Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0001, written 2 Jan 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Jan 2019 |
|---|---|
| Reference | 2019-0001 |
| Deceased | Alexandre Parr |
| Coroner | David Ridley |
| Coroner area | Wiltshire and Swindon |
| Category | Service Personnel related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
David Ridley HM Senior Coroner for Wiltshire and Swindon REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Richard Moriarty Esq. Chief Executive Civil Aviation Authority CAA House 45-59 Kingsway LONDON WC2B 6TE 1 CORONER lam David Ridley, HM Senior Coroner for Wiltshire and Swindon 7) 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. http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http:/Awww. legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On the 12 July 2016, | commenced an investigation into the death of Fit. Lt. Alexandre Jay Parr and an Inquest was opened by Assistant Coroner, lan Singleton on the 21 July 2016. The Inquest, which was held with a Jury, was concluded on the 12 December 2018 and the Jury determined that the medical cause of death was 1a) Multiple traumatic injuries b) Crash landing of aircraft. In box 3 in the Record of Inquest the Jury in relation to the mechanism of death recorded as regard how, when and where Alex came by his death the following: - On Friday 8th July 2016 Ft. Lt. Alexandre Jay Parr was taking part in a training flight in a Yak 52 aircraft. During the flight the engine suffered fuel starvation causing loss of engine power. After various attempts to restart the engine a forced landing was deemed necessary. At 10.34 am the aircraft crashed adjacent to a farm strip in Dinton resulting in the death of Alexandre Jay Parr who was pronounced dead at the scene at 11.20 am. An additional narrative conclusion expanding of the mechanism of death was recorded by the Jury in Box 4 of the Record of Inquest as follows: - NARRATIVE CONCLUSION The Jury believe that the late decision to change the landing site from a wheat field to a farm strip probably contributed to the accident and death of Alexandre Jay Parr. Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP Tel 01722 438900 | Fax 01722 332223 CIRCUMSTANCES OF THE DEATH The circumstances relating to the crash 1 mile north of Dinton close to a Farm strip has already been the subject of a comprehensive investigation undertaken by the Air Accident Investigation Branch which resulted in their bulletin 11/2017 in respect of which | am sure you will already have a copy. In accordance with the decision of the Administrative Court in R (on the application of the Secretary of State) -v- Senior Coroner for Norfolk and the British Airline Pilots Association [2016] EWHC 2279 on the basis that there was no credible evidence or evidence at all that the investigation into this incident was incomplete, flawed or deficient the Jury were directed to record their findings so as not to be inconsistent withthe findings made by the AAIB Investigators. CORONER’S CONCERNS During the course of the inquest the Jury and myself heard evidence from the 2 AAIB Investigators, MK Engineering) and (Pilot) in relation to their investigation and findings and additionally in relation to their recommendations. The Court also heard that tests were also undertaken to establish a cycle rate for the use of the fuel primary pump in the case of an emergency. The 3 areas of concern can be summarised as follows: - a) OVERHAUL OF ENGINE. This particular aircraft G-YAKB a YAK 52 was manufactured in 1992 and had an initial manufacturer's life span of 20 years. The life span was extended in 2013 for a period of 10 years following an overhaul carried out in accordance with CAA Regulations. The manufacturer's specification was that an overhaul of the engine was required at 750 hours. At the time of the crash even though the aircraft was approximately 24 years old the original piston engine had only logged 516 hours. | understand having heard Mr. Hawkins that currently there is a CAA leaflet number 70/80 that requires a 20-year calendar limit in relation to an engine overhaul irrespective as to whether or not the manufacturer's specified number of hours usage has been reached however leaflet 70/80 only applies to engine with more than 400 horsepower. | understand from the AAIB investigators that your organisation is conducting a review as to whether or not this should be extended to all piston engines. Whilst accepting the evidence of the AAIB that there was not an issue with this particular engine this observation made by the AAIB investigators made sense to me from a safety perspective and | would be grateful if you could please advise me as regards the state of this review and ultimately notify me as to whether leaflet 70/80 is to be extended or how the issue is to be resolved through other means. If there is to be no change then please indicate why and how you reached that decision. b) SAFETY HARNESS. This was the subject of a formal safety recommendation made by the AAIB investigators number 2017/021. | was supplied with a copy of the CAA follow-up action on the occurrence report and additionally | have seen a safety notice (SN2018/005) issued on the 30 July 2018. | would be grateful for confirmation as to whether or not the safety notice is the culmination of the CAA addressing the AAIB safety recommendation or whether or not further action is to be taken and if so what action is to be taken. c) THE USE OF THE FUEL PRIMER PUMP IN AN EMERGENCY. Whilst the primer pump may not have originally been specifically designed for use in an emergency | understand from the AAIB investigators that the manufacturer’s state in their manual that the pump can be used in an emergency, for example should the fuel pump fail. Regrettably, | also understand that the manufacturer's manual gives no indication as regards the cycle rate for the use of the primer pump in these emergency circumstances. When G-YAKB experienced a loss of engine power and Alex sitting in the front cockpit used the primer pump he was pumping at a rate of 1 cycle every 3 to 4 seconds. This was found to be insufficient to provide sufficient fuel to the engine in order to regain power. When the AAIB investigators attempted to ascertain a sufficient cycle rate they found that a significantly higher rate was required in order to provide sufficient fuel to the engine. That rate was 1.3 cyctes per second. | am unclear, aside Wiitshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP Tel 01722 438900 | Fax 01722 332223 from the findings of the AAIB report, as to how this potentially important piece of information can be communicated to the YAK user population in the United Kingdom. It seems to me that this information is important and may be unknown to many YAK pilots and | am concerned that if the intention is that YAK 52 pilots are required to read this AAIB Report concerning this incident, then this particular piece of information may be missed if a pilot does not research this particular incident. | would respectfully ask you to consider how best to communicate this information to the wider YAK pilot community in the United Kingdom. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 27 February 2019. |, 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 [havi nta copy of my report to the Chief Coroner and to the following Interested Persons aaa: Hogan Lovells representing the family, at Finch Consulting for Qinetiq. Governmental Legal Department for the MOD and Mr. Calverley. | | have also sent it to , Senior Investigators at the Air Accident Investigation Branch, Farnborough who may find it useful or of interest. lam also under a duty to send the Chief Coroner a copy of 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. Dated 2 January 2019 . ho a TN David W. G. Ridley HM Senior Coroner for Wiltshire and Swindon Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP Tel 01722 438900 | Fax 01722 332223
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
D W G RIDLEY - SENIOR CORONER FOR WILTSHIRE AND
SWINDON
INVESTIGATION INTO THE DEATH OF FLT. LT. ALEXANDRE JAY PARR
CIVIL AVIATION AUTHORITY RESPONSE TO A REPORT ON ACTION TO PREVENT
OTHER DEATHS PURSUANT TO REGULATION 29 OF THE CORONERS
(INVESTIGATIONS) REGULATIONS 2013
The Civil Aviation Authority (CAA) has considered carefully the report of the Senior Coroner
to prevent future deaths and its response to the three areas in question is set out below:
A) Overhaul of Engine
The CAA’s requirements for all National Permit to fly Aircraft[1] now includes an expectation
that appropriate calendar periods for engine overhaul should complement or replace flying
hour-related maintenance tasks in the aircraft maintenance programme for individual aircraft
in the case of low utilisation. Any such calendar period(s) for engine overhaul are expected
to be determined by consideration of manufacturers
recommendations, usage,
environmental conditions (e.g. hangarage) and type of operation (safety risk).
The CAA has reviewed the UK accident safety data related to engine failure on YAK-52
aircraft and confirmed that none of the reports (five in total between January 2003-January
2019) cited engine age or lack of maintenance as a contributory factor. Additionally, the
CAA has reviewed recent overhaul data from a specialist Approved Organisation in Hungary
which is responsible for the maintenance overhaul of 40-50 of this engine type per year. This
review concluded that conventional (flight hour-related) component wear is the main reason
for replacement at overhaul, rather than age.
Additionally, Mandatory Permit Directive, MPD 1998-001R2, which limits the life of the YAK-
52 engine to 2250 flying hours has been superseded by a new MPD 2019-002 which
reinforces the replacement lifespan of this engine and now also ensures owner/operators are
aware of the need for a maximum calendar life, even if engine utilisation (flying hours) is low.
As a consequence of the review conducted by the CAA and the findings set out above, the
applicability of Leaflet 70-80 does not need to be extended.
B) Safety Harness
As part of the follow-up action to AAIB Recommendation 2017-021 (11-2017) the CAA
consulted with GA industry on the potential for mandating a replacement life (or lives) for
safety harnesses on all GA aircraft. Following the outcome of this consultation, the CAA
concluded that mandating a single life for the wide variety of GA aircraft configurations and
types of utilisation may, in fact be counter-productive, in some cases serviceable harnesses
requiring replacement and non-servicable harnesses continuing to be utilised. Instead of
mandating a replacement life (or lives) for safety harnesses, the CAA will improve the
current guidance material to enable a more informed decision to be made by both
maintenance organisations and aircraft owners, on an ongoing use basis as to when the
replacement of individual harness installations is appropriate.
The CAA is working with industry stakeholders on enhancing the existing Safety Notice
2018/005 to emphasise the need to take into account any manufacturer’s specified
‘calendar’ lives for safety harnesses as well as to provide more guidance on individual
aircraft-specific harness assessments/checks that could lead to withdrawal from use before
such calendar periods expire. The CAA intends to publish a revised Safety Notice in the
second quarter of 2019.
C) The Use of The Fuel Primer Pump in an Emergency
The CAA has established there are a number of different technical and human factors that
would have an impact on the effectiveness of utilisation of the Fuel Primer Pump, particularly
in emergency situations where it’s use may, in certain circumstances be counter-productive.
For this reason, the CAA has concluded it would not be appropriate for CAA to request the
[1] British Civil Airworthiness Requirements 553, Section A, Chapter A3-7, Issue 8 incorporating amendment 1,
15 December 2017
manufacturer to specify a rate. The use of the YAK Fuel Primer Pump in the event of a loss
of power, will be included for discussion at the next CAA led YAK & Nanchang ‘Continuing
Airworthiness Forum’ due to be held by the end of the second quarter of 2019 and attended
by key owners and maintainers of the affected types. The Group will consider whether
additional guidance to UK users would be useful and effective.
Civil Aviation Authority
Safety & Airspace Regulation Group
General Aviation Unit
18 February 2019
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