Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0372, written 3 Nov 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Nov 2021 |
|---|---|
| Reference | 2021-0372 |
| Deceased | Steven Evans |
| Coroner | Caroline Saunders |
| Coroner area | Gwent |
| Category | Other related deaths · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 1 2 3 THIS REPORT IS BEING SENT TO: 1. Civil Aviation Authority (CAA) 2. British Gliding Association (BGA) CORONER I am Caroline Saunders, Senior Coroner for the Area of Gwent CORONER’S LEGAL POWERS I 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 INVESTIGATION AND INQUEST On 06/08/2019 an investigation was opened into the death of Steven Phillip Evans The investigation concluded at the end of the inquest on: 26/10/2021 when a jury determined the following: The conclusion of the inquest was recorded as Death by Accident The medical cause of death was: 1a) Polytrauma following a glider crash. 4 CIRCUMSTANCES OF THE DEATH The jury determined the following: On 27th July 2019, Steven Evans was preparing to fly his glider at South Wales Gliding club. Unfortunately, Steven’s failure to secure the tail plane correctly left the glider unsafe to fly. At the point of launch, the tail plane became dislodged, causing the glider to crash to the ground. Steven sustained serious injuries in the impact and despite receiving prompt clinical care, died on 1st August 2019 at the University Hospital of Wales. 5 CORONER’S CONCERNS During the course of the inquest, 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. 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. ACTION SHOULD BE TAKEN 6 In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. I should be grateful if the following information be provided to me: 1. Confirm whether any steps have or will be taken to enforce the use of radios in all aircraft and with groundcrews in gliding clubs. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely 29th December 2021, I, the Coroner, may extend this 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 necessary. 8 COPIES AND PUBLICATION I have sent a copy of my report to the Chief Coroner and the following Interested Person (s) • The family of Steven Phillip Evans. I am 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 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. 9 DATE 03/11/21 Signed Caroline Saunders Her Majesty’s Senior Coroner for the Area of Gwent.
2 responses 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.
8 Merus Court
Meridian Business Park
Leicester
LE19 1RJ
www.gliding.co.uk
Caroline Saunders
Coroners Court
Civic Centre
Godfrey Road
Newport
South Wales
NP20 4UR
3rd December 2021
RE STEPHEN PHILLIP EVANS
Thank you for your letter dated 3rd November 2021 and the accompanying Regulation 28
report that follows a tragic accident at South Wales gliding club near Usk.
The British Gliding Association is the UK governing body of sport gliding. The BGA provides
self-regulated support and guidance to gliding clubs and their individual members, all of
whom are required to comply with BGA operational regulations and associated
requirements. Regulated activity, for example airworthiness, is overseen by the BGA under a
CAA-issued approval. The BGA safety management system supports self-regulated and
regulated activity and the BGA works closely with the CAA on matters of aviation safety. The
BGA discussed this written response with the CAA.
The AAIB report published on 28 May 2020 details the accident investigation and
recommendations. The coroners Regulation 28 report dated 3 November 2021 asks for
details and a timetable of actions taken and to be taken.
Actions taken/to be taken:
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.
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.
3. In early March 2021, an amended BGA operational regulation for all launch signalling
(there are several launch methods in addition to aerotowing) stating “A reliable and
unambiguous signalling system shall be used for all launches” and the associated
requirement “Signalling – aerotow. Radio communication should be established
between the launching operation and the towing aircraft. Where radio communication
is not possible, another of the recognised methods of signalling to stop the launch
British Gliding Association Limited. Registered Office: As above Registered No: 422605 England
should be available” were proposed to and adopted by the membership and
subsequently published and promulgated by the BGA.
4. All gliding club officers responsible for launching and launch signalling have been
directed towards this online published information.
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.
6. Club site safety reviews support checking of the required signalling requirements and
standards.
7. During early June 2021, the AAIB confirmed to the BGA that the AAIB
recommendation had been adequately addressed.
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.
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.
10. Occurrence data relating to launch signalling will continue to be monitored to assess
where further action may be required.
Yours sincerely
Chief Executive Officer
CAROLINE SAUNDERS – HM SENIOR CORONER FOR GWENT INVESTIGATION INTO THE DEATH OF STEVEN PHILLIP EVANS CIVIL AVIATION AUTHORITY RESPONSE TO A REPORT ON ACTION TO PREVENT OTHER DEATHS PURSUANT TO REGULATIONS 28 & 29 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013 The Civil Aviation Authority (“CAA”) has carefully considered the report of the Senior Coroner to prevent future deaths and the concerns raised. The CAA makes the following comments in response: “Enforce the use of radios in all aircraft and with groundcrews in gliding clubs” Background and legal framework supporting gliding in the UK Gliding in the UK is underpinned by a combination of UK regulation, retained-EU regulation, CAA oversight and self-regulation. For the gliding community, the self-regulation is overseen by the British Gliding Association (“BGA”). The BGA is the governing body for the sport of gliding in the UK and publishes its own rules (“Operational Regulations”) and requirements which gliding clubs and their members must adhere. The BGA provides oversight of its members to ensure continuing high standards of safety. In order to achieve this, the BGA provides members with guidance on a variety of topics including operations. The BGA holds several CAA-issued approvals, which gives the BGA delegated authority in areas such as pilot training and airworthiness management of the UK glider fleet. The CAA oversees the BGA in these regulated activities to ensure safety standards are adequately maintained. Given the key operational role of the BGA in UK gliding, the CAA coordinated with BGA colleagues in our preparation of this response. Use of Radios During Glider Launching 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 20201, that aircraft operating under visual flight rules within Class G2 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. In response to AAIB Safety Recommendation 2020-012, the BGA agreed to review and update its Operational Regulations regarding launch signalling. The BGA advised that it would be updating its safety guidance, “Managing Flying Risk”, to clarify best practice around launch signalling. This revised publication was intended to provide the UK gliding community with a reliable and unambiguous guide to signalling for both aerotow and winch launches. On 7 June 2021, the AAIB assessed the BGA’s 1 AAIB final report for the investigation to Standard Cirrus 75, G-DDGX 2 Class G is outside controlled airspace; aircraft may fly when and where they like, subject to a set of simple rules. There is no legal requirement to notify Air Traffic Control of presence or intentions and no requirement to have a radio. 3 A section of airspace, regardless of its designated class, wherein the carriage and operation of a radio is mandatory. response to Safety Recommendation 2020-012 and concluded that it was “Adequate”4. Accordingly, this action was subsequently closed off by the AAIB and the BGA. 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. Timeline of actions taken (as advised by the BGA) 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. 3. 2. During early February 2021, the BGA wrote to club chairmen setting out the scope of the AAIB report, the findings / outcomes, BGA revised operational regulations and associated requirements and the intention to formally adopt those at the next AGM. In early March 2021, an amended BGA operational regulation for all launch signalling (there are several launch methods in addition to aerotowing) stating “A reliable and unambiguous signalling system shall be used for all launches” and the associated requirement “Signalling – aerotow. Radio communication should be established between the launching operation and the towing aircraft. Where radio communication is not possible, another of the recognised methods of signalling to stop the launch should be available” were proposed and adopted by the membership and subsequently published and promulgated by the BGA. 4. All gliding club officers responsible for launching and launch signalling have been directed towards this online published information. 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. 6. Club site safety reviews support checking of the required signalling requirements and standards. 7. During early June 2021, the AAIB confirmed to the BGA that the AAIB recommendation had been adequately addressed. 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. 4 An ‘Adequate’ assessment means the AAIB considers the response fully meets the intent of the Safety Recommendation and the action is expected to address the safety issue (What is a Safety Recommendation? - GOV.UK (www.gov.uk)). Planned CAA Actions 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. 2. The CAA and BGA will continue to monitor launch-related occurrence data to assess if further action is required. Conclusion The CAA endorses the actions taken by the BGA to improve its guidance for launch signalling and the steps it has taken to ensure that this is communicated to its members. The clearer guidance and increased awareness in the UK gliding community stemmed from the BGA’s actions in the wake of the tragic death of Mr Evans, should go a significant way in preventing similar accidents occurring in the future. As outlined above, the CAA will continue to be proactive and work closely with the BGA in this area to ensure that the clear messaging in the BGA’s updated guidance regarding launch signalling to is understood by all stakeholders in the UK gliding community. CAA 6 December 2021
See every Prevention of Future Deaths report matching Wales prevention of future deaths reports (2019 onwards), and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.