Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0307, written 24 Aug 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Aug 2023 |
|---|---|
| Reference | 2023-0307 |
| Deceased | Jonathan Mann and Margaret Costa |
| Coroner | Samantha Marsh |
| Coroner area | Somerset |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Civil Aviation Authority of Canary Wharf London E14 4HD. 2. Military Aviation Authority of Regulatory Publications Team #5102 Level 1 Juniper Building MOD Abbey Wood (North) Bristol BS34 8QW United Kingdom 1 CORONER I am Mrs Marsh, Senior Coroner for the coroner area of Somerset. 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 the 16th September 2021, my predecessor, Mr Tony Williams, commenced an investigation into the deaths of Jonathan Paul Bost Mann, aged 69 and Margaret Jean Costa, aged 74. The investigation concluded at the end of the inquest on 22nd August 2023. The conclusion of the inquest was: Jonathan Paul Bost Mann’s death was recorded as a death by Misadventure, with the medical cause of his death being given as: Ia) Multiple Injuries Margaret Jean Costa’s death was recorded as an Accidental Death, with the medical cause of her death being given as: Ia) Multiple Injuries Mr Mann and Mrs Costa died within the same incident and so their inquests were heard together. 1 4 CIRCUMSTANCES OF THE DEATH Mr Mann had held his pilot’s licence since 2000. He had owned his plane, a Cap- 10-B since 2014. He had a current and valid private pilot’s licence which permitted him to fly under Visual Flight Rules (“VFR”). Mr Mann did not possess the skills, experience of ability to fly in cloud; he could only fly in clear skies as he was unable to “instrument fly” and could only fly by reference to what he could see out of the window. His passenger on the day, Mrs Costa, had no flying experience and did not possess a pilot’s licence. She had no active part in the events that unfolded. On 12th August 2021 at 08:04 Mr Mann took off from Watchford Farm, Yarcombe near Taunton, Somerset with Mrs Costa on a planned pleasure trip for the day to the Isle of Sicily. There was no evidence that Mr Mann had used recognised aviation sources to check the weather prior to departure, instead obtaining weather information from news weather-based apps. At around 09:10 the weather conditions deteriorated and so Mr Mann turned back. At around 10:10 found himself at an altitude of 7,500ft flying above cloud, He was not qualified to fly through cloud. He contacted the Distress and Diversion Cell (“D&D Cell”) on the emergency frequency for assistance. Mr Mann began to descend to a lower altitude but he appears to have become spatially disorientated due to the extreme stress of flying in the weather conditions in which he found himself and when he emerged from cloud, the ground was not where he expected it to be. The plane collided with a large oak tree at Lower Colley Farm, Buckland St Mary near Chard, Somerset and was destroyed on impact with both the pilot and passenger being thrown from the wreckage and suffering catastrophic injuries that were incompatible with life. 5 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 could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – The D&D cell did not request or receive any critical information about (i) (ii) (iii) the pilot’s capabilities (i.e that he could not instrument fly and/or fly in cloud); the plane’s capabilities (i.e. that it was not equipped to allow the pilot to instrument fly) the weather conditions at the selected diversion aerodrome (to ensure that the weather was more favourable to the conditions at the home aerodrome). Checklists and aide memoires were not used by those on the ground and, consequently, there was a lack of knowledge and/or appreciation of the unsuitability of the selected airport (Exeter) as a viable diversion destination; despite it being the closest in geographic proximity. There was no immediate requirement for urgent assistance as the pilot had fuel for a further 1.5hours of 2 flying time and so there was sufficient time for key information to be obtained, analysed and shared between the D&D Cell and Exeter ATC. The incorrect assumptions, misunderstandings and miscommunications between the D&D Cell and Exeter Air Traffic Control limited the ability of those on the ground to provide adequate assistance to a pilot in distress. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation 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 19th October 2023. 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: (i) (ii) (iii) (on behalf of the Mann Family) (on behalf of the Costa Family) The Air Accident Investigation Bureau (AAIB) I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. 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. 9 24th August 2023 3
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