Prevention of Future Deaths reports · 2024

Shaun Crossfield

Regulation 28 report to prevent future deaths, reference 2024-0054, written 2 Feb 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report2 Feb 2024
Reference2024-0054
DeceasedShaun Crossfield
CoronerAngela Brocklehurst
Coroner areaWest Yorkshire Western
CategoryOther related deaths
Sourcejudiciary.uk record · original PDF
Responses published2

The report

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

Regulation 28: REPORT TO PREVENT FUTURE DEATHS 

NOTE:  This form is to be used after an inquest. 
REGULATION 28 REPORT TO PREVENT DEATHS 

THIS REPORT IS BEING SENT TO: 

1 
2 

 (RPAS) 

1  CORONER 

I am Angela BROCKLEHURST, HM Assistant Coroner for the coroner area of West Yorkshire 
Western Coroner Area 

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 16 August 2022 I commenced an investigation into the death of Shaun CROSSFIELD aged 54. 
The investigation concluded at the end of the inquest on 16 March 2023.  The conclusion of the 
inquest was that: 

Upon the 9th August 2022, Shaun Crossfield began a flight upon a Paramotor in a field situated at 
New Church Farm Tong Lane Bradford. 
Mr Crossfield, whilst in flight suffered the impact of air turbulence, which caused the canopy of his 
Paramotor to partially collapse, adversely affecting his ability to maintain a normal flight pattern. 

Due to further damage to the control mechanisms of the Paramotor, it became uncontrollable, 
descending into a downward spiral which could not be reversed; resulting in a catastrophic impact 
with the ground, with an immediate fatal consequence to Mr Crossfield. 
The Ambulance Service was called to the scene where an attending Paramedic certified the death 
of Mr Crossfield at 19:19 hours that day 

4  CIRCUMSTANCES OF THE DEATH 

Shaun is a 54yr old man who lives in Gomersal, Cleckheaton with his father. 

Shaun is described by his family as an avid flyer of Paramotors. He has been engaged in this 
activity for around 4-5years at the time of his death. 
On the 9th of August Shaun has set off from home to head out flying that evening with two friends. 
At around 19:00hrs Shaun got into difficulties, for reasons not yet known, whereupon he and his 
Para-Motor then plummeted to the ground. 

He was declared dead by paramedics at 19:19hrs. 

5  CORONER’S CONCERNS 

During the course of the investigation my inquiries 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. 

Regulation 28 – After Inquest 
Document Template Updated 30/07/2021 

 
 The MATTERS OF CONCERN are as follows: 
(brief summary of matters of concern) 

The Deceased prior to commencing his flight had repaired both propeller blades on his aircraft 
himself, which had previously been damaged, and during his flight the left hand control line came 
into contact with an uneven  repaired section of the propeller. 
The propeller was  turning under power at that time  causing the line to be entrapped and partially 
severed. 

The tension upon the control line instigated a rapid and dynamic turn leading to a spiral dive  from 
which the deceased was unable  to recover before impacting upon the ground. 
It appears to be the case that no regulatory authority is available to control the quality or 
airworthyness of the class BGD Luna 2 Paraglider flown by the deceased. 
The absence of such quality control and licensing for use  and registration of such aircraft  does 
provide the opportunity for future deaths to occur. 

Had a mandatory inspection and certification of fitness  been carried out and imposed  by qualified 
inspectors, in all likelihood  such a death as suffered by the deceased may not have occurred. 

6  ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe you (and/or 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 March 10, 2024.  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 have also sent it to 

(Father-in-Law) 

 (Spouse) 

who may find it useful or of interest. 

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 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 

Regulation 28 – After Inquest 
Document Template Updated 30/07/2021 

 or the publication of your response by the Chief Coroner. 

9  Dated: 02/02/2024 

Angela BROCKLEHURST 
HM Assistant Coroner for 
West Yorkshire Western Coroner Area 

Regulation 28 – After Inquest 
Document Template Updated 30/07/2021

Responses

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.

Response from Birtish Hang Gliding and Paragliding Association (PDF)
8 Merus Court 
Meridian  Business Park 
Leicester LE19 1RJ 

Telephone: 0116 289 4316 
Website: www .bhpa.co.uk 
Email: office@bhpa.co.uk 

The govern ing  body of 
hang gliding and  paragliding 
in  the United Kingdom 

British Hang Gliding and 
Paragliding Association 

11 th  March 2024 

Ms A. Brocklehurst, 
HM Assistant Coroner for the West Yorkshire and  Western Coroner Area 
Cater Building 
1 Cater Street 
Bradford 
BD15AS 

Dear Ms  Brocklehurst 

Regulation 28:  Report to prevent future deaths: Shaun CROSSFIELD. 

BHPA. 

I am  the  named  individual  on  the  Coroner's  Regulation  Order  28  Report  of 2nd  Febru ary  2024  and for  the 
purposes of this Report, I represent the  British  Hang Gliding and  Paragliding Association  (BHPA) . 

In  respect of the points in  your Order which  I am  required to address, I respond  as follows: 

1.  The  BHPA  is  a  members'  organisation  established  as  a  Company  Limited  by  Guarantee.  It  is  not  a 
regulatory  authority.  It  has  no  powers  of  compulsion ,  even  over  its  own  members.  Inter alia,  it  seeks  to 
promote  safety  within  the  sports  of hang  gliding  and  paragliding  and  the  powered  variants  of  those aircraft 
through  progressive training schemes, education,  encouragement, and  persuasion. 

2.  The CM has determined to impose only light touch  regulation  upon these  aircraft due to their low speeds 
and  low  mass  which  means  that  they  present  very  little  risk  to  third  parties,  such  as  members  of  the 
public.  Such light touch  regulation  imposes a responsibility upon pilots to ensure that: 

(a) they are 'qualified' to undertake the flight that they plan to undertake. (Qualified  in this sense mean ing that 
they are sufficiently knowledgeable, informed and educated to complete the flight legally and  safely.). 

(b)  They are sufficiently fit and  well to carry out the planned flight. 

(c) Their aircraft is airworthy. 

(d) The weather is suitable. 

3. Shaun Crossfield had chosen not to join the BHPA, in so far as it can be determined  he had not undertaken 
any BHPA approved  training , nor had  he  completed  any of the  BHPA qualification  schemes.  At the time  of 
the accident which  caused  his death, he  was flying  in  regulated  airspace, contrary to  air law.  He  was flying 
an  aircraft  which  had  previously  been  the  subject  of  a  poor quality  repair,  almost  certainly  undertaken  by 
Shaun.  He was flying  an  aircraft which  had  previously been  damaged, most probably in  a flying  accident  in 
which he was the pilot. 

4.  In  our  experience, had  Shaun  availed  himself of the  training  and  education  offered  by  BHPA  Registered 
Training  Establishments, it  is  unlikely that  he  would  have  been  illegally  flying  in  controlled  airspace,  in  an 
aircraft that he had previously crashed and then performed a wholly inadequate repair. 

5. The BHPA will continue to  seek to encourage people who wish to fly aircraft that fall within our remit to join 
the Association  and to undertake and complete our training programmes. 

Yours sincerely 

BHPA 

British Hang Gliding  and  Paragliding 
Association Limited. 
A company limited by guarantee and 
registered in England no. 2618166. 
Registered office: 8 Merus Court, 
,  .. : .. .....- .. .  1  c1n  "~ 1 

The BHPA Is a member of the  Royal  Aero 
Club of the United Kingdom, through which 
it Is affiliated to 
the Federation 

$ 
~!?In' 

-~-T 

The Association Is recognised 
by the UK Sports Council. 

~

I 

:---\
Response from Civil Aviation Authority (PDF)
OFFICIAL - Public. This information has been cleared for unrestricted distribution.  

ANGELA BROCKLEHURST – HM ASSISTANT CORONER FOR THE CORONER AREA 

OF WEST YORKSHIRE 

INVESTIGATION INTO THE DEATH OF MR SHAUN CROSSFIELD 

CIVIL AVIATION AUTHORITY RESPONSE TO A REPORT ON ACTION TO PREVENT 

OTHER DEATHS PURSUANT TO REGULATIONS 28 & 29 OF THE CORONERS 

(INVESTIGATIONS) REGULATIONS 2013 

Introduction 

The UK Civil Aviation Authority (‘CAA’) would first like to express its sincere condolences to 

the family and friends of Mr Crossfield. 

The  CAA  is  a  public  corporation,  established  by  Parliament  in  1972  as  an  independent 

specialist aviation regulator. The CAA works so that: 

• 

the aviation industry meets the highest safety standards, 

•  consumers have choice, value for money, are protected and treated fairly when they 

fly, 

• 

• 

through efficient use of airspace, the environmental impact of aviation on local 

communities is effectively managed and CO2 emissions are reduced, 

the aviation industry manages security risks effectively. 

The CAA has carefully considered the Regulation 28 Report to prevent future deaths issued 

by  the  Assistant  Coroner  for  West  Yorkshire  (‘the  Report’),  including  the  following 

recommendation that is considered relevant to its role and functions: 

The Deceased prior to commencing his flight had repaired both propeller blades on his aircraft 

himself, which had previously been damaged, and during his flight the left hand control line 

came into contact with an uneven repaired section of the propeller. The propeller was turning 

under power at that time causing the line to be entrapped and partially severed. The tension 

upon the control line instigated a rapid and dynamic turn leading to a spiral dive from which 

1 

 
 
 
 
 
 
 
 
 OFFICIAL - Public. This information has been cleared for unrestricted distribution.  

the deceased was unable to recover before impacting upon the ground. It appears to be the 

case that no regulatory authority is available to control the quality or airworthiness of the class 

BGD  Luna  2  Paraglider  flown  by  the  deceased.  The  absence  of  such  quality  control  and 

licensing for use and registration of such aircraft does provide the opportunity for future deaths 

to occur. Had a mandatory inspection and certification of fitness been carried out and imposed 

by  qualified  inspectors,  in  all  likelihood  such a  death  as  suffered  by  the deceased may  not 

have occurred. 

The CAA was not an Interested Person at this inquest. As such, it did not have access to the 

evidence. When preparing this response, with a view to future action, the CAA has relied on 

the information contained in the Report, together with information shared between the CAA 

and  the  British  Hang  Gliding  and  Paragliding  Association  (‘BHPA’),  including  the  accident 

report GBR-2022-27371 prepared by the BHPA. 

Background to the CAA’s Regulation of the General Aviation Sector 

‘General Aviation’ is considered to incorporate all civil aviation in the UK other than scheduled 

commercial air transport.  Within the CAA, the General Aviation Unit regulates non-complex 

aircraft including microlights, amateur built and historic aircraft, balloons, gliders, piston twins 

and singles up to 5,700kg maximum take-off weight and single pilot helicopters up to 3,175kg. 

The General Aviation Unit is broadly focussed on the regulation of private transport, sport, and 

recreational  flying,  including  civilian  air  display  flying,  though  it  does  also  include  some 

commercial activity, such as certain flight training, aerial work activity, and passenger flying in 

certain historic aircraft.  

The CAA’s statutory functions in relation to General Aviation activities are set out in various 

pieces of legislation: including the Civil Aviation Act 2012, various assimilated regulations, as 

well  as  in  secondary  legislation,  principally,  the  Air  Navigation  Order  2016,  as  amended 

(‘ANO’).  The CAA may only conduct functions given to it under, or pursuant to, legislation.     

The CAA works closely with those that operate and conduct aviation activities with a view to 

maintaining high levels of safety performance in civil aviation.  As with all regulated activities 

however,  the  obligation  to  ensure  safety  is  placed  upon  organisations  and  individuals  that 

undertake aviation activities, not the regulator.   

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Self-Propelled Hang Gliders 

Self-Propelled Hang Gliders (‘SPHG’s’) are defined in the ANO, and are more commonly 

known as ‘Paramotors’, ‘Powered Paragliders’ and ‘Powered Hang Gliders’. SPHG’s have 

no regulated status and are not therefore subject to specific licensing or airworthiness 

requirements.  

Due to their light and simple design, SPHG’s are amongst the most basic general aviation 

aircraft to operate and maintain. Their limited construction results in there being minimal risk 

of airworthiness defects. 

SPHG activity usually takes place at minimal speeds in non-populated areas. These aircraft 

operate with low kinetic energy and mostly below 3,000ft agl, therefore the risk to third 

parties that is presented by this activity is considered low.   

The CAA manages an aviation safety occurrence reporting system (known as ‘ECCAIRS’) 

which contains data on aircraft accident and incident rates. From this system, the CAA has 

noted that since 2010 there have been a total of 6 fatal injuries involving an SPHG aircraft 

and a total of 19 serious injuries, all occurring prior to 2017. Since 2017 there are no records 

of fatal or serious injury occurrences in an SPHG aircraft save for this tragic accident 

involving Mr Crossfield.  

Based on these figures, the CAA considers that the accident rates for SPHG activities 

remain low and stable. 

As SPHG’s are defined under the ANO as aircraft, the pilot-in-command (‘PIC’) of an SPHG 

is required to comply with the rules of the air whilst operating, including the operational 

requirements set out in the ANO. 

It remains the responsibility of the PIC of any aircraft to operate that aircraft in a safe 

manner. The PIC is responsible for ensuring the safety of the aircraft and should only 

commence a flight if they are satisfied that the aircraft is airworthy, the weather conditions 

are suitable and that they are not incapacitated from performing duties by any cause such as 

injury, sickness, fatigue, or the effects of any psychoactive substance.  

Optional pilot training for SPHG pilots is available from various specialist clubs, schools and 

independent instructors. The BHPA provide a syllabus, qualification and membership 

scheme for SPHG pilots and instructors. 

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 OFFICIAL - Public. This information has been cleared for unrestricted distribution.  

The basis for all aviation safety regulation will be informed by taking a risk-based approach 

which incorporates several factors including, but not limited to assessing; relevant UK 

aviation safety data, third party risks, proportionality, impact and cost.  

Given the available safety data, it is the opinion of the CAA that the probability of an SPHG 

accident having unintended consequences for uninvolved third parties remains low. The 

consequences of such an occurrence, given the lightweight profile of these aircraft, are also 

considered to be low, when compared to more complex aviation activities that create greater 

risks to the public, including private transport, flight training and commercial operations.  

Consequently, the CAA does not consider that it would be proportionate, or in line with the 

UK’s risk-based approach to aviation safety regulation to introduce mandatory airworthiness 

requirements for SPHG aircraft at this time.   

The CAA considers those who operate SPHG aircraft understand and accept the risks when 

undertaking SPHG activity.  

As  with  any  activity  that  involves  risk,  the  regulation  and  operation  of  General  Aviation 

activities  requires  a  balance  between  proportionate  controls  and  avoiding  disproportionate 

constraints on activities that people value.  

Next Steps  

Whilst the CAA maintains that the safety risks associated with SPHG activity remain low and 

responsibility for the safety of all such operations rests solely with those who choose to fly 

these aircraft, as a result of the circumstances of the tragic accident involving Mr Crossfield 

the CAA does consider that it would be appropriate to act on the recommendation outlined in 

the Report.  

The CAA therefore considers that it would be appropriate for it to publish new safety 

guidance on the importance of maintaining the airworthiness of all operational SPHG aircraft 

to a high standard.  

The CAA has previously worked with the BHPA to update and revise the Paramotor Code 

published by the CAA in August 2023. This document incorporates best practise for SPHG 

pilots, focussing on the rules of the air and the risks associated with airspace infringements.  

The CAA will therefore continue to work closely with the BHPA to ensure revised guidance is 

now incorporated into the Paramotor Code on the safe maintenance of SPHG aircraft. This 

revised guidance will be published, distributed to SPHG pilots and the wider General 

Aviation community in or before September 2024.  

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 OFFICIAL - Public. This information has been cleared for unrestricted distribution.  

The CAA will also commence a project of work in or before November 2024 to explore ways 

to improve pilot performance, knowledge of the rules of the air and aircraft maintenance. 

This project will include an assessment of whether additional regulation to improve training 

for SPHG pilots is appropriate. The CAA will ensure that the concerns identified by the 

Assistant Coroner in the Report will be specifically highlighted as part of this process.  

Head of General Aviation 

Civil Aviation Authority 

8 March 2024 

5

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