PFD report

John David Coles · Prevention of Future Deaths report

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Issued 24 Jul 2023•West London

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.

View original report
Concerns
2

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

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Difficulty seeing white-coloured vans at uncontrolled crossings
  2. Lack of specific consideration of background visual interference
    Part of recurring concern: Inadequate visual collision-avoidance controls for aircraft in flight
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.3

  1. Action

    Amend the Operational Safety Instruction on temporary vehicle permits to address vehicles lacking sufficient markings.

    Stated by Heathrow Airport LimitedStated plannedThe respondent said that this action was planned when they made their response on 4 August 2023.
  2. Action

    Commission and complete an expert assessment of airside visual interference and vehicle-identification mitigations.

    Stated by Heathrow Airport LimitedStated completedThe respondent said that this action was complete when they made their response on 4 August 2023.
  3. Action

    Develop and introduce mandatory end-to-end retro-reflective vehicle markings, including vertical peripheral markings, across airside vehicles and equipment.

    Stated by Heathrow Airport LimitedStated in progressThe respondent said that this action was in progress when they made their response on 4 August 2023.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    No realistic or practicable intervention can influence background visual interference because little or no change can be made to the visual environment.

    Stated by Heathrow Airport LimitedUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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

Difficulty seeing white-coloured vans at uncontrolled crossings

Wider context from the report

“(3) It is also the case that white-coloured vans driven by British Airways employees may be difficult to see. ████████ opinion was that there may be merit in using side profile lights on vehicles which may need to cross uncontrolled crossings. While this may primarily be a matter for British Airways (and other organisations), HAL has ultimate oversight and has the power at least to recommend consideration of side profile lights. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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 specific consideration of background visual interference

Wider context from the report

“(1) This fatal accident occurred well over 5 years ago. The expert report of ████████, ████████ which raised the issue of background visual interference as a possible causative factor, was produced well over 4 years ago. Nonetheless, prior to the inquest, no specific consideration appears to have been given to this phenomenon by HAL (or by the HSE or in the Jacobs report which HAL commissioned). (2) Indeed, in evidence, you seemed reluctant to accept that this might have been a factor (and may therefore be a factor in a future accident). Despite your Counsel’s submissions, therefore, I believe it is necessary to highlight this hazard by way of this report and to obtain your (HAL’s) response. ”

Is this part of a recurring concern?

Yes — Inadequate visual collision-avoidance controls for aircraft in flight.

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

Amend the Operational Safety Instruction on temporary vehicle permits to address vehicles lacking sufficient markings.

Verbatim wording from the response

“• Amend the existing Operational Safety Instruction relating to temporary vehicle permits to reflect the TRL’s recommendation on vehicles without sufficient marking.”

Source location

Response from Heathrow
Page 4 · response
Published 4 August 2023

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

Commission and complete an expert assessment of airside visual interference and vehicle-identification mitigations.

Verbatim wording from the response

“For that reason, the first action taken was to commission recognised experts to consider the above matters of concern and to make recommendations. HAL commissioned Transport Research Laboratory ("TRL") to carry out an assessment of the airside environment.”

Source location

Response from Heathrow
Page 2 · response
Published 4 August 2023

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 introduce mandatory end-to-end retro-reflective vehicle markings, including vertical peripheral markings, across airside vehicles and equipment.

Verbatim wording from the response

“• HAL should use its powers to mandate a more robust use of airside ground vehicle safety markings;”

Source location

Response from Heathrow
Page 2 · response
Published 4 August 2023

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

No realistic or practicable intervention can influence background visual interference because little or no change can be made to the visual environment.

Verbatim wording from the response

“TRL concluded that there is not a realistic or practicable intervention that could be introduced to influence the background visual interference. This conclusion was reached as, in practical terms, little or no change can be made to the visual vista.”

Source location

Response from Heathrow
Page 2 · response
Published 4 August 2023

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

Background visual interference at Heathrow does not create greater distraction for airside drivers than comparable normal street scenes.

Verbatim wording from the response

“TRL's research concluded that there is background visual interference when driving airside at Heathrow, making particular note of the lighting in and around the terminals. However, TRL concluded that the lighting in and around the terminals did not create a greater visual distraction than normal street lighting would do for persons driving outside the airport environment.”

Source location

Response from Heathrow
Page 2 · response
Published 4 August 2023

Open published response

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.6

  1. 1

    Introduce mandatory rear-mounted amber obstruction beacons on high-sided and long vehicles whose structure masks front-mounted beacons from the rear.

    Stated by Heathrow Airport LimitedStated plannedThe respondent said that this action was planned when they made their response on 4 August 2023.
  2. 2

    Maintain an ongoing relationship with TRL to review and improve the resulting airside safety arrangements.

    Stated by Heathrow Airport LimitedStated in progressThe respondent said that this action was in progress when they made their response on 4 August 2023.
  3. 3

    Use diagonal rather than Battenburg retro-reflective livery on new and replacement airside Operations vehicles.

    Stated by Heathrow Airport LimitedStated plannedThe respondent said that this action was planned when they made their response on 4 August 2023.
  4. 4

    Further enhance airside driver training on visual clutter, change blindness and inattentional blindness while maintaining regulatory compliance.

    Stated by Heathrow Airport LimitedStated in progressThe respondent said that this action was in progress when they made their response on 4 August 2023.
  5. 5

    Share enhanced training materials with approved providers and conduct an awareness campaign for existing airside drivers.

    Stated by Heathrow Airport LimitedStated plannedThe respondent said that this action was planned when they made their response on 4 August 2023.
  6. 6

    Assess the feasibility of introducing activated four-way hazard lights on vehicles operating on stands, while retaining repeater lights on taxiways.

    Stated by Heathrow Airport LimitedStated plannedThe respondent said that this action was planned when they made their response on 4 August 2023.

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

Introduce mandatory rear-mounted amber obstruction beacons on high-sided and long vehicles whose structure masks front-mounted beacons from the rear.

Verbatim wording from the response

“• HAL mandates the fitting of rear-mounted amber obstruction beacon(s) to certain high-sided and long vehicles that have a vehicle structure which prevents the front-mounted beacon being seen from the rear.”

Source location

Response from Heathrow
Page 3 · response
Published 4 August 2023

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

Maintain an ongoing relationship with TRL to review and improve the resulting airside safety arrangements.

Verbatim wording from the response

“HAL intends to maintain an ongoing relationship with TRL, who are recognised experts in their field, to ensure that arrangements are subject to ongoing review. This approach is consistent with HAL's policy of continuous improvement.”

Source location

Response from Heathrow
Page 4 · response
Published 4 August 2023

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

Use diagonal rather than Battenburg retro-reflective livery on new and replacement airside Operations vehicles.

Verbatim wording from the response

“• For HAL airside operations vehicles, the retro-reflective diagonal stripe decal should be applied in favour of the retro-reflective Battenburg livery.”

Source location

Response from Heathrow
Page 3 · response
Published 4 August 2023

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

Further enhance airside driver training on visual clutter, change blindness and inattentional blindness while maintaining regulatory compliance.

Verbatim wording from the response

“• Airside driver training should be further enhanced to highlight the issues of change blindness and inattentional blindness in the context of the airside driven experience.”

Source location

Response from Heathrow
Page 3 · response
Published 4 August 2023

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

Share enhanced training materials with approved providers and conduct an awareness campaign for existing airside drivers.

Verbatim wording from the response

“• Once the new training materials have been developed and shared with approved training providers, to embark on an awareness campaign to alert existing airside drivers of the changes to ensure that the benefit of the further enhanced training is not limited to new airside drivers or those completing the required refresher courses (every 3 years).”

Source location

Response from Heathrow
Page 4 · response
Published 4 August 2023

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

Assess the feasibility of introducing activated four-way hazard lights on vehicles operating on stands, while retaining repeater lights on taxiways.

Verbatim wording from the response

“• Activated four-way hazard lights should be considered for all vehicles operating airside within the taxiways and stands.”

Source location

Response from Heathrow
Page 3 · response
Published 4 August 2023

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

Data last updated 7 September 2026