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recurance

Jonathan Mann and Margaret Costa

24 Aug 2023 · Coroner Samantha Marsh · Somerset

The coroner's concerns

  1. 1. lack of critical information

    “The D&D cell did not request or receive any critical information about (i) the pilot's capabilities (i.e that he could not instrument fly and/or fly in cloud); (ii) the plane's capabilities (i.e. that it was not equipped to allow the pilot to instrument fly) (iii) the weather conditions at the selected diversion aerodrome (to ensure that the weather was more favourable to the conditions at the home aerodrome).”
  2. 2. unsuitability of diversion airport

    “Checklists and aide memoires were not used by those on the ground and, consequently, there was a lack of knowledge and/or appreciation of the unsuitability of the selected airport (Exeter) as a viable diversion destination”
  3. 3. inadequate assistance to pilot

    “The incorrect assumptions, misunderstandings and miscommunications between the D&D Cell and Exeter Air Traffic Control limited the ability of those on the ground to provide adequate assistance to a pilot in distress”

Responses

No published response was found on judiciary.uk.

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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