Accident - G-BXBU

2023-011: It is recommended that the Civil Aviation Authority publish guidance for general aviation pilots on responding to unexpected weather deterioration, highlighting the factors affecting their performance and the benefits of planning before the flight how they will respond.

In addition to the guidance highlighted in the CAA’s initial response to this safety recommendation, the CAA is also developing a new Safety Sense Leaflet (SSL) dedicated to inadvertent entry into Instrument Meteorological Conditions (IMC) when operating under Visual Flight Rules (VFR). The SSL will include guidance on planning to avoid a ‘VFR into IMC’ scenario and what actions to take if a pilot is confronted with deteriorating weather conditions and ends up in IMC when not appropriately qualified.

The SSL has been developed with input from internal and external subject matter experts and is scheduled to be published by March 31st 2024.

The CAA considers the above actions satisfy the intent of the safety recommendation.

Adequate - Closed

Closed

2023-012: It is recommended that the Civil Aviation Authority require air traffic controllers to receive training regarding the human performance characteristics and limitations associated with stress. This should include the verbal cues that may indicate that a pilot is operating under high stress, and mitigation strategies to help controllers deal with such event.

The CAA continues to work with the UK Flight Safety Committee (FSC) to develop a  significant update to ‘Aircraft Emergencies: Considerations for air traffic controllers’ (CAP 745). The intent is to broaden the scope of the document to include scenarios affecting general aviation activities and flight information service officers alongside air traffic controllers.

The CAA is reliant upon the expertise being volunteered by the members of the UK FSC and regretfully, the document has not yet been published but we are expecting to receive a mature draft from the drafting group in March 2025. It will then be reviewed by the CAA prior to publication.

The text of Assimilated regulation 2015/340 (Air Traffic Controllers Certificates and Licences) describing the function of the Distress & Diversion Cell is currently being amended to align with CAP 493 (MATS Pt 1) with a view to publishing in 2025 or early 2026, being subject to the rulemaking process and parliamentary time.

The ATM Inspectorate has seen evidence that this incident has been used by a number of ANSPs as material for ATCO refresher training for revalidation (e.g. NERL and NSL). The CAA will issue a Safety notice in the new year asking ANSPs to include this incident in refresher training if they have not already done so.

Open - Traced actions

July 2025

2023-013: It is recommended that the Civil Aviation Authority specify the types of information that air traffic controllers will obtain and record when responding to aircraft in an emergency to ensure that pilots’ needs are met and reported correctly if communicated to other air traffic control units.

The CAA has reviewed the content of CAP 493 MATS Pt 1, CAP 797, Flight Information Service Officer (FISO) Manual and CAP 413 Radiotelephony manual and have determined that they provide sufficient and appropriate content relating to the information that should be  exchanged in an emergency situation.

In addition, the CAA will issue a Safety Notice in the new year to highlight the content of CAP 413 to flight schools and training organisations.

The syllabus for AGCS training as per CAP 452 has also been reviewed and the CAA is content that it is adequate to ensure appropriate response to aircraft emergencies within their remit.

Open - Tracked actions

July 2025

2023-014: It is recommended that the Civil Aviation Authority encourage the use of checklists in air traffic management operations when dealing with abnormal and emergency situations.

As advised in our last update, whilst the provision of checklists for an infinite set of circumstances/variables is not practicable, the CAA will continue to encourage use of checklists when it is appropriate and will consider this during its routine oversight of ANSPs.

In particular we will encourage the use of a checklist based on information to be provided by pilots which will be supported with additional text and examples of checklists within CAP 745.

Open - Tracked actions

July 2025

2023-015: It is recommended that the Civil Aviation Authority determine the effect the D&D Cell’s executive control has on civil ATCOs and inform civil ATCOs of any differences in their responsibilities whilst executive control is exercised.

Following discussions, the CAA and the MAA have agreed an amendment to terminology to remove possible confusion. The term ‘Executive control’ will be removed from both the MATS Part 1, when the next edition is published early next year, and the FISO manual and the MAA is in the process of amending its own regulatory documents to reflect the same.

Open - Tracked actions

July 2025