Peter Walker: Prevention of future deaths report

Other related deaths

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Date of report: 29/06/2023

Ref: 2023-0217

Deceased name: Peter Walker

Coroner name: Nigel Parsley

Coroner Area: Suffolk

Category: Other related deaths

This report is being sent to: Department for Transport

1    The Right Honourable Mark HARPER MP
3    Chief Coroner’s Office
I am Nigel PARSLEY, Senior Coroner for the coroner area of Suffolk.
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.
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:  

The medical cause of death was confirmed as:
1a Multiple Traumatic Injuries
1b Aircraft Crash
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.
During the course of the investigation my inquiries revealed matters giving rise to concern.

In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows:
(brief summary of matters of concern)
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.
In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action.
You are under a duty to respond to this report within 56 days of the date of this report, namely by August 24, 2023. 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
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons
1. Peter’s next of kin.
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.
929th June 2023
Nigel PARSLEY, HM Senior Coroner for Suffolk