Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0430, written 2 Aug 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Aug 2024 |
|---|---|
| Reference | 2024-0430 |
| Deceased | Peter Gregory |
| Coroner | David Reid |
| Coroner area | Worcestershire |
| Category | Other related deaths · Product related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: , Chief Executive, Civil Aviation Authority, Aviation House, Beehive Ring Road, Crawley, West Sussex, RH6 0YR. 1 CORONER I am David Donald William REID, HM Senior Coroner for Worcestershire. 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 30 June 2023 I commenced an investigation and opened an inquest into the death of Peter GREGORY. The investigation concluded at the end of the inquest on 1 August 2024 The conclusion of the inquest was that Mr. Gregory “died as the result of an accident”. 4 CIRCUMSTANCES OF THE DEATH In answer to the questions “when, where and how did Mr. Gregory come by his death?”, I recorded as follows: “On the morning of 25.6.23 a hot air balloon being flown by Peter Gregory, an experienced balloon pilot, suffered a sudden parachute stall in the course of a rapid ascent during a competition race. The parachute stall caused the envelope of Mr. Gregory’s balloon to collapse, and the balloon to descend rapidly to the ground in a field at Ombersley Court, Ombersley. Mr. Gregory suffered fatal injuries in the resulting impact, and was confirmed deceased at the scene a short time later that day.” 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 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. – 1) The inquest heard evidence from an investigator at the Air Accidents Investigation Branch ( AAIB ) that Mr. Gregory’s balloon was home-built, based on a design produced by a friend and fellow balloon pilot, and that the balloon’s design ( in particular, the location of the balloon parachute’s centralising lines, which determine its height within the balloon envelope ) may have played a part in the parachute stall which led to the balloon’s sudden and fatal descent. The inquest also heard that the AAIB has recommended that the Civil Aviation Authority ( CAA ) publishes guidance on the design, testing and inspection of amateur-built balloons to reduce the risk of accidents due to unsafe conditions such as parachute stall, but that it is up 1 to the CAA whether or not to regulate the design and construction of amateur/home-built balloons; 2) The inquest also heard evidence that the CAA currently neither regulates, nor publishes guidance for the safe oversight of competition balloon flying in the UK. Whilst there is guidance published by the British Balloon and Airship Club ( BBAC ), the BBAC is a sporting body and not a regulator, and therefore does not have the power, for example, to ground a balloon which does not conform to its published guidance. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you, as the Chief Executive of the Civil Aviation Authority, have the power to take such action, by carrying out a review of the regulation of balloon flying in the UK, considering in particular whether there should be regulation of the design, construction, inspection and testing of amateur or home-built balloons, and of competition balloon flying in the UK. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 27 September 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: (a) (b) The Air Accidents Investigation Branch. , Mr. Gregory’s parents; 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 2 August 2024 David REID HM Senior Coroner for Worcestershire 2
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.
OFFICIAL - Named Parties Only. This information is intended for HM Senior Coroner, CAA and Interested Persons only MR D. D. W. REID – HM SENIOR CORONER FOR WORCESTERSHIRE INVESTIGATION INTO THE DEATH OF MR PETER RICHARD GREGORY 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 Gregory. 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 Senior Coroner for Worcestershire dated 2 August 2024 (‘the Report’), including the following recommendation that is relevant to the role of CAA: … In my opinion, action should be taken to prevent future deaths and I believe you, as Chief Executive of the Civil Aviation Authority, have the power to take such action, by carrying out a review of the regulation of balloon flying in the UK, considering in particular whether there should be regulation of the design, construction, inspection and testing of amateur or home-built balloons and of competition balloon flying in the UK . The CAA was not an Interested Person at this inquest. As such, it did not have access to the inquest evidence. When preparing this response, with a view to implementing further action, the CAA has relied on the information contained in the Report, together with the report published by the Air Accidents Investigation Branch (‘AAIB’) into the circumstances of this accident dated 23 May 2024 and regulatory information held by the CAA. 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 1 OFFICIAL - Named Parties Only. This information is intended for HM Senior Coroner, CAA and Interested Persons only 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. Balloons Most hot air balloons recorded on the UK civil aircraft register are classified as ‘Part 21’ aircraft.1 This means they are issued with a Certificate of Airworthiness by the CAA and with an Airworthiness Review Certificate, which is renewed annually. These aircraft are subject to direct CAA airworthiness regulation. There are currently 1263 balloons in this category on the UK register. There are, in addition to the balloons regulated by the CAA, a smaller number of balloons (69) that are not regulated for the purposes of CAA airworthiness oversight and are restricted to recreational or private use, rather than commercial operation. These balloons are classified as ‘non-Part 21’ aircraft2. In respect of this category of balloons, 54 are amateur constructed balloons. Although these amateur- built balloons are not currently subject to CAA airworthiness requirements, they are restricted in respect of volumetric size and occupancy. Competition balloon flying is not a commercial activity. However, it should also be noted that whilst competition balloon flying is not regulated by the CAA, there are competition rules promulgated by the British Balloon and Airship Club (‘BBAC’) that should be followed by competitors. These rules are based on the Federation Aeronautique Internationale Rules for competition ballooning that are used worldwide. The CAA does not currently perform any dedicated oversight of competition balloon flying in the UK but does perform periodic general oversight of UK balloon competitions in the same way as it does for other types of balloon events. This typically consists of checking aircraft and balloon pilots conform to licensing and medical requirements, airworthiness specifications (for Part 21 balloons) and adherence to the UK Rules of the Air. Next Steps The CAA has already conducted an initial review of the regulation of balloon flying in the UK. The DB-6R type balloon involved in this tragic accident was an amateur-built balloon and designed specifically for competition flying. There are two further DB-6R type balloons recorded on the UK civil aircraft register. In October 2023 the CAA issued directions to stop both these aircraft from flying, based on the preliminary findings from the AAIB’s investigation into this accident. These directions will remain in place until the CAA is satisfied that the unsafe conditions identified in the AAIB’s final report have been satisfactorily addressed and the balloons are independently assessed as airworthy. 1 Aircraft in this category are those that were previously managed by the European Union Aviation Safety Agency (EASA) and were considered as EASA types. These are regulated under UK Regulation (EU) 2018/1139 (known as the UK Basic Regulation) and its implementing regulations covering airworthiness, operations, flight crew licensing, etc. 2 Aircraft in this category are managed nationally under the UK Air Navigation Order 2016, as amended. 2 OFFICIAL - Named Parties Only. This information is intended for HM Senior Coroner, CAA and Interested Persons only Following publication of the AAIB’s final report, the Senior Coroner will be aware that two safety recommendations were issued to the CAA. The CAA has accepted both recommendations and has committed to working with the BBAC to produce guidance in relation to the design, testing and inspection of amateur-built balloons (including those used in competition flying). Additionally, the CAA will collaborate with the BBAC to produce guidance for the safe oversight of balloon events. The AAIB has classified the CAA responses as ‘adequate-open’ and the recommendations will remain open until the CAA has delivered on its commitment. The AAIB recommendations and the CAA’s initial response are set out below: AAIB Recommendation 2024-008 It is recommended that the Civil Aviation Authority publish guidance on the design, testing and inspection of amateur-built balloons to reduce the risk of accidents due to unsafe conditions such as parachute stall. CAA Response The CAA accepts this recommendation and will publish guidance to mitigate the risk of accidents caused by unsafe conditions arising from the design, testing, and inspection of amateur-built balloons. The CAA will liaise with the British Balloon and Airship Club (BBAC) in producing this guidance. The CAA will provide an update on the actions taken to address this safety recommendation by the end of February 2025. AAIB Recommendation 2024-012 It is recommended that the Civil Aviation Authority publish guidance for the safe oversight of competition balloon flying in the UK, to ensure the risks associated with the activity are appropriately understood by competitors and managed by competition organisers. CAA Response The CAA accepts this recommendation and will publish safety guidance for balloon events to ensure the risks associated with competition balloon flying are understood by competitors and managed by competition organisers. The CAA will liaise with the British Balloon and Airship Club (BBAC) in producing this safety guidance. The CAA will provide an update on the actions taken to address this safety recommendation by the end of February 2025. Further to the proposed actions set out above, the CAA will continue its review of the regulation of balloon flying in the UK with a particular emphasis on whether there should be regulation of the design, construction, inspection and testing of amateur or home-built balloons and of competition balloon flying. The CAA will continue to work with domestic aviation stakeholders to mitigate the risks to public safety in accordance with the concerns highlighted in the Senior Coroner’s Report. This review process will take several months to conclude and involve dedicated subject matter experts from the CAA’s General Aviation Unit (balloon airworthiness and operations) working in collaboration with the BBAC. The CAA seeks to balance safety with proportionality, taking into account analysis of safety data derived from amateur balloon flying in the UK. At the conclusion of this process the CAA will consider whether rule changes are required. 3 OFFICIAL - Named Parties Only. This information is intended for HM Senior Coroner, CAA and Interested Persons only The CAA is willing to provide the Senior Coroner with a supplemental report on the progress of this work on or before 31st March 2025. Acting Head of General Aviation Civil Aviation Authority 26 September 2024 4
OFFICIAL - Named Parties Only. This information is intended for HM Senior Coroner, CAA and Interested Persons only MR D. D. W. REID – HM SENIOR CORONER FOR WORCESTERSHIRE INVESTIGATION INTO THE DEATH OF MR PETER RICHARD GREGORY CIVIL AVIATION AUTHORITY SUPPLEMENTAL 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’) is providing this supplemental response to HM Senior Coroner’s report on action to prevent future deaths dated 2 August 2024 (‘the report’), issued following the inquest into the tragic death of Mr Peter Richard Gregory. The CAA’s initial regulation 29 response to the report was filed with the coroner’s office on 26 September 2024. Air Accident Investigation Branch Report dated 23 May 2024 The Senior Coroner will be aware that the UK Air Accident Investigations Branch (‘AAIB’) published a final report into the circumstances of this accident on 23 May 2024 which contained two safety recommendations for the CAA. The CAA accepted both recommendations and has been working with the British Balloon and Airship Club to address the issues identified in the report. A written update was recently sent to the AAIB by the CAA, the contents of which are set out below: - Safety Recommendation 2024-008 It is recommended that the Civil Aviation Authority publish guidance on the design, testing and inspection of amateur-built balloons to reduce the risk of accidents due to unsafe conditions such as parachute stall. CAA Response to Safety Recommendation 2024-008 The CAA is currently developing guidance on the design, testing and inspection of amateur-built balloons to reduce the risk of accidents due to unsafe conditions such as parachute stall. The CAA has been liaising with the amateur built balloon community with a view to producing guidance in the form of webpages on the CAA website to provide best practice guidance on the design, testing and inspecting of amateur built balloons and it is hoped the BBAC will also provide guidance in this regard and our liaison with them continues. It is also our intention to issue a Safety Notice (SN) regarding our decision to continue to allow the amateur built balloons to be unregulated. The SN shall also direct to the CAA website guidance and our previous Safety Directive (SD) on volumetric and occupancy limitations which will endure on a non-expiring basis. 1 OFFICIAL - Named Parties Only. This information is intended for HM Senior Coroner, CAA and Interested Persons only The CAA will provide an update on the actions taken to address this Safety Recommendation by the end of June 2025. Safety Recommendation 2024-012 It is recommended that the Civil Aviation Authority publish guidance for the safe oversight of competition balloon flying in the UK, to ensure the risks associated with the activity are appropriately understood by competitors and managed by competition organisers. CAA Response to Safety Recommendation 2024-012 The CAA is currently developing safety guidance for balloon events to ensure the risks associated with competition balloon flying are understood by competitors and managed by competition organisers. This will be in the form of a CAP [Civil Aviation Authority Publication] document. The CAA has been liaising with the British Balloon and Airship Club and a working group has been established with Ballooning SMEs [Subject Matter Experts] from across the event and competition space to produce this CAP with an initial meeting on Thursday 27th February. The working group will review current guidance and rules within the UK and Overseas and identify any gaps to produce material for the CAP. The CAA will provide an update on the actions taken to address this Safety Recommendation by the end of June 2025. There are approximately 50 amateur-built hot air balloons currently flying in the UK. The CAA’s review of available safety data for this aircraft type, and both the AAIB and Senior Coroner’s reports will result in the CAA issuing a new Safety Notice (‘SN’) related to aircraft design, construction and testing. Furthermore, the CAA will publish new guidance for operators. The CAA has determined that the airworthiness of amateur built balloons can remain free of direct regulation, but flight safety will be enhanced with the addition of newly published measures for better managing design integrity, construction, inspection and testing (and consequent in-service performance) that will be promulgated by the CAA in the SN and links to additional guidance available on the CAA website. The CAA has previously published a mandatory Safety Directive (SD) (SD-2021/004: Non-Part 21 Amateur-Built Balloon and Airship Operational Limitations | UK Civil Aviation Authority) for amateur or home-built balloons limiting volumetric size of balloon envelope and occupancy, in keeping with the intent that these aircraft are for recreational, rather than for commercial use. The CAA has also recently hosted a meeting with SMEs from the UK ballooning community. During this meeting, attendees discussed a further proposal for the CAA to issue new operational safety guidance, focussing on acceptable rates of ascent/descent in balloon competition flying, a standardised safety/competition briefing, and broader event guidance with the intention that it shall be more widely promulgated via a newly published CAA CAP. Before the next working group meeting planned for April 2025, the group has been tasked with gathering additional safety data relevant to the matters raised by both the AAIB and Senior Coroner. In addition, two members of this working group will be attending an international sporting conference on competition ballooning during the spring and will report their findings back to the working group. The CAA’s new CAP document will be developed over the summer 2025 flying season with a view to public consultation towards the end of 2025, prior to publication. 2 OFFICIAL - Named Parties Only. This information is intended for HM Senior Coroner, CAA and Interested Persons only The CAA will complete the work outlined above and publish the SN and operational guidance on or before 31st March 2026. This information will be available on the CAA’s website in the publications library and will be promulgated to the UK ballooning community using targeted communications. Publications | UK Civil Aviation Authority Acting Head of General Aviation Civil Aviation Authority 24 March 2025 3
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