Peter Barnes and Matthew Wood · Prevention of Future Deaths report

Re Peter Barnes (0149-13) and Matthew Wood (0150-13) (died 16.01.13) (JB)

On 8th December 2015 I concluded a joint inquest into the above two deaths outside ████████ Wandsworth Road, South Lambeth, before a jury. The conclusion of the jury as to the deaths of the pilot, Mr Barnes, and pedestrian, Mr Wood, was Accident.

The helicopter crashed into a crane at 693 ft altitude on St George’s Wharf and the pilot suffered non survivable injuries. Debris fell on the pedestrian and spilt fuel ignited and caused non survivable burns to the pedestrian.

The circumstances recorded included that the pilot should not have attempted the flight, considering the poor weather. His decision to divert to Battersea Heliport and his decision not to abort the landing were neither safe nor appropriate, but he was likely to have felt under pressure to land at Battersea. His erratic flight path and altitude shifts suggested that Mr Barnes was working hard to steer clear of cloud. Impact was likely a result of loss of situational awareness due to poor visibility.

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.