PFD report

Carl Alan Dickerson and 3 others · Prevention of Future Deaths report

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Issued 2 Feb 2016•Norfolk

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
9

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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Report evidence summary

Concerns raised1

  1. Lack of equivalent regulation for non-commercial departures from unlicensed aerodromes in limited visibility
    Part of recurring concern: Inadequate CAA regulatory oversight of aviation safety
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 a recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. Action

    Conduct regulatory oversight of non-commercial complex-aircraft operators subject to the new declaration requirements.

    Stated by Civil Aviation AuthorityStated plannedThe respondent said that this action was planned when they made their response on 2 February 2016.
  2. Action

    Update the flight-planning and safe-flight-execution Safety Notice to introduce additional risk assessments and safety strategies.

    Stated by Civil Aviation AuthorityStated plannedThe respondent said that this action was planned when they made their response on 2 February 2016.
  3. Action

    Review and reissue the IFR aerodrome operating minima Safety Notice with enhanced information and links to the Air Operations Regulation.

    Stated by Civil Aviation AuthorityStated in progressThe respondent said that this action was in progress when they made their response on 2 February 2016.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Inadequate CAA regulatory oversight of aviation safety.

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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 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
Page 3 · response
Published 2 February 2016

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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
Page 2 · response
Published 2 February 2016

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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 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
Page 2 · response
Published 2 February 2016

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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 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
Page 1 · response
Published 2 February 2016

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Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.5

  1. 1

    Hold a safety-culture seminar for the commercial helicopter industry.

    Stated by Civil Aviation AuthorityStated plannedThe respondent said that this action was planned when they made their response on 2 February 2016.
  2. 2

    Continue applying targeted and continuous improvements in aviation safety systems, culture, processes and capability.

    Stated by Civil Aviation AuthorityStated in progressThe respondent said that this action was in progress when they made their response on 2 February 2016.
  3. 3

    Renew Safety Notices and update associated AIP details with enhanced information for pilots and operators before the European regulatory transition.

    Stated by Civil Aviation AuthorityStated plannedThe respondent said that this action was planned when they made their response on 2 February 2016.
  4. 4

    Publish and maintain guidance and structure for corporate helicopter operators through CAP 686.

    Stated by Civil Aviation AuthorityStated completedThe respondent said that this action was complete when they made their response on 2 February 2016.
  5. 5

    Work with industry and international organisations to develop more effective solutions addressing safety culture and decision-making pressures in corporate aviation.

    Stated by Civil Aviation AuthorityStated in progressThe respondent said that this action was in progress when they made their response on 2 February 2016.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    A separate UK national category for corporate aviation was not pursued because responsibility was consolidated into a European regulatory solution.

    Stated by Civil Aviation AuthorityRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Hold a safety-culture seminar for the commercial helicopter industry.

Verbatim wording from the response

“This will undoubtedly involve education and improved human factors training and to support this we are planning to hold a seminar later this year on safety culture for the commercial helicopter industry. Within the industry itself, this subject is also being addressed by the Corporate Aviation Safety Executive (CASE) with whom we work.”

Source location

Response-by-CAA
Page 3 · response
Published 2 February 2016

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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 applying targeted and continuous improvements in aviation safety systems, culture, processes and capability.

Verbatim wording from the response

“The safety of aviation relies heavily on the conduct of operators and pilots to carry out their duties appropriately. Regulations provide a framework for safe operations but cannot guarantee that all flights will be achieved safely. Part of our Strategic Plan is to “enhance aviation safety performance by pursuing targeted and continuous improvements in systems, culture, processes and capability” and we will apply these principles in taking forward measures to prevent further deaths in circumstances such as those detailed in your report.”

Source location

Response-by-CAA
Page 4 · response
Published 2 February 2016

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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

Renew Safety Notices and update associated AIP details with enhanced information for pilots and operators before the European regulatory transition.

Verbatim wording from the response

“We will renew our Safety Notices and update the associated AIP details to provide enhanced information for pilots and operators in advance of the transition to the European Air Operations Regulation. This is scheduled to be completed by the 31 March 2016.”

Source location

Response-by-CAA
Page 3 · response
Published 2 February 2016

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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 and structure for corporate helicopter operators through CAP 686.

Verbatim wording from the response

“was started on developing such a category. However, at the same time a programme of work was being initiated in the JAA to establish requirements for such corporate type operations and a decision was made to consolidate resources on a European solution and not pursue a lone national one. In the meantime, we produced CAP 686 – Corporate Code of Practice (Helicopters) which sought to provide guidance and structure to operators of corporate helicopters. There was no obligation to comply with this guidance but it was considered as best practice. The JAA initiative transferred to EASA before being completed and has now emerged in the Air Operations Regulation. This requirement is in line with international standards and is probably the first such set of regulations adopted worldwide.”

Source location

Response-by-CAA
Page 3 · response
Published 2 February 2016

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

Work with industry and international organisations to develop more effective solutions addressing safety culture and decision-making pressures in corporate aviation.

Verbatim wording from the response

“One of the driving elements of the JAA work was to establish a set of requirements for business or corporate flying to meet in order to provide an enhanced level of safety over pure private flying and closer to that of CAT but in a graduated and proportionate way. Unlike CAT, where passengers pay for a transport experience and expect high levels of safety, passengers and flight crew in business aviation can be obligated to fly under their terms of employment. This can introduce pressure to fly and poor decision making when otherwise they would not have attempted it. As noted by the AAIB, this situation cannot be managed by regulation alone and we are actively involved with industry and international organisations to find more effective solutions.”

Source location

Response-by-CAA
Page 3 · response
Published 2 February 2016

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

A separate UK national category for corporate aviation was not pursued because responsibility was consolidated into a European regulatory solution.

Verbatim wording from the response

“was started on developing such a category. However, at the same time a programme of work was being initiated in the JAA to establish requirements for such corporate type operations and a decision was made to consolidate resources on a European solution and not pursue a lone national one. In the meantime, we produced CAP 686 – Corporate Code of Practice (Helicopters) which sought to provide guidance and structure to operators of corporate helicopters. There was no obligation to comply with this guidance but it was considered as best practice. The JAA initiative transferred to EASA before being completed and has now emerged in the Air Operations Regulation. This requirement is in line with international standards and is probably the first such set of regulations adopted worldwide.”

Source location

Response-by-CAA
Page 3 · response
Published 2 February 2016

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Official responses located
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Data last updated 7 September 2026