Prevention of Future Deaths report 2021-0392

PENELOPE SCHOFIELD – HM SENIOR CORONER FOR AREA OF WEST SUSSEX 

INVESTIGATION INTO THE DEATHS OF REBECCA DOBSON, JASON HILL, STUART 

HILL, ELEANOR UDALL AND JONATHAN UDALL 

CIVIL AVIATION AUTHORITY RESPONSE TO A REPORT ON ACTION TO PREVENT 

OTHER DEATHS PURSUANT TO PARAGRAPH 7, SCHEDULE 5 OF THE CORONERS 

AND JUSTICE ACT 2009 AND REGULATIONS 28 & 29 OF THE CORONERS 

(INVESTIGATIONS) REGULATIONS 2013 

The UK Civil Aviation Authority (‘CAA’) responded to the Senior Coroner’s report on action to 

prevent other deaths pursuant to Regulation 29 of the Coroners (Investigations) Regulations 

2013 on 13 January 2022. 

In that response, the CAA confirmed that it was willing provide the Senior Coroner with a 

supplemental report on the progress of its work on or before 31 July 2022. 

The purpose of this report is to set out the work undertaken by the CAA since 13 January 

2022 and explain its future actions. 

Update 

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.  

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.  

1 EU Regulation 748/2012 Annex 1 Part 21 as retained (and amended in UK domestic law) under the European 
Union (Withdrawal) Act 2018. 

 
 
 
 
 
 
 The matters raised by the Senior Coroner will continue to be supported by the CAA and will 

form part of a longer-term strategy for rule changes to previously certified Rotorcraft. Any 

proposals put forward by the CAA will be based on the outcome of international safety 

studies and work conducted by the European Aviation Safety Agency (‘EASA’) and the U.S. 

Federal Aviation Authority (‘FAA’) which have both been based on the Rotorcraft Occupancy 

Protection Working Group (ROPWG) final report. 

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.  

Safety promotion in the U.S. has included inviting owners and operators of Rotorcraft, which 

have been certificated without compliance with later CRFS related requirements, to consider 

a partial solution to the safety risk, pending mandating any substantive rule change for all 

Rotorcraft, such as fitting tear resistant bladder inserts to fuel tanks.  

Next Steps  

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. 

The CAA’s recommended safety proposals will be based on the outcome of international 

safety studies and implementation work conducted by EASA and the FAA. 

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. 

2 EU Regulation 2015/640 on additional airworthiness specifications for a given type of operations Annex 1 
Part 26 as retained (and amended in UK domestic law) under the European Union (Withdrawal) Act 2018 

 
 
 
 
 
 
 
 
 
 
 
 
 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.  

The CAA will also implement a targeted promotion strategy to the Rotorcraft aviation 

community.  

CAA 

29 July 2022

PENELOPE SCHOFIELD – HM SENIOR CORONER FOR AREA OF WEST 

SUSSEX 

INVESTIGATION INTO THE DEATHS OF REBECCA DOBSON, JASON HILL, STUART 

HILL, ELEANOR UDALL AND JONATHAN UDALL 

CIVIL AVIATION AUTHORITY RESPONSE TO A REPORT ON ACTION TO PREVENT 

OTHER DEATHS PURSUANT TO PARAGRAPH 7, SCHEDULE 5 OF THE CORONERS 

AND JUSTICE ACT 2009 AND REGULATIONS 28 & 29 OF THE CORONERS 

(INVESTIGATIONS) REGULATIONS 2013 

The UK Civil Aviation Authority (‘CAA’) has considered the Regulation 28 report to prevent 

future deaths, including the following concerns raised by the Senior Coroner: 

1. The current requirements are laid out in EASA Certification Specification CS 27-952 for 
small rotorcraft and CS 29-952 for large rotorcraft, these regulations have been adopted by 
the UK. These requirements do not appear to be fit for purpose as they do not require retrofit 
to all previously certified rotorcraft.  

2. EASA issued a safety bulletin No 2017-18R1 (updated on January 2021) this document 
states “EASA consider that the installation of any of the modifications listed in Table 1 (of the 
SIB) for AS 350/ EC 130 in service aircraft will reduce the risk of post-crash fires and 
contribute to increase the occupant escape time after survival. However, there is no 
mandatory requirement for the CRFS to be fitted on aircraft.  

3. Flying in both small and large rotorcraft that have not been fitted with CRFS, either at 
initial build or as a retrofit, adds significant risk to the occupants in the event of a crash which 
disrupts the fuel system.  

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  

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.  

6. There are still aircraft flying in UK airspace without CRFS which poses a high risk to 
occupants of the aircraft.  

7. These aircraft also pose a risk to the general public who could find themselves in close 
proximity to an aircraft that has crashed where a fire occurs.  

 
 
 
 
 
 
 
 
 
 
 
 8. Serious consideration needs to be given to the issuing of an airworthiness directive to 
prevent further tragedies, similar to this case happening again.  

Introduction 

The CAA would first like to express its sincere condolences to the families, friends, and 

loved ones of those who lost their lives in this tragic accident. 

The CAA was not an Interested Person at these inquests. As such, it did not have access to 

the evidence. When preparing this response, with a view to implementing future actions, the 

CAA has relied on the National Transportation Safety Board Investigation (‘NTSB’) Report 

dated 14th January 2021, information obtained in its capacity as a member of the 

International Civil Aviation Organisation (‘ICAO’), as a former member of the European 

Aviation Safety Agency (‘EASA’)1 and analysis of incident reports received under the UK’s 

mandatory aviation occurrence reporting scheme2.   

The CAA has further relied on engagement with the UK distributor for the EC 130 aircraft 

and representatives from the wider UK rotorcraft industry in the aftermath of this accident.  

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’).  

Responsibility for overseeing the design and certification requirements for rotorcraft 

operating in the UK, including Certification Specifications CS 27-952 and CS 29-9523 was 

transferred to the CAA on 1 January 2021 and now forms part of this rule making 

programme.  

1 The UK CAA ceased its membership of EASA with effect from 31 December 2020. 
2 The CAA is responsible for receiving UK Mandatory Occurrence Reports in accordance with EU Regulation 
376/2014 as retained (and amended in UK domestic law) under the European Union (Withdrawal) Act 2018. 
3 EU Regulation 748/2012 Annex 1 Part 21 as retained (and amended in UK domestic law) under the European 
Union (Withdrawal) Act 2018. 

  
 
 
   
 
 
 
 
 
 
 Next Steps  

EASA continues work to reduce the risks associated with rotorcraft post-crash fires which 

forms part of the European Plan for Aviation Safety 2021-2025 and the Rotorcraft Safety 

Roadmap. The FAA also continues similar work in conjunction with the Rotorcraft Occupant 

Protection Working Group (‘ROPWG’)4. 

EASA issued Safety Information Bulletin (‘SIB’) 2017-18 (updated on 15th May 2019 and 14th 

January 2021) including recommendations for Crash Resistant Fuel System (‘CRFS’) 

modifications for AS 350/EC 130 rotorcraft. EASA subsequently published Terms of 

Reference for Rule Making Task (‘RMT’).0710 on 16 December 2021. The RMT is sub-

divided into two areas; design certification and proposed retrospective action, and future 

production and is focussed on improving survivability in the event of a rotorcraft accident, 

specifically in relation to post accident fires through the installation of CRFS and Crash 

Resistant Seats and Structures (‘CRSS’). The RMT will assess whether it is justifiable to 

retroactively apply the requirements for CRFS and CRSS to existing small CS-27 rotorcraft, 

small CS-27 Category A rotorcraft, and large CS-29 rotorcraft and/or to the future production 

of already type-certified rotorcraft.  

An important step in the RMT process will be for EASA to carry out a Regulatory Impact 

Assessment designed to assess any proposed (mandatory) rule making decision against the 

economic, environmental, proportionality and social impacts of that decision.  The UK will be 

represented during the EASA RMT review process by the British Helicopter Association 

(‘BHA’). Should EASA conclude a mandatory rule change is required, it will issue a Notice of 

Proposed Amendment to the relevant EU Regulations and the Acceptable Means of 

Compliance that accompany those regulations. 

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 

4 The ARAC Rotorcraft Occupant Protection Working Group was established in the US on 22 December 2015. 
This Group has issued safety recommendations for rotorcraft operating in the US, including “The FAA should 
require, in all rotorcraft, the installation (retrofit) of crash resistant fuel bladders that meet the requirements of 
the 50-foot fuel cell drop test in or out of structure, and that demonstrate a minimum of 250 lb puncture 
resistance”. 

 
 
 
  
 
 
 
 ROPWG, including requirements in all rotorcraft for the (retrofit) installation of crash resistant 

fuel bladders.  

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.  

Conclusion 

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.  

The CAA is willing provide the Senior Coroner with a supplemental report on the progress of 

this work on or before 31st July 2022.  

CAA 

13 January 2022