PFD report

Richard Mohamed Fekry Osman · Prevention of Future Deaths report

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Issued 5 Jun 2025•Carmarthenshire and Pembrokeshire

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
7

Raised in this report

Recipients
5

Named on the report

Responses found
2

Of 5 recipients

Stated actions
4

Described in 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.

Report evidence summary

Concerns raised7

  1. Failure to produce timely final reports and interim statements on investigation progress and safety issues
    Part of recurring concern: Unreliable safety investigation reports and disclosure
  2. Failure to recognise oxygen fires and immediately cut off the oxygen supply
    Part of recurring concern: Inadequate controls for oxygen-related fire risks
  3. Uncertainty about the effectiveness of Halon fire extinguishers for onboard fires
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.1

  1. Action

    Continue monitoring safety data and future aviation safety investigation recommendations relating to fire risks.

    Stated by Civil Aviation AuthorityStated in progressThe respondent said that this action was in progress when they made their response on 3 July 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.10

  1. Position

    CAA safety oversight and occurrence data do not indicate a smoking-related safety risk or gap requiring regulatory change.

    Stated by Civil Aviation AuthorityDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Failure to produce timely final reports and interim statements on investigation progress and safety issues

Wider context from the report

“(2) That a drafting committee be convened to consider amending Annex 13 of the Convention on International Civil Aviation signed at Chicago on 7 December 1944 to provide: (a) a right for states entitled to participate in an investigation to have access to evidence to enable those participating states to release a statement in accordance with Chapter 6.6.1 in circumstances where they have been excluded from an investigation by the State of Occurrence; (b) a right of states entitled to participate in an investigation to take over conduct of an investigation in circumstances where a State of Occurrence does not produce a Final Report within a reasonable timeframe and does not produce interim statements indicating the progress of the investigation and safety issues raised within a reasonable timeframe and has not otherwise consented to the delegation of the investigation in accordance with Chapter 5.1. ”

Is this part of a recurring concern?

Yes — Unreliable safety investigation reports and disclosure.

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

Failure to recognise oxygen fires and immediately cut off the oxygen supply

Wider context from the report

“(1) That a full review of cockpit fire/smoke procedures be undertaken to include, but not limited to: - the recognition of an oxygen fire (identifiable by a characteristic noise comparable to that of a blowtorch) and the immediate cutting off this oxygen supply. - the installation or carrying of protective equipment to deal with any cockpit fires. - a review of the effectiveness of Halon fire extinguishers to deal with onboard fires. - a review of regulations (if required) to prevent the use of cigarettes in the cockpit and related flammable items and materials. - the additional risk analyses to take into account the hypothesis of an overpressure in the oxygen distribution system. ”

Is this part of a recurring concern?

Yes — Inadequate controls for oxygen-related fire risks.

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

Uncertainty about the effectiveness of Halon fire extinguishers for onboard fires

Wider context from the report

“(1) That a full review of cockpit fire/smoke procedures be undertaken to include, but not limited to: - the recognition of an oxygen fire (identifiable by a characteristic noise comparable to that of a blowtorch) and the immediate cutting off this oxygen supply. - the installation or carrying of protective equipment to deal with any cockpit fires. - a review of the effectiveness of Halon fire extinguishers to deal with onboard fires. - a review of regulations (if required) to prevent the use of cigarettes in the cockpit and related flammable items and materials. - the additional risk analyses to take into account the hypothesis of an overpressure in the oxygen distribution system. ”

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

Failure to prevent cigarettes and related flammable items and materials in the cockpit

Wider context from the report

“(1) That a full review of cockpit fire/smoke procedures be undertaken to include, but not limited to: - the recognition of an oxygen fire (identifiable by a characteristic noise comparable to that of a blowtorch) and the immediate cutting off this oxygen supply. - the installation or carrying of protective equipment to deal with any cockpit fires. - a review of the effectiveness of Halon fire extinguishers to deal with onboard fires. - a review of regulations (if required) to prevent the use of cigarettes in the cockpit and related flammable items and materials. - the additional risk analyses to take into account the hypothesis of an overpressure in the oxygen distribution system. ”

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

Unavailability of protective equipment for cockpit fires

Wider context from the report

“(1) That a full review of cockpit fire/smoke procedures be undertaken to include, but not limited to: - the recognition of an oxygen fire (identifiable by a characteristic noise comparable to that of a blowtorch) and the immediate cutting off this oxygen supply. - the installation or carrying of protective equipment to deal with any cockpit fires. - a review of the effectiveness of Halon fire extinguishers to deal with onboard fires. - a review of regulations (if required) to prevent the use of cigarettes in the cockpit and related flammable items and materials. - the additional risk analyses to take into account the hypothesis of an overpressure in the oxygen distribution system. ”

Is this part of a recurring concern?

Yes — Inadequate controls for oxygen-related fire risks.

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 evidence access for states entitled to participate in an investigation when excluded by the State of Occurrence

Wider context from the report

“(2) That a drafting committee be convened to consider amending Annex 13 of the Convention on International Civil Aviation signed at Chicago on 7 December 1944 to provide: (a) a right for states entitled to participate in an investigation to have access to evidence to enable those participating states to release a statement in accordance with Chapter 6.6.1 in circumstances where they have been excluded from an investigation by the State of Occurrence; (b) a right of states entitled to participate in an investigation to take over conduct of an investigation in circumstances where a State of Occurrence does not produce a Final Report within a reasonable timeframe and does not produce interim statements indicating the progress of the investigation and safety issues raised within a reasonable timeframe and has not otherwise consented to the delegation of the investigation in accordance with Chapter 5.1. ”

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

Failure of risk analyses to account for overpressure in the oxygen distribution system

Wider context from the report

“(1) That a full review of cockpit fire/smoke procedures be undertaken to include, but not limited to: - the recognition of an oxygen fire (identifiable by a characteristic noise comparable to that of a blowtorch) and the immediate cutting off this oxygen supply. - the installation or carrying of protective equipment to deal with any cockpit fires. - a review of the effectiveness of Halon fire extinguishers to deal with onboard fires. - a review of regulations (if required) to prevent the use of cigarettes in the cockpit and related flammable items and materials. - the additional risk analyses to take into account the hypothesis of an overpressure in the oxygen distribution system. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Continue monitoring safety data and future aviation safety investigation recommendations relating to fire risks.

Verbatim wording from the response

“However, given the specific concerns identified by the Assistant Coroner, the CAA will continue to carefully monitor safety data and future aviation safety investigation recommendations related to fire risks with a view to taking appropriate action where necessary.”

Source location

Response from Civil Aviation Authority
Page 5 · response
Published 3 July 2025

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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

CAA safety oversight and occurrence data do not indicate a smoking-related safety risk or gap requiring regulatory change.

Verbatim wording from the response

“While there is no specific reference to smoking in the flight deck within these regulations, the CAA is not aware of any UK aircraft operators that allow smoking in any part of an aircraft, including the flight deck. Flight crew receive extensive training in safety and risk management, with a strong emphasis on maintaining a controlled and hazard-free operating environment onboard aircraft. In addition, all safety related occurrences must be reported to the CAA, which enables data to be collected and analysed over time. Following a review of the coroner’s request, the UK CAA Safety Intelligence Team have confirmed that there have been no reported UK incidents involving smoking or vaping in the flight deck in the past decade.¹¹”

Source location

Response from Civil Aviation Authority
Page 3 · response
Published 3 July 2025

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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

The Department for Transport will respond separately to report aspects concerning aircraft accident investigation.

Verbatim wording from the response

“The CAA understands that the Department for Transport (‘DfT’) will, therefore, respond separately to those aspects of the Report which relate to aircraft accident investigation. We can confirm that we have exchanged responses with the DfT prior to filing this response with the court.”

Source location

Response from Civil Aviation Authority
Page 2 · response
Published 3 July 2025

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

Aircraft accident and serious-incident investigation is outside the CAA’s responsibility and falls to the Air Accidents Investigation Branch.

Verbatim wording from the response

“The CAA is not responsible for the investigation of aircraft accidents or serious incidents on behalf of the UK, which falls to the Air Accidents Investigation Branch (‘AAIB’), a body who report directly to the Secretary of State for Transport. Procedures for these investigations are laid down in international protocols, specifically the standards and recommended practices defined in Annex 13 to the Convention on International Civil Aviation, Aircraft Accident and Incident Investigation, and published by the International Civil Aviation Organization (‘ICAO’).”

Source location

Response from Civil Aviation Authority
Page 2 · response
Published 3 July 2025

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

Existing airworthiness, operational, certification and safety-management safeguards provide adequate mitigation, so no aviation safety regulatory changes are currently required.

Verbatim wording from the response

“No new fires have been identified by the CAA as a result of this audit programme and the CAA remains satisfied that all known risks fall within existing design, certification and operational controls.”

Source location

Response from Civil Aviation Authority
Page 4 · response
Published 3 July 2025

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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

ICAO’s amended arrangements and public-information encouragement provide adequate assurance without further rights to take over investigations.

Verbatim wording from the response

“In relation to Point 2b, since the accident ICAO has amended Annex 13 via SARP 5.1.3 (Amendment 17 of Annex 13) introducing the right for another state to request that they take over investigative responsibility should no investigation be initiated within thirty days and giving states the right to do their own investigation using widely available information if no investigation is then initiated. ICAO also encourages states to release information publicly in the early days of the investigation. It is important to maintain clear roles and parameters for involvement in accident investigations to ensure they remain impartial, they are investigated thoroughly and lessons are learned to prevent future recurrence.”

Source location

Response from Department of Transport
Page 3 · response
Published 3 July 2025

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

Existing accredited representatives’ full evidence access and safeguards make further amendments on access to evidence unnecessary.

Verbatim wording from the response

“It is already the case that accredited representatives (usually investigators from the state of design, operation or registry) have full access to the investigation materials and evidence. There are safeguards in place to protect evidence in accident investigations being more widely available for very good reasons. These include people being more likely to cooperate knowing any evidence they provide will not be used against them in civil or criminal proceedings. This contributes to a “just culture” of being open and honest and prioritising learning over assigning blame. There are also ethical considerations about protecting individuals involved and controlling access to evidence which also helps maintain the chain of custody. Therefore with regard to Point 2a, we do not believe further amendments regarding access to evidence are necessary.”

Source location

Response from Department of Transport
Page 3 · response
Published 3 July 2025

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

The Department for Transport will respond separately to report aspects concerning aircraft accident investigation.

Verbatim wording from the response

“The CAA understands that the Department for Transport (‘DfT’) will, therefore, respond separately to those aspects of the Report which relate to aircraft accident investigation. We confirm that we have exchanged responses with the DfT prior to filing this response with the court.”

Source location

Response from Civil Aviation Authority
Page 2 · response
Published 3 July 2025

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

CAA safety data does not indicate that onboard fire risks or flight-deck fire consequences require changes to existing rules.

Verbatim wording from the response

“The CAA’s review of the Assistant Coroner’s recommendations has concluded that no change to the existing aviation safety regulatory framework is currently required. The CAA remains satisfied that the safeguards in place, which are underpinned by airworthiness and operational regulations, design and certification requirements and operator safety management systems provide adequate risk mitigation. As part of this review, subject matter experts have examined relevant safety data held by the CAA under the Mandatory Occurrence Reporting Scheme, which does not indicate there is a risk of fire onboard large commercial aircraft - or the consequences of a flight deck fire - necessitate changes to existing rules. The CAA is also mindful of international requirements directed by ICAO which do not support change to existing fire safety controls at the present time.”

Source location

Response from Civil Aviation Authority
Page 5 · response
Published 3 July 2025

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

Existing airworthiness, operational, certification and safety-management controls provide adequate mitigation, so no regulatory framework change is currently required.

Verbatim wording from the response

“The CAA’s review of the Assistant Coroner’s recommendations has concluded that no change to the existing aviation safety regulatory framework is currently required. The CAA remains satisfied that the safeguards in place, which are underpinned by airworthiness and operational regulations, design and certification requirements and operator safety management systems provide adequate risk mitigation. As part of this review, subject matter experts have examined relevant safety data held by the CAA under the Mandatory Occurrence Reporting Scheme, which does not indicate there is a risk of fire onboard large commercial aircraft - or the consequences of a flight deck fire - necessitate changes to existing rules. The CAA is also mindful of international requirements directed by ICAO which do not support change to existing fire safety controls at the present time.”

Source location

Response from Civil Aviation Authority
Page 5 · response
Published 3 July 2025

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

Aircraft accident investigation is outside the CAA’s responsibility and falls to the Air Accidents Investigation Branch.

Verbatim wording from the response

“The CAA is not responsible for the investigation of aircraft accidents or serious incidents on behalf of the UK, which falls to the Air Accidents Investigation Branch (‘AAIB’), a body who report directly to the Secretary of State for Transport. Procedures for these investigations are laid down in international protocols, specifically the standards and recommended practices defined in Annex 13 to the Convention on International Civil Aviation, Aircraft Accident and Incident Investigation, and published by the International Civil Aviation Organization (‘ICAO’).”

Source location

Response from Civil Aviation Authority
Page 2 · response
Published 3 July 2025

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.3

  1. 1

    Continue prioritising improvements to global aviation safety.

    Stated by Department for TransportStated in progressThe respondent said that this action was in progress when they made their response on 3 July 2025.
  2. 2

    Work with domestic and international agencies to pursue zero serious or fatal commercial air transport accidents and third-party aviation fatalities.

    Stated by Department for TransportStated in progressThe respondent said that this action was in progress when they made their response on 3 July 2025.
  3. 3

    Continue monitoring safety data and future aviation safety investigation recommendations concerning fire risks, taking appropriate action where necessary.

    Stated by Civil Aviation AuthorityStated in progressThe respondent said that this action was in progress when they made their response on 3 July 2025.

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 prioritising improvements to global aviation safety.

Verbatim wording from the response

“The safety of the travelling public is a priority and the DfT will continue to prioritise improvements to global aviation safety.”

Source location

Response from Department of Transport
Page 3 · response
Published 3 July 2025

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 domestic and international agencies to pursue zero serious or fatal commercial air transport accidents and third-party aviation fatalities.

Verbatim wording from the response

“The Department for Transport (DfT) is committed to working with other agencies, both domestically and internationally, to strive towards zero accidents involving commercial air transport that result in serious injuries or fatalities and no serious injuries or fatalities to third parties as a result of aviation activities.”

Source location

Response from Department of Transport
Page 2 · response
Published 3 July 2025

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

Continue monitoring safety data and future aviation safety investigation recommendations concerning fire risks, taking appropriate action where necessary.

Verbatim wording from the response

“However, given the specific concerns identified by the Assistant Coroner, the CAA will continue to carefully monitor safety data and future aviation safety investigation recommendations related to fire risks with a view to taking appropriate action where necessary.”

Source location

Response from Civil Aviation Authority
Page 5 · response
Published 3 July 2025

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
2/5

Data last updated 7 September 2026