PFD report

Steven Phillip Evans · Prevention of Future Deaths report

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Issued 3 Nov 2021•Gwent

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
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
11

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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Concerns raised1

  1. Failure to use effective radio communication between ground crew and glider pilots during launch and 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.11

  1. Action

    Coordinate with the BGA to promote launch-signalling safety information at the start of the 2022 gliding season.

    Stated by Civil Aviation AuthorityStated plannedThe respondent said that this action was planned when they made their response on 9 November 2021.
  2. Action

    Continue monitoring launch-related occurrence data with the BGA to assess whether further action is required.

    Stated by Civil Aviation AuthorityStated in progressThe respondent said that this action was in progress when they made their response on 9 November 2021.
  3. Action

    Review the BGA’s updated launch-signalling guidance and confirm that its revision is adequate.

    Stated by Civil Aviation AuthorityStated completedThe respondent said that this action was complete when they made their response on 9 November 2021.

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

  1. Position

    Updated BGA launch-signalling guidance is considered adequate, so further action will depend on monitoring whether occurrence data indicates it is required.

    Stated by Civil Aviation AuthorityExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 use effective radio communication between ground crew and glider pilots during launch and flight

Wider context from the report

“1. Mandatory radio communication between ground crew and aircraft pilots. During the course of the inquest the jury heard that problems with Steven’s glider were observed before the glider was launched however the system of communication did not alert either the tug plane operator or Steven Evans to the problems prior to his launch. In the circumstances I consider this constituted a failure to adopt an effective communication system at launch, a finding endorsed by the Air Accident Investigation Branch. However, there was insufficient information to determine that this contributed to Steven’s death as the glider crashed within seconds of the fault being identified. In evidence it became clear that the CAA do not mandate the use of radios in the relevant aircraft and by the ground crew and whilst this was previously recommended by the BGA it was not usual practice at South Wales Gliding Club until after Steven’s death. Whilst it was not determined that the failure to have radio communication contributed to Steven’s death it appears that radios may still not be in use in other clubs and therefore lives may be put at risk in the future. I consider that further consideration should be given by the CAA to require effective radio communication not only at launch but throughout the glider flight and that the BGA further strengthen the current guidelines that radios are strongly recommended. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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

Coordinate with the BGA to promote launch-signalling safety information at the start of the 2022 gliding season.

Verbatim wording from the response

“1. The CAA will coordinate with the BGA to promote the relevant safety information regarding launch signalling to coincide with the start of the 2022 gliding season.”

Source location

2021-0372-Response-from-Civil-Aviation-Authority
Page 3 · response
Published 9 November 2021

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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 monitoring launch-related occurrence data with the BGA to assess whether further action is required.

Verbatim wording from the response

“The Regulation 28 Report from the Senior Coroner, states that there was insufficient information to determine whether the failure to adopt an effective communication system contributed to Mr Evans’ death. The CAA recognises that radios are one possible means of effective communication between aircraft and groundcrews involved in glider launching, they are not however, the only means. In its updated guidance on this topic, the BGA has outlined the various recognised methods of effective launch signalling, including the associated limitations of each. The CAA has reviewed the updated BGA guidance on launch signalling and is content that the revision is adequate. The CAA will, however, continue to work closely with the BGA and monitor occurrence data for launch-related incidents to determine whether further action is required.”

Source location

2021-0372-Response-from-Civil-Aviation-Authority
Page 2 · response
Published 9 November 2021

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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 the BGA’s updated launch-signalling guidance and confirm that its revision is adequate.

Verbatim wording from the response

“The Regulation 28 Report from the Senior Coroner, states that there was insufficient information to determine whether the failure to adopt an effective communication system contributed to Mr Evans’ death. The CAA recognises that radios are one possible means of effective communication between aircraft and groundcrews involved in glider launching, they are not however, the only means. In its updated guidance on this topic, the BGA has outlined the various recognised methods of effective launch signalling, including the associated limitations of each. The CAA has reviewed the updated BGA guidance on launch signalling and is content that the revision is adequate. The CAA will, however, continue to work closely with the BGA and monitor occurrence data for launch-related incidents to determine whether further action is required.”

Source location

2021-0372-Response-from-Civil-Aviation-Authority
Page 2 · response
Published 9 November 2021

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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

Use club site safety reviews to check compliance with required signalling standards.

Verbatim wording from the response

“6. Club site safety reviews support checking of the required signalling requirements and standards.”

Source location

2021-0372-Response-from-British-Gliding-Association_Published
Page 2 · response
Published 9 November 2021

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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

Provide future reminders to club officials and pilots about aerotow signalling requirements, beginning before the spring 2022 gliding season.

Verbatim wording from the response

“9. Aerotow signalling operational regulation and associated requirements will be the subject of future reminders to club officials and pilots. The next reminder will be provided to clubs just ahead of spring 2022 to coincide with the start of the main gliding season and will be co-ordinated with any CAA safety promotion opportunity.”

Source location

2021-0372-Response-from-British-Gliding-Association_Published
Page 2 · response
Published 9 November 2021

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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

Adopt, publish and promulgate amended launch-signalling regulations requiring reliable, unambiguous signalling and backup methods where radio communication is unavailable.

Verbatim wording from the response

“2. During early February 2021, the BGA wrote to club chairmen describing the AAIB report, the associated outcomes, BGA the revised operational regulations and associated requirements and the intention to formally adopt those at the AGM.”

Source location

2021-0372-Response-from-British-Gliding-Association_Published
Page 1 · response
Published 9 November 2021

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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

Require clubs restarting gliding to have pilots and instructors review safety information, including signalling requirements.

Verbatim wording from the response

“5. During May 2021, gliding restarted after several long pauses associated with Covid restrictions. As part of the restart process, all clubs required their pilots and instructors to review safety information including that relating to signalling.”

Source location

2021-0372-Response-from-British-Gliding-Association_Published
Page 2 · response
Published 9 November 2021

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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

Remind club chairmen and Chief Flying Instructors about the AAIB findings and aerotow signalling requirements.

Verbatim wording from the response

“8. During early November 2021, all BGA club Chairmen and club Chief Flying Instructors (who oversee club flying operations) were again reminded of the AAIB report and outcomes, and the BGA operational regulation and associated requirements for aerotow signalling.”

Source location

2021-0372-Response-from-British-Gliding-Association_Published
Page 2 · response
Published 9 November 2021

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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

Direct club officers responsible for launching and launch signalling to the published signalling requirements and guidance.

Verbatim wording from the response

“4. All gliding club officers responsible for launching and launch signalling have been directed towards this online published information.”

Source location

2021-0372-Response-from-British-Gliding-Association_Published
Page 2 · response
Published 9 November 2021

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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 launch signalling with experts and clubs and clarify required primary and backup signalling in revised rules and guidance.

Verbatim wording from the response

“1. During June 2020, in response to the AAIB’s report and recommendation, the BGA carefully reviewed launch signalling, raised in detail and discussed the issues with subject matter experts and all gliding clubs, and clarified through draft revised rules and associated guidance what type of signalling is required, including guidance on back up signalling.”

Source location

2021-0372-Response-from-British-Gliding-Association_Published
Page 1 · response
Published 9 November 2021

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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 monitoring launch-signalling occurrence data to assess whether further safety action is required.

Verbatim wording from the response

“10. Occurrence data relating to launch signalling will continue to be monitored to assess where further action may be required.”

Source location

2021-0372-Response-from-British-Gliding-Association_Published
Page 2 · response
Published 9 November 2021

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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

Updated BGA launch-signalling guidance is considered adequate, so further action will depend on monitoring whether occurrence data indicates it is required.

Verbatim wording from the response

“The Regulation 28 Report from the Senior Coroner, states that there was insufficient information to determine whether the failure to adopt an effective communication system contributed to Mr Evans’ death. The CAA recognises that radios are one possible means of effective communication between aircraft and groundcrews involved in glider launching, they are not however, the only means. In its updated guidance on this topic, the BGA has outlined the various recognised methods of effective launch signalling, including the associated limitations of each. The CAA has reviewed the updated BGA guidance on launch signalling and is content that the revision is adequate. The CAA will, however, continue to work closely with the BGA and monitor occurrence data for launch-related incidents to determine whether further action is required.”

Source location

2021-0372-Response-from-Civil-Aviation-Authority
Page 2 · response
Published 9 November 2021

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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

Radios are not required in relevant airspace or ground operations and are not the only effective launch-signalling method.

Verbatim wording from the response

“The Air Navigation Order 2016 and the Standardised European Rules of the Air specify which classes of airspace radios are required to be used and in which context. The Air Accidents Investigation Branch (“AAIB”) correctly note in their report for G-DDGX, published 28 May 2020[1], that aircraft operating under visual flight rules within Class G[2] airspace, which has not been declared a Radio Mandatory Zone (“RMZ”)[3] are not required to use a radio whilst airborne. Additionally, in the context of this operational environment, there is no existing requirement for radios to be used during ground operations.”

Source location

2021-0372-Response-from-Civil-Aviation-Authority
Page 1 · response
Published 9 November 2021

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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