Prevention of Future Deaths reports · 2021
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 report | 7 Dec 2021 |
|---|---|
| Reference | 2021-0413 |
| Deceased | Jonathan Bayliss |
| Coroner | Katie Sutherland |
| Coroner area | North West Wales |
| Category | Accident at Work and Health and Safety related deaths · Service Personnel related deaths · Product related deaths · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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
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.
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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