Jonathan Mann and Margaret Costa
24 Aug 2023 · Coroner Samantha Marsh · Somerset
The coroner's concerns
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. 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. 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.