Prevention of Future Deaths reports · 2021

Jonathan Bayliss

Regulation 28 report to prevent future deaths, reference 2021-0413, written 7 Dec 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report7 Dec 2021
Reference2021-0413
DeceasedJonathan Bayliss
CoronerKatie Sutherland
Coroner areaNorth West Wales
CategoryAccident at Work and Health and Safety related deaths · Service Personnel related deaths · Product related deaths · Wales prevention of future deaths reports (2019 onwards)
Sourcejudiciary.uk record · original PDF
Responses published1

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

Katie Sutherland,           Acting 
Senior Coroner for North West Wales 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO:   

The Rt. Honourable Ben Wallace, Secretary of State for Defence, Ministry of Defence                   

1 

CORONER 

I am Katie Sutherland, Acting Senior Coroner for North West Wales                                   

2 

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. 

3 

INVESTIGATION and INQUEST 

On 22/03/2018 the Senior Coroner commenced an investigation into the death of Jonathan 
Harvey Bayliss, aged 41.  The investigation concluded at the end of the inquest on 3rd December 
2021.  The conclusion of the inquest was a narrative. 

4 

5 

, crashed on the airfield at RAF Valley whilst conducting a 

CIRCUMSTANCES OF THE DEATH 
At 13:25 on 20th March 2018 a Royal Air Force Aerobatic Team (RAFAT) or “Red Arrows” Hawk 
aircraft TMk1/1A, tail number 
routine training exercise or sortie, which specifically included the performance of a Practiced 
Engine Failure After Take Off (PEFATO) manoeuvre. 
The aircraft had two persons on board, the pilot in the front cockpit and the engineer in the rear 
cockpit.  The pilot ejected 0.52 seconds before impact, sustaining a major injury.  The engineer, 
Corporal Jonathan Bayliss, did not eject and could not be ejected by the front seat-initiated 
ejection system and was declared dead at the scene. 
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.  – 

As identified by the Service Inquiry the cause of the crash was the aircraft stalling with 
insufficient height to recover.  It was also recognised that the aircraft may in certain 
circumstances stall without pre-stall buffet.  The pre-stall buffet remains the warning sign to the 
pilot of an impending stall.  The Service Inquiry recommended that urgent investigations be 
undertaken into the incorporation of an artificial stall warning capability in the Hawk Mk 1 to 
provide sufficient warning to pilots during low speed low altitude manoeuvring.  Whilst a 
feasibility assessment and cost benefit analysis have been undertaken a final decision is yet to 
be made as to whether or not the recommendations will be adopted.  The current out of service 
date for the said aircraft is at least 2030.  A number of RAF Aerobatic Team pilots will be flying 
every year (including a small number of new arrivals each year) and some circus engineers are 
still being flown in the said aircraft. 

Coroner's Office, Shirehall Street, CAERNARFON, Gwynedd, LL55 1SH 

 
 
 
 
 
 
         
 
 
 
 
 
      
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 It was recommended by the Service Inquiry that the Hawk TMk1/1A simulator training accurately 
reflects an aerodynamic model of a RAF aerobatic aircraft with smoke pod fitted, given that this 
may soon become the only Hawk Mk1/1A operated by the RAF and the current training simulator 
did not have the effect of a smoke pod fitted. Whilst there are developments in this respect there 
is no new synthetic trainer in place as yet. 

6 

ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe that you                                 
have the power to take such action. 

7 

YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, namely by 
1st February 2022. 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. 

8 

COPIES and PUBLICATION 

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

 Family 

1. 
2. 
3. 
4.  MOD (including RAF) 

 via Irwin Mitchell Solicitors 

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 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. 

9 

Dated 7th December 2021 

Signature_________________________ 
Acting Senior Coroner for North West Wales 

Coroner's Office, Shirehall Street, CAERNARFON, Gwynedd, LL55 1SH

Responses

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.

Response from Ministry of Defence (PDF)
SECRETARY OF STATE 
MINISTRY OF DEFENCE 
FLOOR 5, ZONE D, MAIN BUILDING 
WHITEHALL  LONDON  SW1A 2HB 

 7 March 2022 

Dear Ms Sutherland, 

Thank you for your letter of 7 December 2021 with which you enclosed a copy of 
your Regulation 28 report following the inquest into the tragic death of Corporal 
Jonathan  Harvey  Bayliss,  when  a  Royal  Air  Force  Aerobatic  Team  (RAFAT) 
Hawk T Mk1 aircraft crashed at RAF Valley on 20 March 2018.  I very much share 
your desire to prevent any recurrence of such a terrible event and I am grateful 
to you for bringing your findings to my attention. 

I understand that you heard evidence of how changes have been made following 
the  recommendations  of  the  Service  Inquiry.  These  include  a  review  of  flying 
training  publications,  pilot  currency  requirements  and  training  objectives  for 
Supernumerary Crew. In addition, key safety enhancements such as the creation 
of  a  RAFAT-focused  Air  Safety  Management  Team,  the  development  of  a 
Command Ejection capability, and the incorporation of a Cockpit Voice Recorder 
are already in train.  

Addressing  the  matters of  concern,  you  have  raised,  I  set  out below the  steps 
already been taken, and the further action planned. 

Matters of Concern 1 – “As identified by the Service Inquiry the cause of the 
crash  was  the  aircraft  stalling  with  insufficient  height  to  recover.  It  was  also 
recognised  that  the  aircraft  may  in  certain  circumstances  stall  without  pre-stall 
buffet. The pre-stall buffet remains the warning sign to the pilot of an impending 
stall. The Service Inquiry recommended that urgent investigations be undertaken 
into the incorporation of an artificial stall warning capability in the Hawk T Mk1 to 
provide  sufficient  warning  to  pilots  during  low-speed  low-altitude  manoeuvring. 
Whilst a feasibility assessment and cost benefit analysis have been undertaken 
a final decision is yet to be made as to whether or not the recommendation will 
be adopted.” 

Ms Sutherland 
HM Coroner’s Office 
Shirehall Street 
Caernarfon  
Gwynedd 
LL55 1SH 

 
 
 
 
 As you observe, further analysis and evaluation has been carried out after the 
sad death of Corporal Bayliss. I am pleased to say that this has concluded that 
the  incorporation  of  a  combined  ASWS  and  Angle  of  Attack  (AoA)  gauge  to 
enhance  stall  mitigation  is  feasible  and  proportionate.  The  RAF  will  now  take 
forward work to fit a combined ASWS and AoA gauge to the remaining RAFAT 
Hawk T Mk1 aircraft. This will require significant test and evaluation, which will 
be  a  high  priority.  The  exact  timelines  for  test,  evaluation,  development  and 
embodiment of the combined ASWS/AoA gauge will be determined this year. 

RAFAT  pilots  are  regularly  required  to  practice  and  demonstrate  their 
competence to complete a forced landing. The potential for airframe buffet to be 
masked by both the ‘smoke pod’ and when the landing gear is down has been, 
and will continue to be, a key focus of Hawk T Mk1 pilot training, combined with 
the ability to correctly assess a safe approach. The requirement to practise ‘live’ 
forced  landings  will  be  constantly  reviewed,  in-line  with  the  development  of  a 
combined  ASWS/AoA  gauge  and  as  future  RAFAT  Hawk  T  Mk1  synthetic 
developments are realised.  

Continued training and the application of both a combined ASWS and AoA gauge, 
will  collectively  aim  to  ensure  pilots  are  prepared  and  have  sufficient  warning 
during low-speed low-altitude manoeuvring.   

Matters  of  Concern 2  –  “It  was  recommended  by the  Service  Inquiry  that the 
Hawk  T  Mk1  simulator  training  accurately  reflects  an  aerodynamic  model  of  a 
RAF aerobatic aircraft with smoke pod fitted, given that this may soon become 
the only Hawk TMk1/1A operated by the RAF and the current training simulator 
did not have the effect of a smoke pod fitted. Whilst there are developments in 
this respect there is no new synthetic trainer in place as yet.” 

The  Ministry  of  Defence  (MOD)  recognises  that  the  Hawk  Synthetic  Training 
Facility at RAF Valley provides a generic platform for procedural and emergency 
training, for pilots that operate all types of Hawk T Mk1 aircraft. The retirement of 
the  ‘black’  Hawk  T  Mk1,  which  includes  736  Royal  Naval  Air  Squadron  and 
Number 100 Squadron, on 31 March 2022, provides an opportunity to deliver a 
bespoke Hawk Synthetic Training Facility for RAFAT pilots. The RAF has begun 
to identify potential RAFAT focused Hawk Synthetic Training Facility options, to 
be  co-located  with  the  Team at their new home  of  RAF Waddington.  The new 
Facility will correctly reflect the aerodynamic model of a RAFAT aircraft, with a 
smoke pod fitted. A detailed procurement timeline is being developed, with the 
expectation that the new Facility will be in place by 2025. 

Prior  to  this  being  completed,  it  is  important  that  RAFAT  pilots  can  train 
synthetically on an aircraft that is truly representative of the one they fly. MOD 
has therefore taken steps to ensure that, following the retirement of the ‘black’ 
Hawk  T  Mk1  aircraft,  the  current  Hawk  Synthetic  Training  Facility  software  is 
updated  to  closely  reflect  the  aerodynamic  model  of  a  RAFAT  aircraft  with  a 
smoke pod fitted. A period of test and evaluation will be required, although it is 
expected that the remodelling of the software to replicate a RAFAT Hawk T Mk1 

 
 
 
 
 
 aircraft, that enables the Hawk Synthetic Training Facility at RAF Valley, will be 
ready for use in 2023. Collectively, this will aim, as far as possible, to accurately 
replicate flying scenarios for our pilots.  

Thank  you  for  writing  to  me  about  these  important  matters.  I  hope  that  my 
response has demonstrated that the MOD has learned and will continue to learn 
lessons from this dreadful event. I hope too that Corporal Bayliss’ family will draw 
some comfort from the knowledge that your report has prompted action. As ever, 
my  thoughts  remain  with  them,  and  with  all  those  friends  and  colleagues  who 
continue to feel his loss so acutely. 

Yours sincerely, 

THE RT HON BEN WALLACE MP

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