Source · Prevention of Future Deaths

Michael Bostock

Ref: 2020-0083 Date: 31 Mar 2020 Coroner: Peter Nieto Area: Derby and Derbyshire Responses identified: 1 / 1 View PDF

Lack of clear guidance on paraglider speed bar specifications, absence of speed bar inspection in pre-flight checks, and insufficient consideration for pilot size/weight in system configuration pose safety risks.

Date 31 Mar 2020

56-day deadline 15 Jun 2020 est.

Responses identified 1 of 1

Other related deaths

Coroner's concerns

AI summary

View full coroner's concerns

I emphasise that I did not find that Michael had been using his speed bar at the time of his wing collapse.

1. There does not appear to be clear guidance as to specifications for speed bar lines. Advice appears to be necessary to paraglider pilots for them to ensure that a line of the appropriate standard and specification is used to connect the speed bar to the paraglider risers. The BHPA is in a position to provide advice to pilots and to liaise with leading paraglider manufacturers.

2. Existing BHPA guidance to pilots for pre-flight checks does not appear to include inspection of speed bar lines and associated elements of the paraglider. Speed bar inspection could be included with the general and standard pre-flight inspection.

3. Paraglider pilots are of different sizes and weights and on the evidence presented to me speed bar systems should be configured and set-up to take account of such differences. Again the BHPA is placed to consider providing advice to pilots.

It appears to me that paragliding is a surprisingly unregulated activity, given the risks, and in this context it is crucial that the BHPA as the governing body for the activity considers the need for further guidance to pilots on the concerns which I have raised.

Responses

1 respondent

BHPA Other

2 Apr 2020 PDF

Action Planned

The BHPA will publish an article in its "Skywings" magazine addressing specifications for speed bar lines, pre-flight checks and speed system setup. The article is planned for publication in July 2020. (AI summary)

View full response

Dear Mr Nieto, Re: Inquest into the death of Michael Frank Bostock refer to vour Preventing Future Deaths report for Mr Michael Frank Bostock, received by the BHPA by email on 31 March 2020. The actions we propose to take In response to the points You raise in your Section 5 "MATTERS OF CONCERN' are as follows_
1. Specifications for speed bar lines_ This will be addressed in an article in the BHPA's "Skywings" magazine that is circulated to all the Association' $ members
2. Pre-flight checks. The pre-flight checking of speed systems is included In the BHPA's standard pre-flight check which is taught to every paragliding student on a BHPA tralning course (I refer to the BHPA Technical Manual Section 2, Chapter 1, Appendix B1: The Pre-Flight Check, link to online version https ]Iwwwtbhpa co uklpdfIBHPA_Tech_Manual 18pdf) The Association shall remind its members of the importance ofthe pre-flight check through Skywings magazine: 0h US)uwi V-ef Farfxe Hll'0) EHPR nlutWer (1' If1a? 7yelA,"o Tne Anscrigtor (oc(nltise( 4so Aw or" Icil Ctuh} { [ Jin UJtlied) Iingelamn: @MCulgt" ##4*"1 Ixy Ine Uf Scos "; A refui} Inetos;l i:y fU'ITH Yaid #9nled 5Os #tred E4jonn??044B6 Iin? Fedletehcu} f' Qislaied ollk:o Ge Ai:"lki:l 4ixe (eeneler LCI0 1, #xerilivinakc . RAnc' UX sport [ue hat aol Inp '0 T 046

3. Speed system setup. This will be addressed in an article in Skywings magazine; In respect of setting out a timetable for these actions, the article addressing these points will be published in this year_ consider my to respond under Section 7 ofyour report to now be discharged;

Report sections

Investigation and inquest

On 13 December 2018 I commenced an investigation into the death of Michael Frank Bostock (dob: 11 April 1958; dod: 12 December 2017). The investigation concluded by way of an inquest hearing on 24 March 2020 (a copy of the record of inquest is enclosed with the covering letter to this report). My findings at inquest were as follows: -

- Medical cause of death: - 1a Chest injuries. 1b Paraglider crash.

- My conclusion as to Michael’s death was a short form conclusion of accident.

I stated at the end of the inquest that my intention was to send this report to the British Hang Gliding and Paragliding Association (BHPA).

Circumstances of the death

Michael died on 12 December 2017 at Stanage Edge near Hathersage in Derbyshire as a result of his paraglider wing collapsing in strong turbulent wind which caused him to crash and hit the ground in a fast and heavy impact. He sustained serious chest injuries and died at the scene. On the evidence the wind conditions had initially been good but suddenly deteriorated and Michael had been manoeuvring to land when the wing collapse occurred. Witness evidence portrayed Michael as an experienced, competent and diligent paraglider pilot.

Inquest conclusion

-

- Medical cause of death: - 1a Chest injuries. 1b Paraglider crash.

- My conclusion as to Michael’s death was a short form conclusion of accident.

I stated at the end of the inquest that my intention was to send this report to the British Hang Gliding and Paragliding Association (BHPA).

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Shared signals

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Report details

Reference: 2020-0083
Date of report: 31 March 2020
Coroner: Peter Nieto
Coroner area: Derby and Derbyshire

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 15 Jun 2020 (estimated).

Sent to

British Hang Gliding and Paragliding Association Ltd

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.