Steven Evans

British Gliding Association Limited. Registered Office: As above Registered No: 422605 England 8 Merus Court Meridian Business Park Leicester LE19 1RJ

Caroline Saunders Coroners Court Civic Centre Godfrey Road Newport South Wales NP20 4UR

3rd December 2021

RE STEPHEN PHILLIP EVANS

Thank you for your letter dated 3rd November 2021 and the accompanying Regulation 28 report that follows a tragic accident at South Wales gliding club near Usk.

The British Gliding Association is the UK governing body of sport gliding. The BGA provides self-regulated support and guidance to gliding clubs and their individual members, all of whom are required to comply with BGA operational regulations and associated requirements. Regulated activity, for example airworthiness, is overseen by the BGA under a CAA-issued approval. The BGA safety management system supports self-regulated and regulated activity and the BGA works closely with the CAA on matters of aviation safety. The BGA discussed this written response with the CAA.

The AAIB report published on 28 May 2020 details the accident investigation and recommendations. The coroners Regulation 28 report dated 3 November 2021 asks for details and a timetable of actions taken and to be taken.

Actions taken/to be taken:
1. During June 2020, in response to the AAIB’s report and recommendation, the BGA carefully reviewed launch signalling, raised in detail and discussed the issues with subject matter experts and all gliding clubs, and clarified through draft revised rules and associated guidance what type of signalling is required, including guidance on back up signalling.
2. During early February 2021, the BGA wrote to club chairmen describing the AAIB report, the associated outcomes, BGA the revised operational regulations and associated requirements and the intention to formally adopt those at the AGM.
3. In early March 2021, an amended BGA operational regulation for all launch signalling (there are several launch methods in addition to aerotowing) stating “A reliable and unambiguous signalling system shall be used for all launches” and the associated requirement “Signalling – aerotow. Radio communication should be established between the launching operation and the towing aircraft. Where radio communication is not possible, another of the recognised methods of signalling to stop the launch

should be available” were proposed to and adopted by the membership and subsequently published and promulgated by the BGA.
4. All gliding club officers responsible for launching and launch signalling have been directed towards this online published information.
5. During May 2021, gliding restarted after several long pauses associated with Covid restrictions. As part of the restart process, all clubs required their pilots and instructors to review safety information including that relating to signalling.
6. Club site safety reviews support checking of the required signalling requirements and standards.
7. During early June 2021, the AAIB confirmed to the BGA that the AAIB recommendation had been adequately addressed.
8. During early November 2021, all BGA club Chairmen and club Chief Flying Instructors (who oversee club flying operations) were again reminded of the AAIB report and outcomes, and the BGA operational regulation and associated requirements for aerotow signalling.
9. Aerotow signalling operational regulation and associated requirements will be the subject of future reminders to club officials and pilots. The next reminder will be provided to clubs just ahead of spring 2022 to coincide with the start of the main gliding season and will be co-ordinated with any CAA safety promotion opportunity.
10. Occurrence data relating to launch signalling will continue to be monitored to assess where further action may be required.

CAROLINE SAUNDERS – HM SENIOR CORONER FOR GWENT INVESTIGATION INTO THE DEATH OF STEVEN PHILLIP EVANS CIVIL AVIATION AUTHORITY RESPONSE TO A REPORT ON ACTION TO PREVENT OTHER DEATHS PURSUANT TO REGULATIONS 28 & 29 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013

The Civil Aviation Authority (“CAA”) has carefully considered the report of the Senior Coroner to prevent future deaths and the concerns raised. The CAA makes the following comments in response: “Enforce the use of radios in all aircraft and with groundcrews in gliding clubs” Background and legal framework supporting gliding in the UK Gliding in the UK is underpinned by a combination of UK regulation, retained-EU regulation, CAA oversight and self-regulation. For the gliding community, the self-regulation is overseen by the British Gliding Association (“BGA”). The BGA is the governing body for the sport of gliding in the UK and publishes its own rules (“Operational Regulations”) and requirements which gliding clubs and their members must adhere. The BGA provides oversight of its members to ensure continuing high standards of safety. In order to achieve this, the BGA provides members with guidance on a variety of topics including operations. The BGA holds several CAA-issued approvals, which gives the BGA delegated authority in areas such as pilot training and airworthiness management of the UK glider fleet. The CAA oversees the BGA in these regulated activities to ensure safety standards are adequately maintained. Given the key operational role of the BGA in UK gliding, the CAA coordinated with BGA colleagues in our preparation of this response. Use of Radios During Glider Launching The Air Navigation Order 2016 and the Standardised European Rules of the Air specify which classes of airspace radios are required to be used and in which context. The Air Accidents Investigation Branch (“AAIB”) correctly note in their report for G-DDGX, published 28 May 20201, that aircraft operating under visual flight rules within Class G2 airspace, which has not been declared a Radio Mandatory Zone (“RMZ”)3 are not required to use a radio whilst airborne. Additionally, in the context of this operational environment, there is no existing requirement for radios to be used during ground operations. In response to AAIB Safety Recommendation 2020-012, the BGA agreed to review and update its Operational Regulations regarding launch signalling. The BGA advised that it would be updating its safety guidance, “Managing Flying Risk”, to clarify best practice around launch signalling. This revised publication was intended to provide the UK gliding community with a reliable and unambiguous guide to signalling for both aerotow and winch launches. On 7 June 2021, the AAIB assessed the BGA’s

1 AAIB final report for the investigation to Standard Cirrus 75, G-DDGX 2 Class G is outside controlled airspace; aircraft may fly when and where they like, subject to a set of simple rules. There is no legal requirement to notify Air Traffic Control of presence or intentions and no requirement to have a radio. 3 A section of airspace, regardless of its designated class, wherein the carriage and operation of a radio is mandatory.

response to Safety Recommendation 2020-012 and concluded that it was “Adequate”4. Accordingly, this action was subsequently closed off by the AAIB and the BGA. The Regulation 28 Report from the Senior Coroner, states that there was insufficient information to determine whether the failure to adopt an effective communication system contributed to Mr Evans’ death. The CAA recognises that radios are one possible means of effective communication between aircraft and groundcrews involved in glider launching, they are not however, the only means. In its updated guidance on this topic, the BGA has outlined the various recognised methods of effective launch signalling, including the associated limitations of each. The CAA has reviewed the updated BGA guidance on launch signalling and is content that the revision is adequate. The CAA will, however, continue to work closely with the BGA and monitor occurrence data for launch-related incidents to determine whether further action is required.

Timeline of actions taken (as advised by the BGA)
1. During June 2020, in response to the AAIB’s report and recommendation, the BGA carefully reviewed launch signalling, raised in detail and discussed the issues with subject matter experts and all gliding clubs, and clarified through draft revised rules and associated guidance what type of signalling is required, including guidance on back up signalling.
2. During early February 2021, the BGA wrote to club chairmen setting out the scope of the AAIB report, the findings / outcomes, BGA revised operational regulations and associated requirements and the intention to formally adopt those at the next AGM.
3. In early March 2021, an amended BGA operational regulation for all launch signalling (there are several launch methods in addition to aerotowing) stating “A reliable and unambiguous signalling system shall be used for all launches” and the associated requirement “Signalling – aerotow. Radio communication should be established between the launching operation and the towing aircraft. Where radio communication is not possible, another of the recognised methods of signalling to stop the launch should be available” were proposed and adopted by the membership and subsequently published and promulgated by the BGA.
4. All gliding club officers responsible for launching and launch signalling have been directed towards this online published information.
5. During May 2021, gliding restarted after several long pauses associated with Covid restrictions. As part of the restart process, all clubs required their pilots and instructors to review safety information including that relating to signalling.
6. Club site safety reviews support checking of the required signalling requirements and standards.
7. During early June 2021, the AAIB confirmed to the BGA that the AAIB recommendation had been adequately addressed.
8. During early November 2021, all BGA club Chairmen and club Chief Flying Instructors (who oversee club flying operations) were again reminded of the AAIB report and outcomes, and the BGA operational regulation and associated requirements for aerotow signalling.

4 An ‘Adequate’ assessment means the AAIB considers the response fully meets the intent of the Safety Recommendation and the action is expected to address the safety issue (What is a Safety Recommendation? - GOV.UK (www.gov.uk)).

Planned CAA Actions
1. The CAA will coordinate with the BGA to promote the relevant safety information regarding launch signalling to coincide with the start of the 2022 gliding season.
2. The CAA and BGA will continue to monitor launch-related occurrence data to assess if further action is required.

Conclusion The CAA endorses the actions taken by the BGA to improve its guidance for launch signalling and the steps it has taken to ensure that this is communicated to its members. The clearer guidance and increased awareness in the UK gliding community stemmed from the BGA’s actions in the wake of the tragic death of Mr Evans, should go a significant way in preventing similar accidents occurring in the future. As outlined above, the CAA will continue to be proactive and work closely with the BGA in this area to ensure that the clear messaging in the BGA’s updated guidance regarding launch signalling to is understood by all stakeholders in the UK gliding community.

CAA 6 December 2021