Lee Hoyle

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:

Chief Executive

Civil Aviation Authority
CAA House

45-59 Kingsway
London

WC2B 6TE

1 | CORONER

lam JACQUELINE LAKE, Senior Coroner, for the coroner area of NORFOLK

2 | CORONER’S LEGAL POWERS

| make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

3 | INVESTIGATION and INQUEST

On 14 March 2014 | commenced an investigation into the deaths of:

Cart Alan Dickerson, Age: 36 years The investigation concluded at the end of the
inquest on 15 January 2016. The'conclusion of the inquest was medical cause of death:
1a) Head and Chest injuries and short-form conclusion: Accidental Death

‘Edward Enda Haughey — Lord Batlyedmond, Age: 70 years, The investigation concluded
at the end of the inquest on 15 January 2016. The conclusion of the inquest was
medical cause of death: ta) Head injuries and short-form conclusion: Accidental Death.

Lee Christopher Hoyle, Age: 45 years. The investigation concluded at the end of the
inquest on 15 January 2016. The conclusion of the inquest was medical cause of death:
1a) Head and Chest injuries and short-form conclusion: Accidental Death.

Declan Joseph Small, Age: 42 years. The investigation concluded at the end of the
inquest on 15 January 2016. The conclusion of the inquest was medical cause of death:
1a) Head and Chest injuries and short-form conclusion: Accidental Death.

4 | CIRCUMSTANCES OF THE DEATH

On 13 March 2014 all four men were on board an Augusta Westland AW139 helicopter,
G-LBAL. It was dark and foggy. Shortly after take-off the helicopter impacted with the
ground near Gillingham, Norfolk. All four men died as a result of their injuries.

5 | CORONER'S CONCERNS

During the course of the inquest the evidence revealed matters giving rise to concern. In
my opinion there is a risk that future deaths will occur unless action is taken. In the
circumstances it is my statutory duty to report to you.

The MATTERS OF CONCERN are as follows. —

(1) On the 13 March 2013 at the time of take-off, it was dark and there was fog. Visibility
was therefore limited. There are Regulations in place which would have prevented a
take-off in these conditions had this been a departure from a licensed aerodrome and
had this been a commercial venture.

(2) Because this was a departure from a non-commercial venture and take-off was from
an unlicensed aerodrome, those Regulations do not apply. ’
(3) It is understood there was an accident in the 1990s in similar circumstances and
operating under private category rules, as a result of which the Irish Air Accident
Investigation Unit (AAIU) published a report and noted that “The flight used a navigation
approach procedure that would not meet the standards required by the UK Authorities
for public transport operations. However, this was not illegal because the flight was
operated under private category rules.”

| (4) The AAIU made recommendations including that “The UK CAA should consider the
establishment of a special category for the operation of corporate aviation”. It is
understand this recommendation was accepted but no special category was established.
Guidance was provided but not regulation.
(5) New European aviation legislation affecting the non-commercial operation of aircraft
will come into effect in the UK from 25 August 2016 which will introduce new regulations
for the management and operation of this type of aircraft.
(6) It is understood the CAA has decided a broader and deeper review of Instrument
Flight Rules outside controlled airspace in general is necessary and that a project plan is
being developed to address the issues, develop recommendations and suggested
courses of action. There is liaison with the European Aviation Safety Agency “in taking
forward any such changes’.
(7) It is of concern that despite the previous accident in the 1990s and this accident, a
departure from a non-commercial venture and an unlicensed aerodrome is not covered
by the equivalent regulation as a departure from commercial and licensed premises.

‘ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe your
organisation has the power to take such action.

You are under a duty to respond to this report within 56 days of the date of this report,
namely by 29 March 2016. I, the Coroner, may extend the period.

Your response must contain details of action taken or proposed to be taken, setting out
the timetable for action. Otherwise you must explain why no action is proposed.

COPIES and PUBLICATION

| have sent a copy of my report to the Chief Coroner and to the following Interested
Persons:

Family:

Legal:

Stewart Law LLP

JWK Solicitors

Slater Gordon (UK) LLP
Clyde & Co

Holman Fenwick Willan LLP

| have also sent a copy to the AAIB who may find it useful or of interest.

| am also under a duly to send the Chief Coroner a copy of your response.

YOUR RESPONSE '

The Chief Coroner may publish either or both in a complete or redacted or summary
form.

He may send a copy of this report to any person who he believes may find it useful or of
interest. You may make representations to me, the coroner, at the time of your
response, about the release or the publication of your response by the Chief Coroner.

2 February 2016 dys Veevevenseseceanesearseseyeeyeen Paveenee
. Jacqueline Lake LL.M
Senior Coroner for Norfolk Area

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:

Chief Executive

Civil Aviation Authority
CAA House

45-59 Kingsway
London

WC2B 6TE

1 | CORONER

lam JACQUELINE LAKE, Senior Coroner, for the coroner area of NORFOLK

2 | CORONER’S LEGAL POWERS

| make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

3 | INVESTIGATION and INQUEST

On 14 March 2014 | commenced an investigation into the deaths of:

Cart Alan Dickerson, Age: 36 years The investigation concluded at the end of the
inquest on 15 January 2016. The'conclusion of the inquest was medical cause of death:
1a) Head and Chest injuries and short-form conclusion: Accidental Death

‘Edward Enda Haughey — Lord Batlyedmond, Age: 70 years, The investigation concluded
at the end of the inquest on 15 January 2016. The conclusion of the inquest was
medical cause of death: ta) Head injuries and short-form conclusion: Accidental Death.

Lee Christopher Hoyle, Age: 45 years. The investigation concluded at the end of the
inquest on 15 January 2016. The conclusion of the inquest was medical cause of death:
1a) Head and Chest injuries and short-form conclusion: Accidental Death.

Declan Joseph Small, Age: 42 years. The investigation concluded at the end of the
inquest on 15 January 2016. The conclusion of the inquest was medical cause of death:
1a) Head and Chest injuries and short-form conclusion: Accidental Death.

4 | CIRCUMSTANCES OF THE DEATH

On 13 March 2014 all four men were on board an Augusta Westland AW139 helicopter,
G-LBAL. It was dark and foggy. Shortly after take-off the helicopter impacted with the
ground near Gillingham, Norfolk. All four men died as a result of their injuries.

5 | CORONER'S CONCERNS

During the course of the inquest the evidence revealed matters giving rise to concern. In
my opinion there is a risk that future deaths will occur unless action is taken. In the
circumstances it is my statutory duty to report to you.

The MATTERS OF CONCERN are as follows. —

(1) On the 13 March 2013 at the time of take-off, it was dark and there was fog. Visibility
was therefore limited. There are Regulations in place which would have prevented a
take-off in these conditions had this been a departure from a licensed aerodrome and
had this been a commercial venture.

(2) Because this was a departure from a non-commercial venture and take-off was from
an unlicensed aerodrome, those Regulations do not apply. ’
(3) It is understood there was an accident in the 1990s in similar circumstances and
operating under private category rules, as a result of which the Irish Air Accident
Investigation Unit (AAIU) published a report and noted that “The flight used a navigation
approach procedure that would not meet the standards required by the UK Authorities
for public transport operations. However, this was not illegal because the flight was
operated under private category rules.”

| (4) The AAIU made recommendations including that “The UK CAA should consider the
establishment of a special category for the operation of corporate aviation”. It is
understand this recommendation was accepted but no special category was established.
Guidance was provided but not regulation.
(5) New European aviation legislation affecting the non-commercial operation of aircraft
will come into effect in the UK from 25 August 2016 which will introduce new regulations
for the management and operation of this type of aircraft.
(6) It is understood the CAA has decided a broader and deeper review of Instrument
Flight Rules outside controlled airspace in general is necessary and that a project plan is
being developed to address the issues, develop recommendations and suggested
courses of action. There is liaison with the European Aviation Safety Agency “in taking
forward any such changes’.
(7) It is of concern that despite the previous accident in the 1990s and this accident, a
departure from a non-commercial venture and an unlicensed aerodrome is not covered
by the equivalent regulation as a departure from commercial and licensed premises.

‘ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe your
organisation has the power to take such action.

You are under a duty to respond to this report within 56 days of the date of this report,
namely by 29 March 2016. I, the Coroner, may extend the period.

Your response must contain details of action taken or proposed to be taken, setting out
the timetable for action. Otherwise you must explain why no action is proposed.

COPIES and PUBLICATION

| have sent a copy of my report to the Chief Coroner and to the following Interested
Persons:

Family:

Legal:

Stewart Law LLP

JWK Solicitors

Slater Gordon (UK) LLP
Clyde & Co

Holman Fenwick Willan LLP

| have also sent a copy to the AAIB who may find it useful or of interest.

| am also under a duly to send the Chief Coroner a copy of your response.

YOUR RESPONSE '

The Chief Coroner may publish either or both in a complete or redacted or summary
form.

He may send a copy of this report to any person who he believes may find it useful or of
interest. You may make representations to me, the coroner, at the time of your
response, about the release or the publication of your response by the Chief Coroner.

2 February 2016 dys Veevevenseseceanesearseseyeeyeen Paveenee
. Jacqueline Lake LL.M
Senior Coroner for Norfolk Area

Office of the General Counsel 3 MAR 2016

Civil Aviation
Authority

BY POST & EMAIL: norfolk@coroner.norfolk.gov.uk

Ms Jacqueline Lake LL.M

Senior Coroner for the Norfolk Area
69-75 Thorpe Road

Norwich

Norfolk NR1 1UA

1 March 2016

Dear Madam
Norfolk Coroner Report to Prevent Further Deaths dated 2 February 2016

Matters of Concern arising from Inquest into accident to AgustaWestland AW139 G-LBAL
on the 13 March 2014

Thank you for the opportunity to respond to the concerns arising from the Inquest into the
accident to AgustaWestland AW139 helicopter G-LBAL. The Civil Aviation Authority (CAA) fully
understands and acknowledges the importance of identifying, wherever possible, appropriate
measures to prevent further deaths and our role and responsibilities in applying these.

We have closely followed the circumstances surrounding this unfortunate accident and supported
the Air Accidents Investigation Branch (AAIB) during their investigation. Their report was
reviewed carefully and the findings are reflected in your concerns. In addition, and following other
safety recommendations relating to both helicopter and aeroplane accidents, we have instigated a
thorough review of the rules applicable to flights being performed under Instrument Flight Rules
(IFR) outside controlled airspace through our Safety Review Committee. This will cover several of
the issues raised in relation to this accident as well as the wider context of current and emerging
practices and is scheduled to be completed by 30 September 2016.

In reviewing the concerns that have been detailed in your report, we will now provide an overview
of measures that are being taken to address them. Some of these measures are part of a move
from UK national aviation regulations to European regulations which for this type of helicopter and
operation will come into force on 25 August 2016 in all Member States across Europe.

Measures to prevent further deaths

Flight operations
Before taking off, the pilot of a helicopter on a private flight must be satisfied ofa . number of
matters including that—

e the flight can safely be made,

¢ the aircraft is in every way fit for the intended flight

Civil Aviation Authority
CAA House K5 45-59 Kingsway London WC2B6TE  www.caa.co.uk
Telephone 020 7453 6160 Fax 02074536175 kate.staples@caa.co.uk

e the helicopter is capable of safely taking off and reaching and maintaining a safe height,
having regard to the performance of the helicopter in the conditions to be expected on the
intended flight; and any obstructions at the place of departure.

in making this assessment, the commander must take account of any conditions or restrictions in
the helicopter's flight manual. The regulations in place at the time of the accident pertaining to
that flight were contained in the Air Navigation Order 2009 (ANO) and the Rules of the Air
Regulations 2007.

In contrast to Commercial Air Transport (CAT) or Public Transport operations, private and aerial
work flights are allowed more operational flexibility including a greater possible choice of take-off
and landing sites. With that flexibility, however, comes the potential for increased risk and a need
to exercise commensurate standards of airmanship, decision-making and hazard assessment.
This is of particular importance when planning to depart IFR, in Instrument Meteorological
Conditions (IMC) or at night, from a site where instrument procedures and aids are not available
or established. Aerodrome Operating Minima (AOM) should be established for each location
where a private aircraft is intended to be operated to or from under IFR using the recognised
method of compliance. In this instance, the procedures detailed in the Joint Aviation Authorities
(JAA) requirements JAR-OPS 3 were the expected standard for private helicopter operations as
described in the UK Aeronautical Information Publication (AIP).

Recognising that interpreting and fully assimilating these requirements from the ANO is not
immediately straightforward and in an effort to address this, we published a Safety Notice SN-
2014/006 — Private and Aerial Work Helicopter Operations - Guidance on Aerodrome Operating
Minima for IFR Departures shortly. after the accident. This document provides explanation and
guidance for private operators to help them establish their AOM and better understand the
requirements. Nevertheless, the onus remains firmly on the pilot to ensure that any flight can be
conducted safely.

As previously mentioned, in August this year operational rules in the ANO for flights of the sort in
question will be replaced by rules in Commission Regulation (EU) No. 965/2012 — the Air
Operations Regulation. The UK Rules of the Air 2007 have already been largely replaced by the
European Standardised Rules of the Air (SERA). Although these new regulations cover the same
obligations for the safe conduct of flight, their presentation and scope provide for an improved
level of detail to the previous method.

in advance of this change, we are reviewing the contents of the Safety Notice and will re-issue it
by the end of March'with enhanced information and links to the Air Operations Regulation. This
provide operators with a more logical and standard form of meeting their obligations and help the
transition to the new regulations. At the same time, we will also update another Safety Notice
regarding “the Flight Planning and Safe Flight Execution” to introduce additional risk assessments
and safety strategies.

The results of our wider review into IFR outside controlled airspace will be used to address any
shortcomings and provide a basis for working with other agencies such as the European Aviation
Safety Agency (EASA) to progress any necessary changes in regulations or guidance. This
review is scheduled to be completed by 30 September 2016. The improvements in technology
and availability of IFR flight to a wider section of the general aviation community requires that
traditional regulation be revisited and updated to ensure that necessary levels of safety are
retained or improved.

Management of operations

The concerns in your report note that following the investigation into the previous helicopter
accident affecting this operator, the Irish Air Accident Investigation Unit (AAIU) recommended that
“The UK CAA should consider the establishment of a special category for the operation of
corporate aviation’. In the responses to the AAIU, we accepted this recommendation and work

was started on developing such a category. However, at the same time a programme of work
was being initiated in the JAA to establish requirements for such corporate type operations and a
decision was made to consolidate resources on a European solution and not pursue a tone
national one. In the meantime, we produced CAP 686 — Corporate Code of Practice (Helicopters)
which sought to provide guidance and structure to operators of corporate helicopters. There was
no obligation to comply with this guidance but it was considered as best practice. The JAA
initiative transferred to EASA before being completed and has now emerged in the Air Operations
Regulation. This requirement is in line with international standards and is probably the first such
set of regulations adopted worldwide. As the development'was extended with the change of
responsibility, we updated CAP 686 in 2009 to bring it more into line with the developing
regulations.

One of the driving elements of the JAA work was to establish a set of requirements for business
or corporate flying to meet in order to provide an enhanced level of safety over pure private flying
and closer to that of CAT but in a graduated and proportionate way. Unlike CAT, where
passengers pay for a transport experience and expect high levels of safety, passengers and flight
crew in business aviation can be obligated to fly under their terms of employment. This can
introduce pressure to fly and poor decision making when otherwise they would not attempt it. As
noted by the AAIB, this situation cannot be managed by regulation alone and we are actively
involved with industry and international organisations to find more effective solutions. This will
undoubtedly involve education and improved human factors training and to support this we are
planning to hold a seminar later this year on safety culture for the commercial helicopter industry.
Within the industry itself, this subject is also being addressed by the Corporate Aviation Safety
Executive (CASE) with whom we work.

From 25 August 2016, operators of non-commercial complex aircraft, such as G-LBAL, will be
required to make a declaration to the national Competent Authority (CAA for the UK) declaring
that their organisation meets all the relevant requirements in the Air Operations Regulation. This
is the first time that such measures have been applied under law and will require operators to
meet stringent standards including having an accountable manager, an effective management
system and procedures properly documented in their own operations manual detailing how all
flights are to be managed and flown. The CAA will be required to conduct oversight of these
organisations to ensure that they are compliant with the regulations. This is a level of contact that
has not hitherto been required but is expected to help identify and better manage the risks in this
sector of aviation. Although the new regulations will impose a higher level! of effort for the
operators, it is anticipated that this will also engender a more professional and safety conscious
approach to their operations and an overall increase in safety.

Summary

We share the concerns raised within the AAIB and your reports together with other occurrences
that have had similar causes. To that end, we are conducting a review of the rules appertaining to
flight under IFR outside controlled airspace and will take any necessary action to improve the
tegulations and the safety of such operations. As previously noted, this review is scheduled to be
completed by 30 September 2016.

We will renew our Safety Notices and update the associated AIP details to provide enhanced
’ information for pilots and operators in advance of the transition to the European Air Operations
Regulation. This is scheduled to be completed by the 31 March 2016.

We believe that the new European regulations for operators of aircraft such as G-LBAL to be
introduced in August 2016 will introduce a significant change to the way such operations are
managed and overseen. The increased administrative burden of requirements will have an impact
on such operations but it is anticipated that this will have a positive effect on safety and due to the
required declaration process clearer identification of operators to the competent authorities
providing the regulatory oversight.

Conclusion

The safety of aviation relies heavily on the conduct of operators and pilots to carry out their duties
appropriately. Regulations provide a framework for safe operations but cannot guarantee that all
flights will be achieved safely. Part of our Strategic Plan is to “enhance aviation safely
performance by pursuing targeted and continuous improvements in systems, culture, processes
and capability” and we will apply these principles in taking forward measures to prevent further
deaths in circumstances such as those detailed in your report.

We believe that the measures discussed above will make significant improvements and help to
achieve the aim.

Yours faithfully

Kate Staples :
General Counsel and Secretary to the Civil Aviation Authority