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.
On the 8th February 2019 an investigation was commenced into the death of Emiliano Raul Sala, born on the 31st October 1990.
The investigation concluded at the end of the Inquest on the 17th March 2022.
The Medical Cause of Death was:
1a Head and trunk injuries
The narrative conclusion of the Inquest recorded by the jury was “Emiliano Raul Sala died as a consequence of injuries sustained in an aircraft crash, where the flight was operated as a commercial flight without the required authorisations, certification or permission being in place.”
Circumstances of the death
On the 21st January 2019 Emiliano Raul Sala was a passenger in a Piper PA-46-310P Malibu aircraft, registration ████████, flying from Nantes, France to Cardiff, UK. At approximately 20:16 hours the aircraft disappeared from radar. Emiliano was recovered from the wreckage on the sea bed on the 6th February 2019.
Emiliano died instantly from fatal head and trunk injuries due to a high energy aircraft crash. It is likely that Emiliano was deeply unconscious due to carbon monoxide poisoning at the time of the accident.
The organiser, of this flight, charted the aircraft from an unlicensed operator. This flight was a commercial flight operating without the correct certification and relevant permissions.
The owner of the aircraft did not have any written contract wither the operator and minimal oversight of the day to day operations.
The operator hired the pilot who did not have a commercial pilots license, no night rating and his rating to fly single engine piston aircraft had expired. He had limited experience in flying in instrument meteorological conditions.
The aircraft maintenance was up to date in line with part 91 and part 43 however, was not consistent with a part 135 maintenance schedule for a commercial aircraft.
These circumstances culminated in an unlicensed night flight, undertaken in poor weather conditions with the pilot under visual meteorological conditions.
The pilot likely felt under pressure to complete the flight for a highly valued customer. The pilot lost control of the aircraft during a manually flown turn which was probably initiated the remain in, or regain visual meteorological conditions. The aircraft then suffered an inflight breakup whilst manoeuvring at an airspeed significantly outside its design parameters.
The aircraft struck the sea, nose high and in an inverted attitude.
The pilot was likely to have been affected by carbon monoxide poisoning. This was caused by a failure in aircraft exhaust system. In-service inspections of the exhaust system do not eliminate the risk of carbon monoxide poisoning.
Coroner’s concerns
1. During the inquest evidence was heard that:
i. Emiliano Sala was an international professional footballer. On the 21st January 2019 Emiliano was a passenger in a single piston engine aircraft flight from Nantes in France to Cardiff in Wales when it crashed into the sea leading to his death.
ii. This flight was an illegal flight due to the fact that it was a commercial flight without the required authorisations, certification or permission.
iii. There is a market in the illegal provision of flights for reward on private aircraft or flown by pilots without an Air Operators Certificate (AOC). Evidence was given that this market particularly exists in the world of sport and music.
iv. These flights do not meet the minimum safety standards for commercial operations and evidence was given this could lead to future aircraft crashes and subsequently, future deaths.
v. In September 2019, following Emiliano’s death the Chief Executive of the Civil Aviation Authority (CAA) wrote to a number of organisations about the risks associated with these flights and the launch of the safety campaign by the CAA. Evidence has been given that all those listed at the top of this report numbered 3 to 18 were written to and none of the organisations responded. I attach one sample copy of the CAA letter to this report. In order to stop these illegal flights and therefore prevent future deaths, it is important that these organisations make their members aware of the risks associated with these flights.
vi. Whilst the CAA do investigate, and have successfully prosecuted, those involved with these flights, they have limited powers in securing evidence to assist in the investigation of breaches of aviation regulations and such illegal flights.
vii. The CAA successfully prosecuted an individual in respect of the operation of the flight which led to Emiliano’s death. One of the offences the individual was convicted of was endangering an aircraft. Clearly this is an offence that can lead to death. This successful prosecution relied heavily on evidence that the CAA were only able to obtain with the help of the Police, using their powers under the Police and Criminal Evidence Act 1984. One example of this was the access to phone records and email correspondence from the devices seized by the Police, another was access to financial records seized by the Police. The CAA do not have powers to seize or inspect such devices or records which therefore restricts them in their investigation of breaches of aviation regulations. In circumstances when the CAA are therefore investigating offences alone, they will not have the support of the Police.
viii. The CAA investigator provided evidence at the Inquest that without the support from the Police in their investigation linked to Emiliano’s death, it is unlikely the CAA would have been able to secure the criminal prosecution.
ix. This lack of powers means that the CAA are restricted in their ability to access information which may lead them to identify the illegal flights that are taking place. Having access to such documentation is likely to reduce the illegal flights that take place due to the increase in detection and enforcement. Having these powers, and increasing the number of opportunities to prosecute, would also act as a deterrent to such illegal flights being arranged.
2. I have concerns with regard to the following:
i. There could be future deaths as a result of these illegal flights, and I request that the Secretary of State for Transport conducts a review of the powers available to the CAA in investigating breaches of aviation regulations. I request that the Secretary of State for Transport consider meeting with the CAA to establish what powers they would find of assistance in their investigative and enforcement role.
ii. I further request that a review is undertaken by the Secretary of State for Digital, Culture, Media and Sport of the guidance given to the general public, especially all those involved in the sporting and music worlds, about the illegality of these flights and the risks associated with them. I would again request that consideration be given to meeting with the CAA who can properly advise on the risks associated with these flights, especially of future deaths that can occur and what support may assist them in deterring people from using these flights.
iii. I would request that all the organisations identified at numbers 3-20 in the list at the beginning of this report, consider cascading to all their members, and anyone else they consider will benefit from the information, the illegality of these flights and the risks associated with them, especially of a future death, in order to discourage the use of these flights. I would again request that consideration be given to liaising with the CAA who can properly advise on the risks and what support would be of benefit to reduce the use of these flights and prevent future deaths.
Concerns and recipient responses
Select any concern, action or position to view the source wording.
Report evidence summary
Concerns raised4
Risk of future deaths from illegal flights
Failure of relevant organisations to communicate illegal-flight risks to their members
Insufficient CAA powers for investigating and enforcing aviation regulation breaches
Lack of effective public guidance about illegal flights and their risks
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.31
Action
Publish advice to license holders through the website and monthly ezine on privately chartered aircraft airworthiness, pilot qualification checks, and referring concerns to the CAA.
Stated byMotorsport UK Association LimitedStated plannedThe respondent said that this action was planned when they made their response on 22 March 2022.
Action
Distribute the PFD report and associated flight-safety guidance to Premiership clubs.
Stated byRugby Football UnionStated completedThe respondent said that this action was complete when they made their response on 22 March 2022.
Action
Provide a further update on the Department’s work addressing illegal flight activity.
Stated byDepartment for TransportStated plannedThe respondent said that this action was planned when they made their response on 22 March 2022.
Action
Complete a review with the CAA of powers available for investigating breaches of aviation regulations.
Stated byDepartment for TransportStated completedThe respondent said that this action was complete when they made their response on 22 March 2022.
Action
Continue working closely with the CAA on measures addressing illegal flight activity.
Stated byDepartment for TransportStated in progressThe respondent said that this action was in progress when they made their response on 22 March 2022.
Action
Consider consultation responses on cost-sharing regulations for private pilots as part of the aviation safety rule-making programme.
Stated byDepartment for TransportStated in progressThe respondent said that this action was in progress when they made their response on 22 March 2022.
Action
Continue considering policy and legal changes that could improve the CAA’s investigation of suspected illegal flight activity.
Stated byDepartment for TransportStated in progressThe respondent said that this action was in progress when they made their response on 22 March 2022.
Action
Meet with the CAA to establish which powers would assist its investigative and enforcement role.
Stated byDepartment for TransportStated completedThe respondent said that this action was complete when they made their response on 22 March 2022.
Action
Circulated aviation-risk briefing materials to Chamber members and instructed network CEOs to disseminate them through their membership networks.
Stated byBritish Chambers of CommerceStated completedThe respondent said that this action was complete when they made their response on 22 March 2022.
Action
Disseminate CAA unlicensed-aircraft guidance to current members through direct messaging and the website, with repeat circulation before each transfer window.
Stated byProfessional Footballers' AssociationStated completedThe respondent said that this action was complete when they made their response on 22 March 2022.
Action
Add unlicensed-aircraft safety to the next relevant FIFPRO meeting agenda for discussion by trade unions from other associations.
Stated byProfessional Footballers' AssociationStated plannedThe respondent said that this action was planned when they made their response on 22 March 2022.
Action
Require aircraft movements to be booked in advance and managed through designated aviation services.
Stated byThe Jockey ClubStated completedThe respondent said that this action was complete when they made their response on 22 March 2022.
Action
Require aircraft operators to obtain landing permission and verify licensing, registration, insurance and site-use briefings before landing.
Stated byThe Jockey ClubStated completedThe respondent said that this action was complete when they made their response on 22 March 2022.
Action
Circulated the CAA’s updated Illegal Public Transport guidance to clubs and Registered Intermediaries.
Stated byThe Football Association LimitedStated completedThe respondent said that this action was complete when they made their response on 22 March 2022.
Action
Share current aviation safety guidance and supporting information with sports and music organisations for dissemination to private-flight charterers.
Develop and validate guidance with the CAA on illegal-flight risks and checking aircraft safety licences and certificates.
Stated byBritish Horseracing Authority and The Jockey ClubStated in progressThe respondent said that this action was in progress when they made their response on 22 March 2022.
Action
Continue working with the CAA to circulate relevant further illegal-flight guidance to racing participants promptly and appropriately.
Stated byBritish Horseracing Authority and The Jockey ClubStated in progressThe respondent said that this action was in progress when they made their response on 22 March 2022.
Action
Include a statement about the report and unauthorised-flight risks in the membership email.
Stated byInstitute of DirectorsStated plannedThe respondent said that this action was planned when they made their response on 22 March 2022.
Action
Publish a website notice warning members about the dangers of unauthorised flights.
Stated byInstitute of DirectorsStated completedThe respondent said that this action was complete when they made their response on 22 March 2022.
Action
Notify all member clubs and relevant club decision-makers and CEOs about the flight-related safety concern and request that they avoid such flights.
Stated byRugby Football LeagueStated completedThe respondent said that this action was complete when they made their response on 22 March 2022.
Action
Email relevant players information about the risks and legality of flights operated by unlicensed commercial operators, including Civil Aviation Authority guidance.
Stated byLawn Tennis Association LimitedStated completedThe respondent said that this action was complete when they made their response on 22 March 2022.
Action
Reissue links to CAA guidance before each transfer window, including updated guidance issued from time to time.
Stated byEFLStated plannedThe respondent said that this action was planned when they made their response on 22 March 2022.
Action
Issue CAA guidance on flight risks to all Clubs and make it available through the Club portal.
Stated byEFLStated completedThe respondent said that this action was complete when they made their response on 22 March 2022.
Action
Circulate safety communications containing CAA guidance to ECB, county, regional host and PCA representatives, players, agents and relevant ECB executives.
Stated byEngland and Wales Cricket BoardStated plannedThe respondent said that this action was planned when they made their response on 22 March 2022.
Action
Flag risks from host-arranged internal flights to relevant ECB executives and request flight details so appropriate safety checks can be undertaken.
Stated byEngland and Wales Cricket BoardStated plannedThe respondent said that this action was planned when they made their response on 22 March 2022.
Action
Flag the case to account managers serving CBI aerospace members to raise awareness of unregulated-flight risks.
Stated byConfederation of British IndustryStated plannedThe respondent said that this action was planned when they made their response on 22 March 2022.
Action
Use CBI social media to retweet and amplify the article’s employee wellbeing and safety message to members and followers.
Stated byConfederation of British IndustryStated plannedThe respondent said that this action was planned when they made their response on 22 March 2022.
Action
Send correspondence to each member Club’s Legal, Club Secretarial and Football departments, signposting Civil Aviation Authority guidance on transfers and travel arrangements.
Distribute private-flight safety information to relevant athletes, their agents and coaches, and Home Country Athletic Federations for onward distribution.
Stated byUK Athletics LimitedStated plannedThe respondent said that this action was planned when they made their response on 22 March 2022.
Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.21
Position
The Civil Aviation Authority is identified as the first point of contact for queries or concerns about the PFD report or commercial charter flights.
Stated byRugby Football UnionRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Further action and its timetable cannot yet be specified because potential legal changes require careful consideration, justification, consultation and interdepartmental cooperation.
Stated byDepartment for TransportUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
The obligation to raise awareness of risks from non-AOC flights has been met through briefing materials and dissemination across the Chamber network.
Stated byBritish Chambers of CommerceNo action considered necessaryThe respondent said that no further action was needed.
Position
The players’ trade union has limited ability to effect change on travel arrangements.
Any specific football-industry rules or regulations must be introduced by leagues or governing bodies.
Stated byProfessional Footballers' AssociationRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Clubs and players’ intermediaries usually make travel arrangements, not individual players.
Stated byProfessional Footballers' AssociationRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Responsibility for customers’ flight-operator choices and the legality of their operations cannot be assumed or policed.
Stated byThe Jockey ClubOutside remitThe respondent said that this matter was outside its role or authority.
Position
Private flight operators cannot be required to provide commercial-flight information.
Stated byThe Jockey ClubUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Without the inquest evidence and expert advice, the respondent cannot comment on the CAA’s regulatory functions or investigative and prosecutorial powers.
Stated byThe Football Association LimitedUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
The CAA regulates aviation safety, while ministerial responsibility lies with the Department for Transport, not DCMS.
The report need not be shared with other RFU clubs because they are highly unlikely to charter commercial flights.
Stated byRugby Football UnionNo action considered necessaryThe respondent said that no further action was needed.
Position
The risk of RFU member clubs chartering commercial flights is considered minimal because of their limited financial resources.
Stated byRugby Football UnionDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The Civil Aviation Authority is asked to publicise the risks of unauthorised flights among members and the general public.
Stated byInstitute of DirectorsRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Rugby League does not use flights of the type involved in this case.
Stated byRugby Football LeagueDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Clubs, rather than the league, have the legal duty to manage travel risks for employees and others connected with them.
Stated byEFLRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Because the ECB arranges The Hundred flights, it considers separate communications to The Hundred team representatives unnecessary.
Stated byEngland and Wales Cricket BoardExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Illegal private plane journeys are prohibited with UK Sport funding, so no further action is considered necessary.
Stated byUK SportExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The risk of illegal private plane hire is considered minimal because government-funded sports are unlikely to afford such journeys.
Stated byUK SportDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The air-travel concerns are not applicable because the organisation arranges no member or guest travel and members do not fly to meetings.
Publish a member-facing article on employee wellbeing and safety, linking to the Sala case and public Coroner’s findings.
Stated byConfederation of British IndustryStated plannedThe respondent said that this action was planned when they made their response on 22 March 2022.
6
Raise the matter personally with attending Club Chairs, Chief Executives and Owners at the Annual General Meeting.
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