Mr Bryan Allsop · Prevention of Future Deaths report

On 13 May 2017 I commenced an investigation into the death of Mr Bryan Allsop (dob: 1 June 1937; dod: 28 May 2017). The investigation concluded at the end of the inquest (with jury) on 6 June 2018. The conclusion of the inquest was: -

- Medical cause of death: -
1a Head and chest injuries.

- Summary of circumstances: -
Mr Allsop died on 28 May 2017 as a result of a crash of the light aircraft which he was piloting. The severe injuries he sustained resulted in death very soon after the crash and the crash occurred within a short time of take-off from his local airstrip at Coal Aston in North Derbyshire.

- The jury's conclusion at inquest was that the death was an accident, but that a number of factors had been contributory.

Mr Allsop had been conducting some short flights on the morning of 28 May 2017, principally to test a device to prompt and remind with regards to deployment of the landing gear. On the third take-off his plane failed to reach full power or to attain sufficient altitude and in the course of turning back to the landing strip he lost control of the aircraft and crashed into a nearby field. The jury found there to be four significant contributory factors to the crash, which acted in combination: -

- The aircraft's fuel vapour return line was configured so that fuel vapour was routed back to the engine rather than the fuel reserve tank to dissipate.

- Mr Allsop was using E5 Mogas but his plane had not had the necessary checks and authorisation for this type of fuel.

- The warm weather conditions on the day, the series of short flights and the aircraft engine running in between flights whilst not airborne, combined to make the engine more susceptible to vapour production.

- On the third flight the engine did not reach full power and the aircraft could not gain sufficient altitude making Mr Allsop’s attempted turn back to the airstrip likely to end in a crash.

The inquest heard that Mr Allsop's air crash occurred in the context of him attempting to turn back to the airstrip to land but insufficient altitude and lack of engine power made a crash whilst turning highly likely.

The court heard evidence that neither the pilot training leading to issue of a pilot’s license (for light aircraft) nor the biennial pilot license revalidation have mandatory requirements for instruction and testing in partial loss of engine power scenarios. This is the case for both EASA and non-EASA licences. The court also heard evidence that a significant number of aircraft crashes and near crashes occur in the context of partial loss of engine power scenarios. Reference was made to Australian research and also awareness of the issue at the AAIB and the LAA. The court was informed that pilot licenses require instruction and testing in full loss of engine power scenarios but that a partial loss of engine power, particularly at low altitude, presents distinct and very difficult challenges to pilots.

My specific concern relates to there being no mandatory requirement for instruction and testing in partial loss of engine power scenarios in relation to light aircraft pilot’s licences. If this is also the case for more powerful classes of aircraft for license purposes this would also be a concern.