PFD report

Rebecca Dobson and 4 others · Prevention of Future Deaths report

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Issued 18 Nov 2021•West Sussex

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
13

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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Report evidence summary

Concerns raised2

  1. Lack of a central register recording crash-resistant fuel system fitment
  2. Failure to mandate retrofit of crash-resistant fuel systems on rotorcraft
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.8

  1. Action

    Conduct detailed analysis of risks affecting UK-registered rotorcraft and assess the impacts of subsequent rule-change and safety-guidance proposals.

    Stated by Civil Aviation AuthorityStated plannedThe respondent said that this action was planned when they made their response on 22 November 2021.
  2. Action

    Consider whether UK aviation safety requirements require rule changes, following technical evaluation of applicable crash-resistant fuel systems and structures.

    Stated by Civil Aviation AuthorityStated plannedThe respondent said that this action was planned when they made their response on 22 November 2021.
  3. Action

    Contact the FAA to understand the rationale for rotorcraft crash-resistant fuel bladder retrofit recommendations.

    Stated by Civil Aviation AuthorityStated plannedThe respondent said that this action was planned when they made their response on 22 November 2021.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    UK accident data does not indicate an imminent safety risk requiring immediate changes to rotorcraft certification requirements or a UK-wide safety directive.

    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

Lack of a central register recording crash-resistant fuel system fitment

Wider context from the report

“5. For the public there does not appear to be any way of knowing whether a particular aircraft has been fitted with the CRFS as there is no central register which records this. The public cannot therefore make an informed decision as to whether to fly on that aircraft. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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 mandate retrofit of crash-resistant fuel systems on rotorcraft

Wider context from the report

“4. There is nothing in place to mandate the fitting of CRFS as a retrofit and so the risk of post-crash fire in non-CRFS fitted helicopters remains very high with the likelihood of loss of life ”

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

Conduct detailed analysis of risks affecting UK-registered rotorcraft and assess the impacts of subsequent rule-change and safety-guidance proposals.

Verbatim wording from the response

“The CAA will continue to work with international and domestic aviation stakeholders to mitigate the risks to public safety in accordance with the concerns highlighted in the Senior Coroner’s Regulation 28 report. The CAA will conduct further detailed analysis of those risks, insofar as they relate to UK registered rotorcraft, together with an assessment of the impact of any subsequent proposals for rule changes and amendments to safety guidance. The CAA will be informed by analysis of UK aviation safety data, the progress of EASA RMT.0710 and work undertaken by the FAA arising from the ROPWG.”

Source location

2021-0392-Response-from-Civil-Aviation-Authority
Page 4 · response
Published 22 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

Consider whether UK aviation safety requirements require rule changes, following technical evaluation of applicable crash-resistant fuel systems and structures.

Verbatim wording from the response

“The CAA will then consider whether rule changes are required to align UK aviation safety requirements, where appropriate. Any decision reached to take mandatory action must follow extensive technical evaluation including, but not limited to, testing CRFS and CRSS to ensure compliance with design and certification requirements for each applicable aircraft type.”

Source location

2021-0392-Response-from-Civil-Aviation-Authority
Page 4 · response
Published 22 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

Contact the FAA to understand the rationale for rotorcraft crash-resistant fuel bladder retrofit recommendations.

Verbatim wording from the response

“The CAA will continue to review UK aviation safety data relevant to the concerns raised by the Senior Coroner and monitor related developments arising from EASA RMT.0710. The CAA will also contact the FAA to understand the rationale for recommendations from”

Source location

2021-0392-Response-from-Civil-Aviation-Authority
Page 3 · response
Published 22 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

Establish and operate a national aviation safety rule-making programme covering rotorcraft design and certification requirements.

Verbatim wording from the response

“With effect from 1 January 2021 the CAA has established a national rule making programme, working with the Department for Transport, for managing proposed changes to the existing regulatory framework for aviation safety in the UK. This programme is designed to align, where appropriate, with technical specifications, known as Standards and Recommended Practices (‘SARP’s) adopted by the Council of ICAO and separate global rule making, including that directed by EASA and the US Federal Aviation Authority (‘FAA’).”

Source location

2021-0392-Response-from-Civil-Aviation-Authority
Page 2 · response
Published 22 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

Undertake consultation with owners and operators as part of the wider impact assessment for proposed retrospective rotorcraft requirements.

Verbatim wording from the response

“These proposals will be retrospective and targeted into Part 26 for existing type designed Rotorcraft,² and will require the CAA to undertake a period of consultation with owners and operators as part a wider impact assessment.”

Source location

Response from Civil Aviation Authority
Page 2 · response
Published 22 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

Consider safety proposals for existing UK-registered rotorcraft within the aviation legislation and policy rulemaking programme.

Verbatim wording from the response

“Based on the work carried out to date, including a preliminary assessment of the impact on owners and operators, the CAA is considering safety proposals for existing Rotorcraft on the UK register to be incorporated into the aviation legislation and policy rulemaking programme.”

Source location

Response from Civil Aviation Authority
Page 2 · response
Published 22 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

Monitor UK rotorcraft safety following the Senior Coroner’s recommendations.

Verbatim wording from the response

“In the meantime, the CAA will continue to carefully monitor Rotorcraft safety in the U.K. following the recommendations issued by the Senior Coroner and encourage owners and operators of Rotorcraft in the U.K., particularly those performing commercial air transport operations to consider enhancing safety by voluntarily fitting CRFS design provisions, including, tear resistant bladder inserts to fuel tanks pending any future mandatory rule changes.”

Source location

Response from Civil Aviation Authority
Page 3 · response
Published 22 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

Implement targeted safety promotion for the rotorcraft community, including collaboration with industry and operators to encourage best practice and voluntary CRFS fitting.

Verbatim wording from the response

“The CAA has already held meetings with representatives of both EASA and the FAA to ensure that it is working collaboratively with European and U.S. policy teams on this issue. In addition, the CAA intends to work with U.K. industry and operators to raise public awareness and encourage best practice.”

Source location

Response from Civil Aviation Authority
Page 2 · response
Published 22 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

UK accident data does not indicate an imminent safety risk requiring immediate changes to rotorcraft certification requirements or a UK-wide safety directive.

Verbatim wording from the response

“The CAA reviewed the UK Rotorcraft accident data relevant to the specific concerns raised by the Senior Coroner. The accident data relevant to operations in the UK does not highlight an imminent safety risk to passengers who are travelling in previously certified Rotorcraft without CRFS provisions fitted, or to the general public, such that an unsafe condition exists requiring an immediate change to the design and certification requirements or a U.K. wide safety directive.”

Source location

Response from Civil Aviation Authority
Page 1 · response
Published 22 November 2021

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.5

  1. 1

    Continue working with international and domestic aviation stakeholders to mitigate rotorcraft post-crash fire risks.

    Stated by Civil Aviation AuthorityStated in progressThe respondent said that this action was in progress when they made their response on 22 November 2021.
  2. 2

    Continue reviewing UK aviation safety data and monitoring developments from EASA rule-making task RMT.0710.

    Stated by Civil Aviation AuthorityStated in progressThe respondent said that this action was in progress when they made their response on 22 November 2021.
  3. 3

    Meet with EASA and FAA representatives to collaborate with international policy teams on rotorcraft occupant-protection measures.

    Stated by Civil Aviation AuthorityStated completedThe respondent said that this action was complete when they made their response on 22 November 2021.
  4. 4

    Review UK rotorcraft accident data to assess whether existing CRFS requirements present an imminent safety risk.

    Stated by Civil Aviation AuthorityStated completedThe respondent said that this action was complete when they made their response on 22 November 2021.
  5. 5

    Maintain CRFS requirements for all new rotorcraft types in the applicable certification specifications.

    Stated by Civil Aviation AuthorityStated completedThe respondent said that this action was complete when they made their response on 22 November 2021.

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 working with international and domestic aviation stakeholders to mitigate rotorcraft post-crash fire risks.

Verbatim wording from the response

“The CAA will continue to work with international and domestic aviation stakeholders to mitigate the risks to public safety in accordance with the concerns highlighted in the Senior Coroner’s Regulation 28 report. The CAA will conduct further detailed analysis of those risks, insofar as they relate to UK registered rotorcraft, together with an assessment of the impact of any subsequent proposals for rule changes and amendments to safety guidance. The CAA will be informed by analysis of UK aviation safety data, the progress of EASA RMT.0710 and work undertaken by the FAA arising from the ROPWG.”

Source location

2021-0392-Response-from-Civil-Aviation-Authority
Page 4 · response
Published 22 November 2021

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 reviewing UK aviation safety data and monitoring developments from EASA rule-making task RMT.0710.

Verbatim wording from the response

“The CAA will continue to review UK aviation safety data relevant to the concerns raised by the Senior Coroner and monitor related developments arising from EASA RMT.0710. The CAA will also contact the FAA to understand the rationale for recommendations from”

Source location

2021-0392-Response-from-Civil-Aviation-Authority
Page 3 · response
Published 22 November 2021

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

Meet with EASA and FAA representatives to collaborate with international policy teams on rotorcraft occupant-protection measures.

Verbatim wording from the response

“The CAA has already held meetings with representatives of both EASA and the FAA to ensure that it is working collaboratively with European and U.S. policy teams on this issue. In addition, the CAA intends to work with U.K. industry and operators to raise public awareness and encourage best practice.”

Source location

Response from Civil Aviation Authority
Page 2 · response
Published 22 November 2021

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

Review UK rotorcraft accident data to assess whether existing CRFS requirements present an imminent safety risk.

Verbatim wording from the response

“The CAA reviewed the UK Rotorcraft accident data relevant to the specific concerns raised by the Senior Coroner. The accident data relevant to operations in the UK does not highlight an imminent safety risk to passengers who are travelling in previously certified Rotorcraft without CRFS provisions fitted, or to the general public, such that an unsafe condition exists requiring an immediate change to the design and certification requirements or a U.K. wide safety directive.”

Source location

Response from Civil Aviation Authority
Page 1 · response
Published 22 November 2021

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 CRFS requirements for all new rotorcraft types in the applicable certification specifications.

Verbatim wording from the response

“As recognised by the Senior Coroner, the design and certification requirements relevant to fitting crash resistant fuel systems (‘CRFS’) in rotorcraft operating in the UK are contained within Certification Specifications CS 27-952 and CS 29-952¹. These Certification Specifications now include requirements for CRFS capability in all new Rotorcraft types.”

Source location

Response from Civil Aviation Authority
Page 1 · response
Published 22 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

Official responses located
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Data last updated 7 September 2026