per point 21.A.3A(a)(1), identification of adverse trends or deficiencies that might cause adverse effects on the continuing airworthiness of the product.” Source location Response from European Union Aviation Safety 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 regulations adequately establish and control life limits for critical parts already in service, so their airworthiness status need not be redefined.
Verbatim wording from the response ““In accordance with point 21.A.7 of Annex I (Part 21) to Regulation (EU) No 748/2012, the Type Certificate Holder (TC Holder) must provide Instructions for Continued Airworthiness (ICA) for critical parts, either structural or non-structural, and, in case of large rotorcraft, the preparation of ICA must be performed in compliance with the Certification Specification (CS) 29.1529.” Source location Response from European Union Aviation Safety 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 certification provisions adequately address hazardous and catastrophic failures, so systematically mandating additional design mitigations could be counterproductive.
Verbatim wording from the response “Nevertheless, additional CS-29 provisions help to meet the intent of this safety recommendation:” Source location Response from European Union Aviation Safety Authority
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.
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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.
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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 European Union Aviation Safety Agency; 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
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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 Member States to reconsider defibrillator carriage through available-data analysis and an initial discussion at the scheduled advisory-group meeting.
Verbatim wording from the response “We will therefore engage with our Member States to reconsider the situation through analysis of available data. We will launch a first discussion on this matter at our next meeting with Member” Source location 2015-0252-Response-by-EASA
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations