Source · Prevention of Future Deaths

Peter Walker

Ref: 2023-0217 Date: 29 Jun 2023 Coroner: Nigel Parsley Area: Suffolk Responses identified: 1 / 2 View PDF

The CAA's self-declaration system for older pilots lacks comprehensive medical guidance and a central licence revocation system, allowing revalidation without independent assessment of fitness to fly.

Date 29 Jun 2023
56-day deadline 24 Aug 2023 est.
Responses identified 1 of 2
Other related deaths

Coroner's concerns

AI summary
The CAA's self-declaration system for older pilots lacks comprehensive medical guidance and a central licence revocation system, allowing revalidation without independent assessment of fitness to fly.
View full coroner's concerns
Evidence was heard from a number of individuals including two investigators from the Air Accident Investigation Branch (AAIB). It was heard that in this case there was no available evidence to suggest that Peter’s age (87 years old), played a part in this tragic incident. However, because of Peter’s age, as part of their enquiries AAIB investigators reviewed the system used by the UK Civil Aviation Authority (CAA) to provide requalification for a Private Pilots Licence, for pilots aged 70 years of age and over. It was identified that the CAA had adopted essentially the same system used by the Driver and Vehicle Licensing Agency (DVLA) for private car drivers over 70 years of age. As such, the CAA use a Pilot Medical Declaration system for revalidation, under which a pilot aged 70 is required to make a self-declaration that tthey are still medically fit to fly. The self-declaration is required once every three years following the first declaration at the age of 70. However, unlike the DVLA the CAA provides no comprehensive guidance for the individual pilot making the self-declaration. As such the CAA provides no list of identifiable conditions that would either preclude the pilot flying, or any conditions which suggest the pilot should seeks further medical opinion regarding their fitness to fly. It was identified that the CAA provided no guidance to any medical professionals to alert them to the medical standards required for an individual making a Pilot Medical Declaration, should that individual approach them for a medical opinion regarding their fitness to fly. It was identified that the DVLA has an efficient centrally controlled system to manage medically related driving licence decisions and to coordinate licence revocation and licence surrender activities. The CAA has no such system to coordinate their licence revocation and licence surrender activities. It was identified, that any pilot of the type of aircraft being flown by Peter, who qualified on that type prior to 2008, can revalidate their licence to fly that type of aircraft by providing a self-declaration of evidence of experience of flying that aircraft. As the Pilot Medication Declaration system, and the licence revalidation procedure for this type of aircraft both rely on self-declarations only, it was identified that a pilot over 70 who flies this type of aircraft, can be revalidated to fly it without any independent third-party assessment of their actual ability or fitness to fly. In this case the Air Accident Investigation Branch have made the following recommendations to the CAA: Safety Recommendation 2023-007. It is recommended that the UK Civil Aviation Authority provides comprehensive guidance for pilots on the medical factors that must be considered when making an online Pilot Medical Declaration Safety Recommendation 2023-008. It is recommended that the UK Civil Aviation Authority provides guidance for medical professionals to promote awareness of the medical standards required by the Pilot Medical Declaration scheme. Safety Recommendation 2023-009. It is recommended that the UK Civil Aviation Authority engages with the UK Driver and Vehicle Licensing Agency to understand their process for managing medical related driving licence decisions, and ensure that the UK Civil Aviation Authority’s process for managing the Pilot Medical Declaration scheme is as effective. Safety Recommendation 2023-010. It is recommended that the UK Civil Aviation Authority assesses the continued appropriateness for holders of UK PPLs with microlight class ratings issued before 1 February 2008 to revalidate that rating solely by providing evidence of experience. The court was informed that once the AAIB has made its recommendations, it has no power to ensure they are acted upon.

Responses

1 respondent
Department for Transport Central Government
21 Aug 2023 PDF
Action Planned

The CAA has accepted the AAIB recommendations and is planning to update its Pilot Medical Declaration (PMD) system, including updating the PMD webpage and form, providing guidance to medical professionals, reviewing administrative approaches with the DVLA, and introducing PMD 'spot checks'. They will also review revalidation processes for certain pilots. (AI summary)

View full response
Dear Mr Parsley,

I am writing to acknowledge, accept and respond to the Regulation 28 Report to Prevent Future Deaths concerning your investigation into the death of Mr Peter John Walker and update on action taken by the CAA to implement the safety recommendations made to them by the Air Accident Investigation Branch (AAIB).

The Civil Aviation Authority (CAA) has accepted the recommendations issued by the AAIB and has commenced work to address them. This includes a project to look at the current Pilot Medical Declaration (PMD) system and whether it is fit for purpose. As part of this, the CAA has committed to the following:

1. Updating the CAA’s PMD webpage with supplementary information for pilots. This will also include a link to information on the UK Driver and Vehicle Licensing Agency (DVLA) website;
2. Updating the PMD declaration form to include additional guidance for pilots;
3. Ensuring guidance is available to medical professionals to promote awareness of the medical standards required by the PMD scheme by adapting guidance which already exists for Aero Medical Examiners (AMEs) for wider use;
4. CAA to build on their relationship with DVLA to review their administrative approach to PMD and adapt their ‘False and Non- Declaration of Medical Certificate Holders’ policy to include the PMD scheme;
5. Introducing PMD ‘spot checks’ to ensure declarations are being made correctly.

From the Secretary of State The Rt Hon Mark Harper MP

Great Minster House 33 Horseferry Road London SW1P 4DR

Web site: www.gov.uk/dft

In addition, the CAA will be reviewing the appropriateness of continued use of revalidation solely by experience for holders of UK PPLs with microlight class ratings issued before 1 February 2008. The outcome of this review will feed into the ongoing Licensing and Training Simplification project which is considering changes to the system of pilot licensing in the UK following our withdrawal from the European Union.

Work is ongoing on the measures above and may require the CAA to consult with industry. In addition, they have confirmed that they have received positive acknowledgement from the AAIB of their plan to address the four safety recommendations. The CAA has committed to provide an update to the AAIB by Q4 2023 and I have asked to be kept updated on progress.

I consider this action, on the part of CAA, to adequately address the recommendations made by the AAIB, though I note that the AAIB will continue to monitor progress. I do not therefore believe that, in light of CAA’s response, further intervention is needed by my Department to prevent further deaths, such as through the exercise of Civil Aviation Act 1982 powers to direct the CAA. I have requested that officials monitor the CAA’s work on this and provide support as needed to ensure the AAIB recommendations are adequately addressed. This will be done as part of a clear governance process under the UK’s State Safety Programme for Aviation.

Report sections

Investigation and inquest
On 04 April 2022 I commenced an investigation into the death of Peter John WALKER aged
87. The investigation concluded at the end of the inquest on 21 June 2023. The conclusion of the inquest was that: Accident The medical cause of death was confirmed as: 1a Multiple Traumatic Injuries 1b Aircraft Crash 1c
Circumstances of the death
Peter Walker came by his death at Beccles Aerodrome, Ellough Airfield, near Beccles in Suffolk on Thursday 24th March 2022. Peter had been flying alone in a CT2K Microlight aircraft, registration G-CBDJ, that had attempted to land at Beccles Aerodrome, at approximately 13:55 that afternoon. Upon landing Peter’s aircraft was seen to bounce 5 to 10 feet into the air before touching down again heavily, nose wheel first. The aircraft bounced a second time and then the nose pitched markedly upwards. The aircraft reached a height of approximately 100ft, veered to the left and rolled nose downwards before crashing in a field adjacent to the runway. Peter received multiple injuries and was declared deceased at the scene short while later. At the time of his death Peter was 87 years old.

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Report details

Reference
2023-0217
Date of report
29 June 2023
Coroner
Nigel Parsley
Coroner area
Suffolk

Responses identified

Responses identified 1 of 2
1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 24 Aug 2023 (estimated).

Sent to

Department for Transport
UK Civil Aviation Authority

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