PFD report

Peter GREGORY · Prevention of Future Deaths report

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Issued 2 Aug 2024•Worcestershire

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
9

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

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Failure of CAA oversight for competition balloon flying in the UK
    Part of recurring concern: Inadequate CAA regulatory oversight of aviation safety
  2. Lack of CAA guidance on the design, testing and inspection of amateur-built balloons
    Part of recurring concern: Inadequate CAA regulatory oversight of aviation safety
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.7

  1. Action

    Establish and use a ballooning subject-matter-expert working group to develop competition-flying safety guidance.

    Stated by Civil Aviation AuthorityStated completedThe respondent said that this action was complete when they made their response on 9 August 2024.
  2. Action

    Develop and publish web guidance on the design, testing and inspection of amateur-built balloons.

    Stated by Civil Aviation AuthorityStated in progressThe respondent said that this action was in progress when they made their response on 9 August 2024.
  3. Action

    Develop and publish a CAP containing operational safety guidance for competition balloon flying, including ascent and descent rates, standardised briefings and event guidance, then disseminate it to the ballooning community.

    Stated by Civil Aviation AuthorityStated in progressThe respondent said that this action was in progress when they made their response on 9 August 2024.

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

  1. Position

    Direct regulation of amateur-built balloon airworthiness is not considered necessary because safety will be enhanced through published measures and guidance.

    Stated by Civil Aviation AuthorityNo action considered necessaryThe respondent said that 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 of CAA oversight for competition balloon flying in the UK

Wider context from the report

“2) The inquest also heard evidence that the CAA currently neither regulates, nor publishes guidance for the safe oversight of competition balloon flying in the UK. Whilst there is guidance published by the British Balloon and Airship Club ( BBAC ), the BBAC is a sporting body and not a regulator, and therefore does not have the power, for example, to ground a balloon which does not conform to its published guidance. ”

Is this part of a recurring concern?

Yes — Inadequate CAA regulatory oversight of aviation safety.

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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

Lack of CAA guidance on the design, testing and inspection of amateur-built balloons

Wider context from the report

“1) The inquest heard evidence from an investigator at the Air Accidents Investigation Branch ( AAIB ) that Mr. Gregory’s balloon was home-built, based on a design produced by a friend and fellow balloon pilot, and that the balloon’s design ( in particular, the location of the balloon parachute’s centralising lines, which determine its height within the balloon envelope ) may have played a part in the parachute stall which led to the balloon’s sudden and fatal descent. The inquest also heard that the AAIB has recommended that the Civil Aviation Authority ( CAA ) publishes guidance on the design, testing and inspection of amateur-built balloons to reduce the risk of accidents due to unsafe conditions such as parachute stall, but that it is up to the CAA whether or not to regulate the design and construction of amateur/home-built balloons; ”

Is this part of a recurring concern?

Yes — Inadequate CAA regulatory oversight of aviation safety.

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

Establish and use a ballooning subject-matter-expert working group to develop competition-flying safety guidance.

Verbatim wording from the response

“The CAA is currently developing safety guidance for balloon events to ensure the risks associated with competition balloon flying are understood by competitors and managed by competition organisers. This will be in the form of a CAP [Civil Aviation Authority Publication] document.”

Source location

Supplemental Response from Civil Aviation Authority 25.03.2025
Page 2 · response
Published 9 August 2024

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

Develop and publish web guidance on the design, testing and inspection of amateur-built balloons.

Verbatim wording from the response

“It is recommended that the Civil Aviation Authority publish guidance on the design, testing and inspection of amateur-built balloons to reduce the risk of accidents due to unsafe conditions such as parachute stall.”

Source location

Supplemental Response from Civil Aviation Authority 25.03.2025
Page 1 · response
Published 9 August 2024

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

Develop and publish a CAP containing operational safety guidance for competition balloon flying, including ascent and descent rates, standardised briefings and event guidance, then disseminate it to the ballooning community.

Verbatim wording from the response

“The CAA is currently developing safety guidance for balloon events to ensure the risks associated with competition balloon flying are understood by competitors and managed by competition organisers. This will be in the form of a CAP [Civil Aviation Authority Publication] document.”

Source location

Supplemental Response from Civil Aviation Authority 25.03.2025
Page 2 · response
Published 9 August 2024

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

Issue a Safety Notice addressing amateur-built balloon design, construction, testing and continued non-regulation, with links to supporting guidance.

Verbatim wording from the response

“The CAA has been liaising with the amateur built balloon community with a view to producing guidance in the form of webpages on the CAA website to provide best practice guidance on the design, testing and inspecting of amateur built balloons and it is hoped the BBAC will also provide guidance in this regard and our liaison with them continues. It is also our intention to issue a Safety Notice (SN) regarding our decision to continue to allow the amateur built balloons to be unregulated. The SN shall also direct to the CAA website guidance and our previous Safety Directive (SD) on volumetric and occupancy limitations which will endure on a non-expiring basis.”

Source location

Supplemental Response from Civil Aviation Authority 25.03.2025
Page 1 · response
Published 9 August 2024

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

Publish safety guidance for competition balloon events, working with the BBAC to address risks for competitors and organisers.

Verbatim wording from the response

“Following publication of the AAIB’s final report, the Senior Coroner will be aware that two safety recommendations were issued to the CAA. The CAA has accepted both recommendations and has committed to working with the BBAC to produce guidance in relation to the design, testing and inspection of amateur-built balloons (including those used in competition flying). Additionally, the CAA will collaborate with the BBAC to produce guidance for the safe oversight of balloon events. The AAIB has classified the CAA responses as ‘adequate-open’ and the recommendations will remain open until the CAA has delivered on its commitment. The AAIB recommendations and the CAA’s initial response are set out below:”

Source location

Response from Civil Aviation Authority
Page 3 · response
Published 9 August 2024

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

Publish guidance on the design, testing and inspection of amateur-built balloons, working with the BBAC.

Verbatim wording from the response

“Following publication of the AAIB’s final report, the Senior Coroner will be aware that two safety recommendations were issued to the CAA. The CAA has accepted both recommendations and has committed to working with the BBAC to produce guidance in relation to the design, testing and inspection of amateur-built balloons (including those used in competition flying). Additionally, the CAA will collaborate with the BBAC to produce guidance for the safe oversight of balloon events. The AAIB has classified the CAA responses as ‘adequate-open’ and the recommendations will remain open until the CAA has delivered on its commitment. The AAIB recommendations and the CAA’s initial response are set out below:”

Source location

Response from Civil Aviation Authority
Page 3 · response
Published 9 August 2024

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 balloon-flying regulation, including possible regulation of amateur-built balloon design, construction, inspection, testing and competition flying.

Verbatim wording from the response

“Further to the proposed actions set out above, the CAA will continue its review of the regulation of balloon flying in the UK with a particular emphasis on whether there should be regulation of the design, construction, inspection and testing of amateur or home-built balloons and of competition balloon flying. The CAA will continue to work with domestic aviation stakeholders to mitigate the risks to public safety in accordance with the concerns highlighted in the Senior Coroner’s Report.”

Source location

Response from Civil Aviation Authority
Page 3 · response
Published 9 August 2024

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

Direct regulation of amateur-built balloon airworthiness is not considered necessary because safety will be enhanced through published measures and guidance.

Verbatim wording from the response

“The CAA has determined that the airworthiness of amateur built balloons can remain free of direct regulation, but flight safety will be enhanced with the addition of newly published measures for better managing design integrity, construction, inspection and testing (and consequent in-service performance) that will be promulgated by the CAA in the SN and links to additional guidance available on the CAA website. The CAA has previously published a mandatory Safety Directive (SD) (SD-2021/004: Non-Part 21 Amateur-Built Balloon and Airship Operational Limitations | UK Civil Aviation Authority) for amateur or home-built balloon limiting volumetric size of balloon envelope and occupancy, in keeping with the intent that these aircraft are for recreational, rather than for commercial use.”

Source location

Supplemental Response from Civil Aviation Authority 25.03.2025
Page 2 · response
Published 9 August 2024

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.2

  1. 1

    Issued directions preventing two DB-6R balloons from flying until identified unsafe conditions are addressed and independent airworthiness assessments completed.

    Stated by Civil Aviation AuthorityStated completedThe respondent said that this action was complete when they made their response on 9 August 2024.
  2. 2

    Conducted an initial review of UK balloon-flying regulation.

    Stated by Civil Aviation AuthorityStated completedThe respondent said that this action was complete when they made their response on 9 August 2024.

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

Issued directions preventing two DB-6R balloons from flying until identified unsafe conditions are addressed and independent airworthiness assessments completed.

Verbatim wording from the response

“The DB-6R type balloon involved in this tragic accident was an amateur-built balloon and designed specifically for competition flying. There are two further DB-6R type balloons recorded on the UK civil aircraft register. In October 2023 the CAA issued directions to stop both these aircraft from flying, based on the preliminary findings from the AAIB’s investigation into this accident. These directions will remain in place until the CAA is satisfied that the unsafe conditions identified in the AAIB’s final report have been satisfactorily addressed and the balloons are independently assessed as airworthy.”

Source location

Response from Civil Aviation Authority
Page 2 · response
Published 9 August 2024

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

Conducted an initial review of UK balloon-flying regulation.

Verbatim wording from the response

“Next Steps”

Source location

Response from Civil Aviation Authority
Page 2 · response
Published 9 August 2024

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

Data last updated 7 September 2026