Richard Osman

OFFICIAL - Named Parties Only. This information is intended for HM Assistant Coroner, CAA and Interested Persons only 

MR JONATHAN MARK LAYTON – HM ASSISTANT CORONER FOR CARMARTHENSHIRE & 
PEMBROKESHIRE CORONER’S COURT 

INVESTIGATION INTO THE DEATH OF RICHARD MOHAMED FEKRY OSMAN 

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. Osman.  

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  Carmarthenshire  &  Pembrokeshire  dated  5  June  2025  (‘the  Report’),  which 
includes  the  following  recommendations  that  are  relevant  to  the  role  and  functions  of  the  CAA, 
insofar as they apply only to aircraft registered and operated within the UK: 

… That a full review of cockpit fire/smoke procedures be undertaken to include, but not limited 
to: 
- the recognition of an oxygen fire (identifiable by a characteristic noise comparable to that of 
a blowtorch) and the immediate cutting off this oxygen supply. 
- the installation or carrying of protective equipment to deal with any cockpit fires. 
 - a review of the effectiveness of Halon fire extinguishers to deal with onboard fires. 
- a review of regulations (if required) to prevent the use of cigarettes in the cockpit and related 
flammable items and materials. 
- the additional risk analyses to take into account the hypothesis of an overpressure in the 
oxygen distribution system. 

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 explaining the outcome of its review, the CAA 
has relied on the information contained in the Report, together with regulatory information and safety 
data held by the CAA and input from regulatory subject matter experts in civilian flight operations, 

OFFICIAL SENSITIVE - Named Parties Only: Legal Privilege 

 
 
 
 
                                                                                                                                                                   
 
 
 
 
 
 
 OFFICIAL - Named Parties Only. This information is intended for HM Assistant Coroner, CAA and Interested Persons only 

aircraft airworthiness and aeromedicine. 

The CAA’s Approach 

The  CAA  has  acknowledged  the  concerns  identified  by  the  Assistant  Coroner.  In  particular,  those 
related  to  the  risk  of  oxygen  fire  onboard  a  commercial  aircraft,  cockpit  (‘flight  deck’)  fire/smoke 
procedures, the effectiveness of equipment for dealing with fire and how the current aviation safety 
regulation 
the 
recommendations  in  the  report,  specifically  in  relation  to  large  commercial  aircraft.  It outlines the 
relevant regulatory requirements, the measures in place to mitigate and respond to such risks, and 
the CAA’s role and function in overseeing these processes. 

incidents.  This  response  addresses 

framework  works 

to  prevent  such 

The CAA is not responsible for the investigation of aircraft accidents or serious incidents on behalf of 
the UK, which falls to the Air Accidents Investigation Branch (‘AAIB’), a body who report directly to the 
Secretary of State for Transport. Procedures for these investigations are laid down in international 
protocols,  specifically  the  standards  and  recommended  practices  defined  in Annex  13 to  the 
Convention on International Civil Aviation, Aircraft Accident and Incident Investigation, and published 
by the International Civil Aviation Organization (‘ICAO’). 

The CAA understands that the Department for Transport (‘DfT’) will, therefore, respond separately to 
those aspects of the Report which relate to aircraft accident investigation. We can confirm that we 
have exchanged responses with the DfT prior to filing this response with the court.  

Regulatory framework 

The  UK’s  aviation safety  framework  is  designed to  ensure  that  aircraft  systems  are  developed and 
maintained to the highest safety standards. As the UK’s specialist aviation regulator, the CAA oversees 
compliance  with  domestic  aviation  safety  regulations,  including  those  covering  the  design, 
certification, operation, and ongoing maintenance of aircraft on the UK register. The CAA is also the 
UK’s  competent  authority  for  ensuring  compliance  with  international  obligations,  including  those 
issued by ICAO. 

The  process  of  ensuring  commercial  aircraft  are  safe  to  operate  begins  with initial  airworthiness1, 
referring to the design and certification phase, during which aircraft and their systems (including those 
which  mitigate  the  risk  of  hazards  onboard  aircraft)  must  demonstrate  compliance  with  detailed 
safety requirements before entering service. For large commercial aircraft, design standards are set 
out  in  Certification  Specifications  (‘CS’)  (CS-252  applies  to  large  aircraft).  Although  applied  within 
individual international jurisdictions, CS are developed with close collaboration between regulators 
working  across  international  jurisdictions,  with  extensive  input  from  the  wider  aircraft  design  and 
manufacturing  community.  In  practice,  this  results  in  a  high  degree  of  international  consistency, 
ensuring  that  standards  are  technically  robust and  harmonised across  regulatory  systems. Once in 
service, aircraft must comply with the requirements within the UK Air Operations Regulation3 which 
are underpinned by a safety management system: a structured and proactive approach to managing 
safety risks that supports day-to-day safety management and operational decision making4. Alongside 
this,  aircraft  must  continue  to  meet  ongoing  technical  and  maintenance  requirements  through  a 
process known as continuing airworthiness5, including compliance with any Airworthiness Directives 

1 UK Regulation (EU) No. 748/2012 (“UK Initial Airworthiness Regulation”) 
2 CS-25 Amendment 28 
3 UK Regulation (EU) No.  965/2012 (“UK Air Operations Regulation”)  
4 UK Air Operations Regulation ORO.GEN.200; Annex 19 to the Convention on International Civil Aviation 
5  UK Regulation (EU) No. 1321/2014 (“UK Continuing Airworthiness Regulation”) 

OFFICIAL SENSITIVE - Named Parties Only: Legal Privilege 

 
 
 
 
 
 OFFICIAL - Named Parties Only. This information is intended for HM Assistant Coroner, CAA and Interested Persons only 

(ADs) issued to address emerging concerns. 

Together,  these  requirements  ensure  that  systems  remain  safe  and  effective  over  time,  including 
systems for the prevention and management of operational risks including onboard fires. 

Fire prevention onboard commercial aircraft 

Oxygen systems and pressurisation 

Commercial  aircraft  are  typically  equipped  with  gaseous  oxygen  systems,  which  are  designed  to 
supply oxygen to passengers and crew in the event of emergencies such as cabin depressurisation or 
severe fume events. These systems play a critical safety role but are not used during routine flight 
operations,  as  the  aircraft’s  pressurisation  system  provides  sufficient  oxygen  under  standard 
conditions. 

Design and certification specifications for gaseous oxygen systems onboard commercial aircraft are 
designed to prevent a fire from occurring, noting the impact of fire risks on such systems, and include 
multiple  safeguards  and  mitigations.6  These  systems  must  meet  stringent  safety  requirements; 
oxygen  systems  are  required  to  be  free  from  hazards,  with  design  organisations  required  to 
demonstrate, through system safety assessments, that the likelihood of an uncontrolled oxygen fire 
at the aircraft level is extremely improbable and would not result from a single failure of any system 
or associated component7. Risk assessments are comprehensive and should cover equipment failures, 
operating  conditions,  components  and  materials,  ignition  mechanism  and  kindling  chain.  Current 
design standards for large commercial aircraft already require oxygen systems to be resilient against 
potential  pressure  surges  and  temperature  effects8.  The  risk  of  overpressure  in  gaseous  oxygen 
systems is addressed through design specifications, requiring oxygen equipment to be protected from 
rupture. These systems are built with proof and burst pressure factors, and all oxygen systems are 
required to have overpressure relief valves to safely vent excess pressure.  

Smoking and other flammable materials in the flight deck 

The Air Navigation Order 20169 and the UK Air Operations Regulation10 provide the legal framework 
for restricting smoking onboard commercial aircraft. The UK Air Operations Regulation enables the 
pilot-in-command to prohibit smoking anywhere on board in a range of operational scenarios and 
whenever considered necessary in the interest of safety.  

While there is no specific reference to smoking in the flight deck within these regulations, the CAA is 
not aware of any UK aircraft operators that allow smoking in any part of an aircraft, including the flight 
deck. Flight crew receive extensive training in safety and risk management, with a strong emphasis on 
maintaining  a  controlled  and  hazard-free  operating  environment  onboard  aircraft.  In  addition,  all 
safety  related  occurrences  must  be  reported  to  the  CAA,  which  enables  data  to  be  collected  and 
analysed over time. Following a review of the coroner’s request, the UK CAA Safety Intelligence Team 
have confirmed  that  there  have  been  no  reported UK incidents  involving  smoking or  vaping  in  the 
flight deck in the past decade.11 

Whilst we recognise the legal framework does not expressly prohibit smoking in the flight deck, the 
CAA’s regulatory oversight derived from working closely with operators, and safety data derived from 

6 CS 25.1441, CS 25.869  
7 CS 25.1309(b) 
8 CS 25.1453 
9 Article 243 The Air Navigation Order 2016 
10 UK Air Operations Regulation CAT.OP.MPA.240  
11 Mandatory Occurrence Reporting data analysis for period 01/01/15 to 24/06/25 

OFFICIAL SENSITIVE - Named Parties Only: Legal Privilege 

 
 
 
 
 
 
 OFFICIAL - Named Parties Only. This information is intended for HM Assistant Coroner, CAA and Interested Persons only 

the  UK  Mandatory  Occurrence  Reporting  Regulation12,  does  not  currently  indicate  a  safety  risk  or 
safety gap that would require regulatory change.  

Regarding other flammable materials, aircraft design standards require that all installed equipment in 
the  flight  deck  and  aircraft  cabin  are  fire-resistant  and  meet  specific  fire-resistance  criteria13. 
Operators  are  also  expected  to  manage  their  risks  associated  with  flight  crew  personal  items  and 
equipment, with specific Dangerous Goods approval required for the carriage of certain hazardous 
materials, in accordance with ICAO specifications. This approval is obtained by applying to the CAA 
and  demonstrating  compliance  with  safety  requirements,  including  staff  training  and  operational 
procedures14. Flight crew are also subject to aviation security screening15.  

The role of ongoing maintenance in prevention 

The  CAA  places  significant  emphasis  on  the  continuing  airworthiness  of  commercial  aircraft  as  a 
further layer of safety risk mitigation. All CS systems, including oxygen systems and fire protection 
equipment, are subject to regular inspection, testing, and maintenance in accordance with approved 
maintenance  programmes.  This  ensures  that  any  degradation  or  malfunction  is  identified  and 
addressed before it may contribute to an incident.  

Continuing  airworthiness  involves  a  structured  programme  of regular  inspections,  maintenance, 
repairs,  and  system  checks,  performed  by 
licensed  engineers  and  approved  maintenance 
organisations. Operators are required to follow a maintenance schedule tailored to each aircraft type, 
which includes both routine servicing and in-depth checks at defined intervals, as well as specific pre-
flight  checks16.  In  addition,  any  defects  or  unusual  findings  must  be  reported,  investigated,  and 
resolved before an aircraft can return to service. This process is supported by detailed record-keeping, 
ensuring traceability and accountability for maintenance actions.  

The CAA is responsible for conducting compliance audits of approved maintenance organisations in 
accordance with the requirements set out in the UK Continuing Airworthiness Regulation.  

No new fire risks have been identified by the CAA as a result of this audit programme and the CAA 
remains satisfied that all known risks fall within existing design, certification and operational controls.  

Managing fires onboard commercial aircraft 

The regulatory framework is designed to address both the prevention of onboard fires, as well as the 
ability to detect and respond effectively should they occur. 

Under the UK Air Operations Regulation, large transport category aircraft must carry fire extinguishers 
in the flight deck and cabin, with at least one located in the flight deck. The number of additional 
extinguishers required in the aircraft cabin are linked to passenger capacity17. 

Halon fire extinguishers have traditionally been used by commercial aircraft operators to meet these 
requirements due to their effectiveness in confined aircraft environments. However, their use is being 
phased out due to environmental concerns18, and from 31 December 2025, Halon-free extinguishers, 

12 Occurrence Reporting | UK Civil Aviation Authority 
13  CS 25.853, Appendix F to CS 25.853 
14 SPA.DG.105 Approval to transport dangerous goods, UK Air Operations Regulation AMC3 ORO.MLR.100 
15 Regulation (EC) No 300/2008 of the European Parliament  (retained EU law) 
16 UK Continuing Airworthiness Regulation Annex I (Part-M) GM M.A.301(i); UK Regulation (EU) 2018/1139 (‘UK Basic   
Regulation’) Annex V, 6.2  
17 UK Air Operations Regulation CAT.IDE.A.250 
18 Regulation (EC) No 1005/2009 (retained EU law) 

OFFICIAL SENSITIVE - Named Parties Only: Legal Privilege 

 
 
 
 
 
 
 OFFICIAL - Named Parties Only. This information is intended for HM Assistant Coroner, CAA and Interested Persons only 

which must meet the same minimum performance standards will be mandated by CS25.851(a) and 
the Minimum Operating Standards defined in FAA Advisory Circular AC20-42D. The CAA supports this 
transition.  

All flight crew onboard large commercial transport aircraft are required to undergo regular training 
on the handling and use of fire-fighting equipment, protective breathing equipment, and the effects 
of smoke on an enclosed area19. In the event of fire in the flight deck, flight crew must also have access 
to a crash axe or crowbar20 in order to access panels where fire sources may originate, as well as to 
portable oxygen to enable movement around the flight deck and aircraft cabin21. 

Conclusion 

The CAA’s review of the Assistant Coroner’s recommendations has concluded that no change to the 
existing aviation safety regulation framework is currently required. The CAA remains satisfied that the 
safeguards in place, which are underpinned by airworthiness and operational regulations, design and 
certification  requirements  and  operator  safety  management  systems  provide  adequate  risk 
mitigation. As part of this review, subject matter experts have examined relevant safety data held by 
the CAA under the Mandatory Occurrence Reporting Scheme, which does not indicate there is a risk 
of  fire  onboard  large  commercial  aircraft  -  or  the  consequences  of  a  flight  deck  fire  -  necessitate 
changes  to  existing  rules.  The  CAA  is  also  mindful  of  international  requirements  directed  by  ICAO 
which do not support change to existing fire safety controls at the present time.   

However, given the specific concerns identified by the Assistant Coroner, the CAA will continue to 
carefully monitor safety data and future aviation safety investigation recommendations related to fire 
risks with a view to taking appropriate action where necessary. 

Signed:     

Head of Design & Certification (Chief Engineer) 

Future Safety & Innovation  

Civil Aviation Authority  

24 July 2025 

19 UK Air Operations Regulation ORO.FC.230; AMC1 ORO.FC.230  
20 UK Air Operations Regulation CAT.IDE.A.255 
21 UK Air Operations Regulation CAT.IDE.A.235 

OFFICIAL SENSITIVE - Named Parties Only: Legal Privilege

OFFICIAL - Named Parties Only. This information is intended for HM Assistant Coroner, CAA and Interested Persons only 

MR JONATHAN MARK LAYTON – HM ASSISTANT CORONER FOR CARMARTHENSHIRE & 
PEMBROKESHIRE CORONER’S COURT 

INVESTIGATION INTO THE DEATH OF RICHARD MOHAMED FEKRY OSMAN 

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. Osman.  

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  Carmarthenshire  &  Pembrokeshire  dated  5  June  2025  (‘the  Report’),  which 
includes  the  following  recommendations  that  are  relevant  to  the  role  and  functions  of  the  CAA, 
insofar as they apply only to aircraft registered and operated within the UK: 

… That a full review of cockpit fire/smoke procedures be undertaken to include, but not limited 
to: 
- the recognition of an oxygen fire (identifiable by a characteristic noise comparable to that of 
a blowtorch) and the immediate cutting off this oxygen supply. 
- the installation or carrying of protective equipment to deal with any cockpit fires. 
 - a review of the effectiveness of Halon fire extinguishers to deal with onboard fires. 
- a review of regulations (if required) to prevent the use of cigarettes in the cockpit and related 
flammable items and materials. 
- the additional risk analyses to take into account the hypothesis of an overpressure in the 
oxygen distribution system. 

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 explaining the outcome of its review, the CAA 
has relied on the information contained in the Report, together with regulatory information and safety 
data held by the CAA and input from regulatory subject matter experts in civilian flight operations, 

OFFICIAL SENSITIVE - Named Parties Only: Legal Privilege 

 
 
 
 
                                                                                                                                                                   
 
 
 
 
 
 
 OFFICIAL - Named Parties Only. This information is intended for HM Assistant Coroner, CAA and Interested Persons only 

aircraft airworthiness and aeromedicine. 

The CAA’s Approach 

The  CAA  has  acknowledged  the  concerns  identified  by  the  Assistant  Coroner.  In  particular,  those 
related  to  the  risk  of  oxygen  fire  onboard  a  commercial  aircraft,  cockpit  (‘flight  deck’)  fire/smoke 
procedures, the effectiveness of equipment for dealing with fire and how the current aviation safety 
regulation 
the 
recommendations  in  the  report,  specifically  in  relation  to  large  commercial  aircraft.  It outlines the 
relevant regulatory requirements, the measures in place to mitigate and respond to such risks, and 
the CAA’s role and function in overseeing these processes. 

incidents.  This  response  addresses 

framework  works 

to  prevent  such 

The CAA is not responsible for the investigation of aircraft accidents or serious incidents on behalf of 
the UK, which falls to the Air Accidents Investigation Branch (‘AAIB’), a body who report directly to the 
Secretary of State for Transport. Procedures for these investigations are laid down in international 
protocols,  specifically  the  standards  and  recommended  practices  defined  in Annex  13 to  the 
Convention on International Civil Aviation, Aircraft Accident and Incident Investigation, and published 
by the International Civil Aviation Organization (‘ICAO’). 

The CAA understands that the Department for Transport (‘DfT’) will, therefore, respond separately to 
those aspects of the Report which relate to aircraft accident investigation. We can confirm that we 
have exchanged responses with the DfT prior to filing this response with the court.  

Regulatory framework 

The  UK’s  aviation safety  framework  is  designed to  ensure  that  aircraft  systems  are  developed and 
maintained to the highest safety standards. As the UK’s specialist aviation regulator, the CAA oversees 
compliance  with  domestic  aviation  safety  regulations,  including  those  covering  the  design, 
certification, operation, and ongoing maintenance of aircraft on the UK register. The CAA is also the 
UK’s  competent  authority  for  ensuring  compliance  with  international  obligations,  including  those 
issued by ICAO. 

The  process  of  ensuring  commercial  aircraft  are  safe  to  operate  begins  with initial  airworthiness1, 
referring to the design and certification phase, during which aircraft and their systems (including those 
which  mitigate  the  risk  of  hazards  onboard  aircraft)  must  demonstrate  compliance  with  detailed 
safety requirements before entering service. For large commercial aircraft, design standards are set 
out  in  Certification  Specifications  (‘CS’)  (CS-252  applies  to  large  aircraft).  Although  applied  within 
individual international jurisdictions, CS are developed with close collaboration between regulators 
working  across  international  jurisdictions,  with  extensive  input  from  the  wider  aircraft  design  and 
manufacturing  community.  In  practice,  this  results  in  a  high  degree  of  international  consistency, 
ensuring  that  standards  are  technically  robust and  harmonised across  regulatory  systems. Once in 
service, aircraft must comply with the requirements within the UK Air Operations Regulation3 which 
are underpinned by a safety management system: a structured and proactive approach to managing 
safety risks that supports day-to-day safety management and operational decision making4. Alongside 
this,  aircraft  must  continue  to  meet  ongoing  technical  and  maintenance  requirements  through  a 
process known as continuing airworthiness5, including compliance with any Airworthiness Directives 

1 UK Regulation (EU) No. 748/2012 (“UK Initial Airworthiness Regulation”) 
2 CS-25 Amendment 28 
3 UK Regulation (EU) No.  965/2012 (“UK Air Operations Regulation”)  
4 UK Air Operations Regulation ORO.GEN.200; Annex 19 to the Convention on International Civil Aviation 
5  UK Regulation (EU) No. 1321/2014 (“UK Continuing Airworthiness Regulation”) 

OFFICIAL SENSITIVE - Named Parties Only: Legal Privilege 

 
 
 
 
 
 OFFICIAL - Named Parties Only. This information is intended for HM Assistant Coroner, CAA and Interested Persons only 

(ADs) issued to address emerging concerns. 

Together,  these  requirements  ensure  that  systems  remain  safe  and  effective  over  time,  including 
systems for the prevention and management of operational risks including onboard fires. 

Fire prevention onboard commercial aircraft 

Oxygen systems and pressurisation 

Commercial  aircraft  are  typically  equipped  with  gaseous  oxygen  systems,  which  are  designed  to 
supply oxygen to passengers and crew in the event of emergencies such as cabin depressurisation or 
severe fume events. These systems play a critical safety role but are not used during routine flight 
operations,  as  the  aircraft’s  pressurisation  system  provides  sufficient  oxygen  under  standard 
conditions. 

Design and certification specifications for gaseous oxygen systems onboard commercial aircraft are 
designed to prevent a fire from occurring, noting the impact of fire risks on such systems, and include 
multiple  safeguards  and  mitigations.6  These  systems  must  meet  stringent  safety  requirements; 
oxygen  systems  are  required  to  be  free  from  hazards,  with  design  organisations  required  to 
demonstrate, through system safety assessments, that the likelihood of an uncontrolled oxygen fire 
at the aircraft level is extremely improbable and would not result from a single failure of any system 
or associated component7. Risk assessments are comprehensive and should cover equipment failures, 
operating  conditions,  components  and  materials,  ignition  mechanism  and  kindling  chain.  Current 
design standards for large commercial aircraft already require oxygen systems to be resilient against 
potential  pressure  surges  and  temperature  effects8.  The  risk  of  overpressure  in  gaseous  oxygen 
systems is addressed through design specifications, requiring oxygen equipment to be protected from 
rupture. These systems are built with proof and burst pressure factors, and all oxygen systems are 
required to have overpressure relief valves to safely vent excess pressure.  

Smoking and other flammable materials in the flight deck 

The Air Navigation Order 20169 and the UK Air Operations Regulation10 provide the legal framework 
for restricting smoking onboard commercial aircraft. The UK Air Operations Regulation enables the 
pilot-in-command to prohibit smoking anywhere on board in a range of operational scenarios and 
whenever considered necessary in the interest of safety.  

While there is no specific reference to smoking in the flight deck within these regulations, the CAA is 
not aware of any UK aircraft operators that allow smoking in any part of an aircraft, including the flight 
deck. Flight crew receive extensive training in safety and risk management, with a strong emphasis on 
maintaining  a  controlled  and  hazard-free  operating  environment  onboard  aircraft.  In  addition,  all 
safety  related  occurrences  must  be  reported  to  the  CAA,  which  enables  data  to  be  collected  and 
analysed over time. Following a review of the coroner’s request, the UK CAA Safety Intelligence Team 
have confirmed  that  there  have  been  no  reported UK incidents  involving  smoking or  vaping  in  the 
flight deck in the past decade.11 

Whilst we recognise the legal framework does not expressly prohibit smoking in the flight deck, the 
CAA’s regulatory oversight derived from working closely with operators, and safety data derived from 

6 CS 25.1441, CS 25.869  
7 CS 25.1309(b) 
8 CS 25.1453 
9 Article 243 The Air Navigation Order 2016 
10 UK Air Operations Regulation CAT.OP.MPA.240  
11 Mandatory Occurrence Reporting data analysis for period 01/01/15 to 24/06/25 

OFFICIAL SENSITIVE - Named Parties Only: Legal Privilege 

 
 
 
 
 
 
 OFFICIAL - Named Parties Only. This information is intended for HM Assistant Coroner, CAA and Interested Persons only 

the  UK  Mandatory  Occurrence  Reporting  Regulation12,  does  not  currently  indicate  a  safety  risk  or 
safety gap that would require regulatory change.  

Regarding other flammable materials, aircraft design standards require that all installed equipment in 
the  flight  deck  and  aircraft  cabin  are  fire-resistant  and  meet  specific  fire-resistance  criteria13. 
Operators  are  also  expected  to  manage  their  risks  associated  with  flight  crew  personal  items  and 
equipment, with specific Dangerous Goods approval required for the carriage of certain hazardous 
materials, in accordance with ICAO specifications. This approval is obtained by applying to the CAA 
and  demonstrating  compliance  with  safety  requirements,  including  staff  training  and  operational 
procedures14. Flight crew are also subject to aviation security screening15.  

The role of ongoing maintenance in prevention 

The  CAA  places  significant  emphasis  on  the  continuing  airworthiness  of  commercial  aircraft  as  a 
further layer of safety risk mitigation. All CS systems, including oxygen systems and fire protection 
equipment, are subject to regular inspection, testing, and maintenance in accordance with approved 
maintenance  programmes.  This  ensures  that  any  degradation  or  malfunction  is  identified  and 
addressed before it may contribute to an incident.  

Continuing  airworthiness  involves  a  structured  programme  of regular  inspections,  maintenance, 
repairs,  and  system  checks,  performed  by 
licensed  engineers  and  approved  maintenance 
organisations. Operators are required to follow a maintenance schedule tailored to each aircraft type, 
which includes both routine servicing and in-depth checks at defined intervals, as well as specific pre-
flight  checks16.  In  addition,  any  defects  or  unusual  findings  must  be  reported,  investigated,  and 
resolved before an aircraft can return to service. This process is supported by detailed record-keeping, 
ensuring traceability and accountability for maintenance actions.  

The CAA is responsible for conducting compliance audits of approved maintenance organisations in 
accordance with the requirements set out in the UK Continuing Airworthiness Regulation.  

No new fire risks have been identified by the CAA as a result of this audit programme and the CAA 
remains satisfied that all known risks fall within existing design, certification and operational controls.  

Managing fires onboard commercial aircraft 

The regulatory framework is designed to address both the prevention of onboard fires, as well as the 
ability to detect and respond effectively should they occur. 

Under the UK Air Operations Regulation, large transport category aircraft must carry fire extinguishers 
in the flight deck and cabin, with at least one located in the flight deck. The number of additional 
extinguishers required in the aircraft cabin are linked to passenger capacity17. 

Halon fire extinguishers have traditionally been used by commercial aircraft operators to meet these 
requirements due to their effectiveness in confined aircraft environments. However, their use is being 
phased out due to environmental concerns18, and from 31 December 2025, Halon-free extinguishers, 

12 Occurrence Reporting | UK Civil Aviation Authority 
13  CS 25.853, Appendix F to CS 25.853 
14 SPA.DG.105 Approval to transport dangerous goods, UK Air Operations Regulation AMC3 ORO.MLR.100 
15 Regulation (EC) No 300/2008 of the European Parliament  (retained EU law) 
16 UK Continuing Airworthiness Regulation Annex I (Part-M) GM M.A.301(i); UK Regulation (EU) 2018/1139 (‘UK Basic   
Regulation’) Annex V, 6.2  
17 UK Air Operations Regulation CAT.IDE.A.250 
18 Regulation (EC) No 1005/2009 (retained EU law) 

OFFICIAL SENSITIVE - Named Parties Only: Legal Privilege 

 
 
 
 
 
 
 OFFICIAL - Named Parties Only. This information is intended for HM Assistant Coroner, CAA and Interested Persons only 

which must meet the same minimum performance standards will be mandated by CS25.851(a) and 
the Minimum Operating Standards defined in FAA Advisory Circular AC20-42D. The CAA supports this 
transition.  

All flight crew onboard large commercial transport aircraft are required to undergo regular training 
on the handling and use of fire-fighting equipment, protective breathing equipment, and the effects 
of smoke on an enclosed area19. In the event of fire in the flight deck, flight crew must also have access 
to a crash axe or crowbar20 in order to access panels where fire sources may originate, as well as to 
portable oxygen to enable movement around the flight deck and aircraft cabin21. 

Conclusion 

The CAA’s review of the Assistant Coroner’s recommendations has concluded that no change to the 
existing aviation safety regulation framework is currently required. The CAA remains satisfied that the 
safeguards in place, which are underpinned by airworthiness and operational regulations, design and 
certification  requirements  and  operator  safety  management  systems  provide  adequate  risk 
mitigation. As part of this review, subject matter experts have examined relevant safety data held by 
the CAA under the Mandatory Occurrence Reporting Scheme, which does not indicate there is a risk 
of  fire  onboard  large  commercial  aircraft  -  or  the  consequences  of  a  flight  deck  fire  -  necessitate 
changes  to  existing  rules.  The  CAA  is  also  mindful  of  international  requirements  directed  by  ICAO 
which do not support change to existing fire safety controls at the present time.   

However, given the specific concerns identified by the Assistant Coroner, the CAA will continue to 
carefully monitor safety data and future aviation safety investigation recommendations related to fire 
risks with a view to taking appropriate action where necessary. 

Signed:     

Head of Design & Certification (Chief Engineer) 

Future Safety & Innovation  

Civil Aviation Authority  

24 July 2025 

19 UK Air Operations Regulation ORO.FC.230; AMC1 ORO.FC.230  
20 UK Air Operations Regulation CAT.IDE.A.255 
21 UK Air Operations Regulation CAT.IDE.A.235 

OFFICIAL SENSITIVE - Named Parties Only: Legal Privilege

OFFICIAL 

From the Minister for Aviation, 
Maritime and Security 

Department for Transport 
Great Minster House 
33 Horseferry Road 
London 
SW1P 4DR 

P Bennett 
North Wing 
County Hall 
Haverfordwest 
SA61 1TP 

28th July 2025 

Dear Mr Bennett, 

Prevention of Future Deaths Notice Response 

Thank you for your report of 10th June 2025 (Case Reference 
the Coroners and Justice Act 2009 and the Coroners (Investigations) Regulations 
2013, following the conclusion of the inquest conducted into the death of Richard 
Mohamed Fekry Osman. I am responding as Minister for Aviation, Maritime and 
Security. 

 made under 

I was deeply saddened by the circumstances of Mr Osman’s death and extend my 
condolences to Mr Osman’s family and friends. 

The UK Civil Aviation Authority (CAA) is addressing Point 1 of the Coroner’s 
Prevention of Future Deaths Notice in their own response. This letter is to address 
Points 2) (a) and (b) of your report: 

(2) That a drafting committee be convened to consider amending Annex 13 of the 
Convention on International Civil Aviation signed at Chicago on 7 December 1944 to 
provide: 

(a) a right for states entitled to participate in an investigation to have access to 
evidence to enable those participating states to release a statement in 
accordance with Chapter 6.6.1 in circumstances where they have been 
excluded from an investigation by the state of occurrence; 

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(b) A right of states entitled to participate in an investigation to take over conduct 
of an investigation in circumstances where a state of occurrence does not 
produce a final report within a reasonable timeframe and does not produce 
interim statements indicating the progress of the investigation and safety 
issues raised within a reasonable timeframe and has not otherwise consented 
to the delegation of the investigation in accordance with Chapter 5.1. 

The Department for Transport (DfT) is committed to working with other agencies, 
both domestically and internationally, to strive towards zero accidents involving 
commercial air transport that result in serious injuries or fatalities and no serious 
injuries or fatalities to third parties as a result of aviation activities.  

As a signatory to the Chicago Convention on Civil Aviation, the investigation of all 
aircraft accidents involving the United Kingdom and its citizens is governed by the 
International Civil Aviation Organization (ICAO), as detailed in Annex 13 to the 
Convention on International Civil Aviation. 

All ICAO member states can contribute to the development or modification of a 
Standard and Recommended Practice (SARP). Other than in exceptional 
circumstances, member states are expected to transpose the contents of a SARP 
into domestic regulations. There are currently 193 ICAO member states, including 
Egypt, France and the United Kingdom. The United Kingdom has transposed the 
contents of Annex 13 into domestic law through The Civil Aviation (Investigation of 
Air Accidents and Incidents) Regulations 2018.  

Annex 13 clearly sets out the roles in air accident investigation. Where a state has 
the technical competencies to do so, the state of occurrence will lead on the accident 
investigation, for EgyptAir Flight 804 investigation this was the Egyptian Aircraft 
Accident Investigation Directorate (EAAID). The investigative authorities of the 
state(s) where the aircraft and its engines were designed and/or manufactured are 
afforded the status of ‘accredited representative’, which allows them full access to 
and participation in the investigation. As the state of design and manufacture of the 
aircraft type, the French aircraft accident investigation authority, the Bureau of 
Enquiry and Analysis for Civil Aviation Safety (BEA) participated in the accident 
investigation, as did the National Transportation Safety Board (NTSB), as the state 
of design of the aircraft’s engines.   

Investigative authorities from states whose nationals were killed or injured in an 
accident are afforded ‘expert’ status in accident investigations, the United Kingdom’s 
Air Accidents Investigation Branch (AAIB) was assigned this status for the EgyptAir 
Flight 804 investigation as one British national had died. ‘Expert’ officials have more 
limited access to the investigation and are only entitled to visit the scene of the 

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accident, access information approved for public release, receive information on the 
progress of the investigation and receive a copy of the final report. 

It is already the case that accredited representatives (usually investigators from the 
state of design, operation or registry) have full access to the investigation materials 
and evidence. There are safeguards in place to protect evidence in accident 
investigations being more widely available for very good reasons. These include 
people being more likely to cooperate knowing any evidence they provide will not be 
used against them in civil or criminal proceedings. This contributes to a “just culture” 
of being open and honest and prioritising learning over assigning blame. There are 
also ethical considerations about protecting individuals involved and controlling 
access to evidence which also helps maintain the chain of custody. Therefore with 
regard to Point 2a, we do not believe further amendments regarding access to 
evidence are necessary. 

In relation to Point 2b, since the accident ICAO has amended Annex 13 via SARP 
5.1.3 (Amendment 17 of Annex 13) introducing the right for another state to request 
that they take over investigative responsibility should no investigation be initiated 
within thirty days and giving states the right to do their own investigation using widely 
available information if no investigation is then initiated. ICAO also encourages 
states to release information publicly in the early days of the investigation. It is 
important to maintain clear roles and parameters for involvement in accident 
investigations to ensure they remain impartial, they are investigated thoroughly and 
lessons are learned to prevent future recurrence.  

The DfT believes the above provides adequate assurance that accidents involving 
British nationals abroad will be appropriately investigated.  

The safety of the travelling public is a priority and the DfT will continue to prioritise 
improvements to global aviation safety.  

Yours sincerely, 

MINISTER FOR AVIATION, MARITIME AND SECURITY 

OFFICIAL