Richard Osman
PFD Report
All Responded
Ref: 2025-0311
All 3 responses received
· Deadline: 28 Jul 2025
Response Status
Responses
3 of 4
56-Day Deadline
28 Jul 2025
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
(1) That a full review of cockpit fire/smoke procedures be undertaken to include, but not limited to:
- the recognition of an oxygen fire (identifiable by a characteristic noise comparable to that of a blowtorch) and the immediate cutting off this oxygen supply.
- the installation or carrying of protective equipment to deal with any cockpit fires.
- a review of the effectiveness of Halon fire extinguishers to deal with onboard fires.
- a review of regulations (if required) to prevent the use of cigarettes in the cockpit and related flammable items and materials.
- the additional risk analyses to take into account the hypothesis of an overpressure in the oxygen distribution system.
(2) That a drafting committee be convened to consider amending Annex 13 of the Convention on International Civil Aviation signed at Chicago on 7 December 1944 to provide: (a) a right for states entitled to participate in an investigation to have access to evidence to enable those participating states to release a statement in accordance with Chapter 6.6.1 in circumstances where they have been excluded from an investigation by the State of Occurrence; (b) a right of states entitled to participate in an investigation to take over conduct of an investigation in circumstances where a State of Occurrence does not produce a Final Report within a reasonable timeframe and does not produce interim statements indicating the progress of the investigation and safety issues raised within a reasonable timeframe and has not otherwise consented to the delegation of the investigation in accordance with Chapter 5.1.
- the recognition of an oxygen fire (identifiable by a characteristic noise comparable to that of a blowtorch) and the immediate cutting off this oxygen supply.
- the installation or carrying of protective equipment to deal with any cockpit fires.
- a review of the effectiveness of Halon fire extinguishers to deal with onboard fires.
- a review of regulations (if required) to prevent the use of cigarettes in the cockpit and related flammable items and materials.
- the additional risk analyses to take into account the hypothesis of an overpressure in the oxygen distribution system.
(2) That a drafting committee be convened to consider amending Annex 13 of the Convention on International Civil Aviation signed at Chicago on 7 December 1944 to provide: (a) a right for states entitled to participate in an investigation to have access to evidence to enable those participating states to release a statement in accordance with Chapter 6.6.1 in circumstances where they have been excluded from an investigation by the State of Occurrence; (b) a right of states entitled to participate in an investigation to take over conduct of an investigation in circumstances where a State of Occurrence does not produce a Final Report within a reasonable timeframe and does not produce interim statements indicating the progress of the investigation and safety issues raised within a reasonable timeframe and has not otherwise consented to the delegation of the investigation in accordance with Chapter 5.1.
Responses
The Department for Transport stated that ICAO has already amended Annex 13 (SARP 5.1.3) to allow states to request takeover of investigations if no report is produced within thirty days. They do not believe further amendments regarding access to evidence are necessary, as accredited representatives already have full access.
AI summary
View full response
Dear Mr Bennett,
Prevention of Future Deaths Notice Response
Thank you for your report of 10th June 2025 (Case Reference made under the Coroners and Justice Act 2009 and the Coroners (Investigations) Regulations 2013, following the conclusion of the inquest conducted into the death of Richard Mohamed Fekry Osman. I am responding as Minister for Aviation, Maritime and Security.
I was deeply saddened by the circumstances of Mr Osman’s death and extend my condolences to Mr Osman’s family and friends.
The UK Civil Aviation Authority (CAA) is addressing Point 1 of the Coroner’s Prevention of Future Deaths Notice in their own response. This letter is to address Points 2) (a) and (b) of your report:
(2) That a drafting committee be convened to consider amending Annex 13 of the Convention on International Civil Aviation signed at Chicago on 7 December 1944 to provide:
(a) a right for states entitled to participate in an investigation to have access to evidence to enable those participating states to release a statement in accordance with Chapter 6.6.1 in circumstances where they have been excluded from an investigation by the state of occurrence;
P Bennett North Wing County Hall Haverfordwest SA61 1TP From the Minister for Aviation, Maritime and Security
Department for Transport Great Minster House 33 Horseferry Road London SW1P 4DR
OFFICIAL
OFFICIAL
(b) A right of states entitled to participate in an investigation to take over conduct of an investigation in circumstances where a state of occurrence does not produce a final report within a reasonable timeframe and does not produce interim statements indicating the progress of the investigation and safety issues raised within a reasonable timeframe and has not otherwise consented to the delegation of the investigation in accordance with Chapter 5.1.
The Department for Transport (DfT) is committed to working with other agencies, both domestically and internationally, to strive towards zero accidents involving commercial air transport that result in serious injuries or fatalities and no serious injuries or fatalities to third parties as a result of aviation activities.
As a signatory to the Chicago Convention on Civil Aviation, the investigation of all aircraft accidents involving the United Kingdom and its citizens is governed by the International Civil Aviation Organization (ICAO), as detailed in Annex 13 to the Convention on International Civil Aviation.
All ICAO member states can contribute to the development or modification of a Standard and Recommended Practice (SARP). Other than in exceptional circumstances, member states are expected to transpose the contents of a SARP into domestic regulations. There are currently 193 ICAO member states, including Egypt, France and the United Kingdom. The United Kingdom has transposed the contents of Annex 13 into domestic law through The Civil Aviation (Investigation of Air Accidents and Incidents) Regulations 2018.
Annex 13 clearly sets out the roles in air accident investigation. Where a state has the technical competencies to do so, the state of occurrence will lead on the accident investigation, for EgyptAir Flight 804 investigation this was the Egyptian Aircraft Accident Investigation Directorate (EAAID). The investigative authorities of the state(s) where the aircraft and its engines were designed and/or manufactured are afforded the status of ‘accredited representative’, which allows them full access to and participation in the investigation. As the state of design and manufacture of the aircraft type, the French aircraft accident investigation authority, the Bureau of Enquiry and Analysis for Civil Aviation Safety (BEA) participated in the accident investigation, as did the National Transportation Safety Board (NTSB), as the state of design of the aircraft’s engines.
Investigative authorities from states whose nationals were killed or injured in an accident are afforded ‘expert’ status in accident investigations, the United Kingdom’s Air Accidents Investigation Branch (AAIB) was assigned this status for the EgyptAir Flight 804 investigation as one British national had died. ‘Expert’ officials have more limited access to the investigation and are only entitled to visit the scene of the
OFFICIAL
OFFICIAL accident, access information approved for public release, receive information on the progress of the investigation and receive a copy of the final report.
It is already the case that accredited representatives (usually investigators from the state of design, operation or registry) have full access to the investigation materials and evidence. There are safeguards in place to protect evidence in accident investigations being more widely available for very good reasons. These include people being more likely to cooperate knowing any evidence they provide will not be used against them in civil or criminal proceedings. This contributes to a “just culture” of being open and honest and prioritising learning over assigning blame. There are also ethical considerations about protecting individuals involved and controlling access to evidence which also helps maintain the chain of custody. Therefore with regard to Point 2a, we do not believe further amendments regarding access to evidence are necessary.
In relation to Point 2b, since the accident ICAO has amended Annex 13 via SARP
5.1.3 (Amendment 17 of Annex 13) introducing the right for another state to request that they take over investigative responsibility should no investigation be initiated within thirty days and giving states the right to do their own investigation using widely available information if no investigation is then initiated. ICAO also encourages states to release information publicly in the early days of the investigation. It is important to maintain clear roles and parameters for involvement in accident investigations to ensure they remain impartial, they are investigated thoroughly and lessons are learned to prevent future recurrence.
The DfT believes the above provides adequate assurance that accidents involving British nationals abroad will be appropriately investigated.
The safety of the travelling public is a priority and the DfT will continue to prioritise improvements to global aviation safety.
Prevention of Future Deaths Notice Response
Thank you for your report of 10th June 2025 (Case Reference made under the Coroners and Justice Act 2009 and the Coroners (Investigations) Regulations 2013, following the conclusion of the inquest conducted into the death of Richard Mohamed Fekry Osman. I am responding as Minister for Aviation, Maritime and Security.
I was deeply saddened by the circumstances of Mr Osman’s death and extend my condolences to Mr Osman’s family and friends.
The UK Civil Aviation Authority (CAA) is addressing Point 1 of the Coroner’s Prevention of Future Deaths Notice in their own response. This letter is to address Points 2) (a) and (b) of your report:
(2) That a drafting committee be convened to consider amending Annex 13 of the Convention on International Civil Aviation signed at Chicago on 7 December 1944 to provide:
(a) a right for states entitled to participate in an investigation to have access to evidence to enable those participating states to release a statement in accordance with Chapter 6.6.1 in circumstances where they have been excluded from an investigation by the state of occurrence;
P Bennett North Wing County Hall Haverfordwest SA61 1TP From the Minister for Aviation, Maritime and Security
Department for Transport Great Minster House 33 Horseferry Road London SW1P 4DR
OFFICIAL
OFFICIAL
(b) A right of states entitled to participate in an investigation to take over conduct of an investigation in circumstances where a state of occurrence does not produce a final report within a reasonable timeframe and does not produce interim statements indicating the progress of the investigation and safety issues raised within a reasonable timeframe and has not otherwise consented to the delegation of the investigation in accordance with Chapter 5.1.
The Department for Transport (DfT) is committed to working with other agencies, both domestically and internationally, to strive towards zero accidents involving commercial air transport that result in serious injuries or fatalities and no serious injuries or fatalities to third parties as a result of aviation activities.
As a signatory to the Chicago Convention on Civil Aviation, the investigation of all aircraft accidents involving the United Kingdom and its citizens is governed by the International Civil Aviation Organization (ICAO), as detailed in Annex 13 to the Convention on International Civil Aviation.
All ICAO member states can contribute to the development or modification of a Standard and Recommended Practice (SARP). Other than in exceptional circumstances, member states are expected to transpose the contents of a SARP into domestic regulations. There are currently 193 ICAO member states, including Egypt, France and the United Kingdom. The United Kingdom has transposed the contents of Annex 13 into domestic law through The Civil Aviation (Investigation of Air Accidents and Incidents) Regulations 2018.
Annex 13 clearly sets out the roles in air accident investigation. Where a state has the technical competencies to do so, the state of occurrence will lead on the accident investigation, for EgyptAir Flight 804 investigation this was the Egyptian Aircraft Accident Investigation Directorate (EAAID). The investigative authorities of the state(s) where the aircraft and its engines were designed and/or manufactured are afforded the status of ‘accredited representative’, which allows them full access to and participation in the investigation. As the state of design and manufacture of the aircraft type, the French aircraft accident investigation authority, the Bureau of Enquiry and Analysis for Civil Aviation Safety (BEA) participated in the accident investigation, as did the National Transportation Safety Board (NTSB), as the state of design of the aircraft’s engines.
Investigative authorities from states whose nationals were killed or injured in an accident are afforded ‘expert’ status in accident investigations, the United Kingdom’s Air Accidents Investigation Branch (AAIB) was assigned this status for the EgyptAir Flight 804 investigation as one British national had died. ‘Expert’ officials have more limited access to the investigation and are only entitled to visit the scene of the
OFFICIAL
OFFICIAL accident, access information approved for public release, receive information on the progress of the investigation and receive a copy of the final report.
It is already the case that accredited representatives (usually investigators from the state of design, operation or registry) have full access to the investigation materials and evidence. There are safeguards in place to protect evidence in accident investigations being more widely available for very good reasons. These include people being more likely to cooperate knowing any evidence they provide will not be used against them in civil or criminal proceedings. This contributes to a “just culture” of being open and honest and prioritising learning over assigning blame. There are also ethical considerations about protecting individuals involved and controlling access to evidence which also helps maintain the chain of custody. Therefore with regard to Point 2a, we do not believe further amendments regarding access to evidence are necessary.
In relation to Point 2b, since the accident ICAO has amended Annex 13 via SARP
5.1.3 (Amendment 17 of Annex 13) introducing the right for another state to request that they take over investigative responsibility should no investigation be initiated within thirty days and giving states the right to do their own investigation using widely available information if no investigation is then initiated. ICAO also encourages states to release information publicly in the early days of the investigation. It is important to maintain clear roles and parameters for involvement in accident investigations to ensure they remain impartial, they are investigated thoroughly and lessons are learned to prevent future recurrence.
The DfT believes the above provides adequate assurance that accidents involving British nationals abroad will be appropriately investigated.
The safety of the travelling public is a priority and the DfT will continue to prioritise improvements to global aviation safety.
The Civil Aviation Authority concluded that no changes to the existing aviation safety regulation framework for cockpit fire/smoke procedures are currently required, as current safeguards provide adequate risk mitigation. They will, however, continue to monitor safety data and future investigation recommendations.
AI summary
View full response
- Named Parties Only. This information is intended for HM Assistant Coroner, CAA and Interested Persons only OFFICIAL SENSITIVE - Named Parties Only: Legal Privilege
MR JONATHAN MARK LAYTON – HM ASSISTANT CORONER FOR CARMARTHENSHIRE & PEMBROKESHIRE CORONER’S COURT INVESTIGATION INTO THE DEATH OF RICHARD MOHAMED FEKRY OSMAN
CIVIL AVIATION AUTHORITY RESPONSE TO A REPORT ON ACTION TO PREVENT OTHER DEATHS PURSUANT TO REGULATIONS 28 & 29 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013
Introduction The UK Civil Aviation Authority (‘CAA’) would first like to express its sincere condolences to the family and friends of Mr. Osman. The CAA is a public corporation, established by Parliament in 1972 as an independent specialist aviation regulator. The CAA works so that:
• the aviation industry meets the highest safety standards,
• consumers have choice, value for money, are protected and treated fairly when they fly,
• through efficient use of airspace, the environmental impact of aviation on local communities is effectively managed and CO2 emissions are reduced,
• the aviation industry manages security risks effectively.
The CAA has carefully considered the Regulation 28 Report to prevent future deaths issued by the Assistant Coroner for Carmarthenshire & Pembrokeshire dated 5 June 2025 (‘the Report’), which includes the following recommendations that are relevant to the role and functions of the CAA, insofar as they apply only to aircraft registered and operated within the UK:
… That a full review of cockpit fire/smoke procedures be undertaken to include, but not limited to:
- the recognition of an oxygen fire (identifiable by a characteristic noise comparable to that of a blowtorch) and the immediate cutting off this oxygen supply.
- the installation or carrying of protective equipment to deal with any cockpit fires.
- a review of the effectiveness of Halon fire extinguishers to deal with onboard fires.
- a review of regulations (if required) to prevent the use of cigarettes in the cockpit and related flammable items and materials.
- the additional risk analyses to take into account the hypothesis of an overpressure in the oxygen distribution system. The CAA was not an Interested Person at this inquest. As such, it did not have access to the inquest evidence. When preparing this response, with a view to explaining the outcome of its review, the CAA has relied on the information contained in the Report, together with regulatory information and safety data held by the CAA and input from regulatory subject matter experts in civilian flight operations,
OFFICIAL - Named Parties Only. This information is intended for HM Assistant Coroner, CAA and Interested Persons only OFFICIAL SENSITIVE - Named Parties Only: Legal Privilege aircraft airworthiness and aeromedicine. The CAA’s Approach The CAA has acknowledged the concerns identified by the Assistant Coroner. In particular, those related to the risk of oxygen fire onboard a commercial aircraft, cockpit (‘flight deck’) fire/smoke procedures, the effectiveness of equipment for dealing with fire and how the current aviation safety regulation framework works to prevent such incidents. This response addresses the recommendations in the report, specifically in relation to large commercial aircraft. It outlines the relevant regulatory requirements, the measures in place to mitigate and respond to such risks, and the CAA’s role and function in overseeing these processes. The CAA is not responsible for the investigation of aircraft accidents or serious incidents on behalf of the UK, which falls to the Air Accidents Investigation Branch (‘AAIB’), a body who report directly to the Secretary of State for Transport. Procedures for these investigations are laid down in international protocols, specifically the standards and recommended practices defined in Annex 13 to the Convention on International Civil Aviation, Aircraft Accident and Incident Investigation, and published by the International Civil Aviation Organization (‘ICAO’). The CAA understands that the Department for Transport (‘DfT’) will, therefore, respond separately to those aspects of the Report which relate to aircraft accident investigation. We can confirm that we have exchanged responses with the DfT prior to filing this response with the court. Regulatory framework The UK’s aviation safety framework is designed to ensure that aircraft systems are developed and maintained to the highest safety standards. As the UK’s specialist aviation regulator, the CAA oversees compliance with domestic aviation safety regulations, including those covering the design, certification, operation, and ongoing maintenance of aircraft on the UK register. The CAA is also the UK’s competent authority for ensuring compliance with international obligations, including those issued by ICAO. The process of ensuring commercial aircraft are safe to operate begins with initial airworthiness1, referring to the design and certification phase, during which aircraft and their systems (including those which mitigate the risk of hazards onboard aircraft) must demonstrate compliance with detailed safety requirements before entering service. For large commercial aircraft, design standards are set out in Certification Specifications (‘CS’) (CS-252 applies to large aircraft). Although applied within individual international jurisdictions, CS are developed with close collaboration between regulators working across international jurisdictions, with extensive input from the wider aircraft design and manufacturing community. In practice, this results in a high degree of international consistency, ensuring that standards are technically robust and harmonised across regulatory systems. Once in service, aircraft must comply with the requirements within the UK Air Operations Regulation3 which are underpinned by a safety management system: a structured and proactive approach to managing safety risks that supports day-to-day safety management and operational decision making4. Alongside this, aircraft must continue to meet ongoing technical and maintenance requirements through a process known as continuing airworthiness5, including compliance with any Airworthiness Directives
1 UK Regulation (EU) No. 748/2012 (“UK Initial Airworthiness Regulation”) 2 CS-25 Amendment 28 3 UK Regulation (EU) No. 965/2012 (“UK Air Operations Regulation”) 4 UK Air Operations Regulation ORO.GEN.200; Annex 19 to the Convention on International Civil Aviation 5 UK Regulation (EU) No. 1321/2014 (“UK Continuing Airworthiness Regulation”)
OFFICIAL - Named Parties Only. This information is intended for HM Assistant Coroner, CAA and Interested Persons only OFFICIAL SENSITIVE - Named Parties Only: Legal Privilege (ADs) issued to address emerging concerns. Together, these requirements ensure that systems remain safe and effective over time, including systems for the prevention and management of operational risks including onboard fires. Fire prevention onboard commercial aircraft Oxygen systems and pressurisation Commercial aircraft are typically equipped with gaseous oxygen systems, which are designed to supply oxygen to passengers and crew in the event of emergencies such as cabin depressurisation or severe fume events. These systems play a critical safety role but are not used during routine flight operations, as the aircraft’s pressurisation system provides sufficient oxygen under standard conditions. Design and certification specifications for gaseous oxygen systems onboard commercial aircraft are designed to prevent a fire from occurring, noting the impact of fire risks on such systems, and include multiple safeguards and mitigations.6 These systems must meet stringent safety requirements; oxygen systems are required to be free from hazards, with design organisations required to demonstrate, through system safety assessments, that the likelihood of an uncontrolled oxygen fire at the aircraft level is extremely improbable and would not result from a single failure of any system or associated component7. Risk assessments are comprehensive and should cover equipment failures, operating conditions, components and materials, ignition mechanism and kindling chain. Current design standards for large commercial aircraft already require oxygen systems to be resilient against potential pressure surges and temperature effects8. The risk of overpressure in gaseous oxygen systems is addressed through design specifications, requiring oxygen equipment to be protected from rupture. These systems are built with proof and burst pressure factors, and all oxygen systems are required to have overpressure relief valves to safely vent excess pressure. Smoking and other flammable materials in the flight deck The Air Navigation Order 20169 and the UK Air Operations Regulation10 provide the legal framework for restricting smoking onboard commercial aircraft. The UK Air Operations Regulation enables the pilot-in-command to prohibit smoking anywhere on board in a range of operational scenarios and whenever considered necessary in the interest of safety.
While there is no specific reference to smoking in the flight deck within these regulations, the CAA is not aware of any UK aircraft operators that allow smoking in any part of an aircraft, including the flight deck. Flight crew receive extensive training in safety and risk management, with a strong emphasis on maintaining a controlled and hazard-free operating environment onboard aircraft. In addition, all safety related occurrences must be reported to the CAA, which enables data to be collected and analysed over time. Following a review of the coroner’s request, the UK CAA Safety Intelligence Team have confirmed that there have been no reported UK incidents involving smoking or vaping in the flight deck in the past decade.11 Whilst we recognise the legal framework does not expressly prohibit smoking in the flight deck, the CAA’s regulatory oversight derived from working closely with operators, and safety data derived from
6 CS 25.1441, CS 25.869 7 CS 25.1309(b) 8 CS 25.1453 9 Article 243 The Air Navigation Order 2016 10 UK Air Operations Regulation CAT.OP.MPA.240 11 Mandatory Occurrence Reporting data analysis for period 01/01/15 to 24/06/25
OFFICIAL - Named Parties Only. This information is intended for HM Assistant Coroner, CAA and Interested Persons only OFFICIAL SENSITIVE - Named Parties Only: Legal Privilege the UK Mandatory Occurrence Reporting Regulation12, does not currently indicate a safety risk or safety gap that would require regulatory change. Regarding other flammable materials, aircraft design standards require that all installed equipment in the flight deck and aircraft cabin are fire-resistant and meet specific fire-resistance criteria13. Operators are also expected to manage their risks associated with flight crew personal items and equipment, with specific Dangerous Goods approval required for the carriage of certain hazardous materials, in accordance with ICAO specifications. This approval is obtained by applying to the CAA and demonstrating compliance with safety requirements, including staff training and operational procedures14. Flight crew are also subject to aviation security screening15. The role of ongoing maintenance in prevention The CAA places significant emphasis on the continuing airworthiness of commercial aircraft as a further layer of safety risk mitigation. All CS systems, including oxygen systems and fire protection equipment, are subject to regular inspection, testing, and maintenance in accordance with approved maintenance programmes. This ensures that any degradation or malfunction is identified and addressed before it may contribute to an incident. Continuing airworthiness involves a structured programme of regular inspections, maintenance, repairs, and system checks, performed by licensed engineers and approved maintenance organisations. Operators are required to follow a maintenance schedule tailored to each aircraft type, which includes both routine servicing and in-depth checks at defined intervals, as well as specific pre- flight checks16. In addition, any defects or unusual findings must be reported, investigated, and resolved before an aircraft can return to service. This process is supported by detailed record-keeping, ensuring traceability and accountability for maintenance actions. The CAA is responsible for conducting compliance audits of approved maintenance organisations in accordance with the requirements set out in the UK Continuing Airworthiness Regulation. No new fire risks have been identified by the CAA as a result of this audit programme and the CAA remains satisfied that all known risks fall within existing design, certification and operational controls.
Managing fires onboard commercial aircraft The regulatory framework is designed to address both the prevention of onboard fires, as well as the ability to detect and respond effectively should they occur. Under the UK Air Operations Regulation, large transport category aircraft must carry fire extinguishers in the flight deck and cabin, with at least one located in the flight deck. The number of additional extinguishers required in the aircraft cabin are linked to passenger capacity17. Halon fire extinguishers have traditionally been used by commercial aircraft operators to meet these requirements due to their effectiveness in confined aircraft environments. However, their use is being phased out due to environmental concerns18, and from 31 December 2025, Halon-free extinguishers,
12 Occurrence Reporting | UK Civil Aviation Authority 13 CS 25.853, Appendix F to CS 25.853 14 SPA.DG.105 Approval to transport dangerous goods, UK Air Operations Regulation AMC3 ORO.MLR.100 15 Regulation (EC) No 300/2008 of the European Parliament (retained EU law) 16 UK Continuing Airworthiness Regulation Annex I (Part-M) GM M.A.301(i); UK Regulation (EU) 2018/1139 (‘UK Basic Regulation’) Annex V, 6.2 17 UK Air Operations Regulation CAT.IDE.A.250 18 Regulation (EC) No 1005/2009 (retained EU law)
OFFICIAL - Named Parties Only. This information is intended for HM Assistant Coroner, CAA and Interested Persons only OFFICIAL SENSITIVE - Named Parties Only: Legal Privilege which must meet the same minimum performance standards will be mandated by CS25.851(a) and the Minimum Operating Standards defined in FAA Advisory Circular AC20-42D. The CAA supports this transition. All flight crew onboard large commercial transport aircraft are required to undergo regular training on the handling and use of fire-fighting equipment, protective breathing equipment, and the effects of smoke on an enclosed area19. In the event of fire in the flight deck, flight crew must also have access to a crash axe or crowbar20 in order to access panels where fire sources may originate, as well as to portable oxygen to enable movement around the flight deck and aircraft cabin21. Conclusion The CAA’s review of the Assistant Coroner’s recommendations has concluded that no change to the existing aviation safety regulation framework is currently required. The CAA remains satisfied that the safeguards in place, which are underpinned by airworthiness and operational regulations, design and certification requirements and operator safety management systems provide adequate risk mitigation. As part of this review, subject matter experts have examined relevant safety data held by the CAA under the Mandatory Occurrence Reporting Scheme, which does not indicate there is a risk of fire onboard large commercial aircraft - or the consequences of a flight deck fire - necessitate changes to existing rules. The CAA is also mindful of international requirements directed by ICAO which do not support change to existing fire safety controls at the present time. However, given the specific concerns identified by the Assistant Coroner, the CAA will continue to carefully monitor safety data and future aviation safety investigation recommendations related to fire risks with a view to taking appropriate action where necessary.
Signed: Head of Design & Certification (Chief Engineer) Future Safety & Innovation Civil Aviation Authority 24 July 2025
19 UK Air Operations Regulation ORO.FC.230; AMC1 ORO.FC.230 20 UK Air Operations Regulation CAT.IDE.A.255 21 UK Air Operations Regulation CAT.IDE.A.235
MR JONATHAN MARK LAYTON – HM ASSISTANT CORONER FOR CARMARTHENSHIRE & PEMBROKESHIRE CORONER’S COURT INVESTIGATION INTO THE DEATH OF RICHARD MOHAMED FEKRY OSMAN
CIVIL AVIATION AUTHORITY RESPONSE TO A REPORT ON ACTION TO PREVENT OTHER DEATHS PURSUANT TO REGULATIONS 28 & 29 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013
Introduction The UK Civil Aviation Authority (‘CAA’) would first like to express its sincere condolences to the family and friends of Mr. Osman. The CAA is a public corporation, established by Parliament in 1972 as an independent specialist aviation regulator. The CAA works so that:
• the aviation industry meets the highest safety standards,
• consumers have choice, value for money, are protected and treated fairly when they fly,
• through efficient use of airspace, the environmental impact of aviation on local communities is effectively managed and CO2 emissions are reduced,
• the aviation industry manages security risks effectively.
The CAA has carefully considered the Regulation 28 Report to prevent future deaths issued by the Assistant Coroner for Carmarthenshire & Pembrokeshire dated 5 June 2025 (‘the Report’), which includes the following recommendations that are relevant to the role and functions of the CAA, insofar as they apply only to aircraft registered and operated within the UK:
… That a full review of cockpit fire/smoke procedures be undertaken to include, but not limited to:
- the recognition of an oxygen fire (identifiable by a characteristic noise comparable to that of a blowtorch) and the immediate cutting off this oxygen supply.
- the installation or carrying of protective equipment to deal with any cockpit fires.
- a review of the effectiveness of Halon fire extinguishers to deal with onboard fires.
- a review of regulations (if required) to prevent the use of cigarettes in the cockpit and related flammable items and materials.
- the additional risk analyses to take into account the hypothesis of an overpressure in the oxygen distribution system. The CAA was not an Interested Person at this inquest. As such, it did not have access to the inquest evidence. When preparing this response, with a view to explaining the outcome of its review, the CAA has relied on the information contained in the Report, together with regulatory information and safety data held by the CAA and input from regulatory subject matter experts in civilian flight operations,
OFFICIAL - Named Parties Only. This information is intended for HM Assistant Coroner, CAA and Interested Persons only OFFICIAL SENSITIVE - Named Parties Only: Legal Privilege aircraft airworthiness and aeromedicine. The CAA’s Approach The CAA has acknowledged the concerns identified by the Assistant Coroner. In particular, those related to the risk of oxygen fire onboard a commercial aircraft, cockpit (‘flight deck’) fire/smoke procedures, the effectiveness of equipment for dealing with fire and how the current aviation safety regulation framework works to prevent such incidents. This response addresses the recommendations in the report, specifically in relation to large commercial aircraft. It outlines the relevant regulatory requirements, the measures in place to mitigate and respond to such risks, and the CAA’s role and function in overseeing these processes. The CAA is not responsible for the investigation of aircraft accidents or serious incidents on behalf of the UK, which falls to the Air Accidents Investigation Branch (‘AAIB’), a body who report directly to the Secretary of State for Transport. Procedures for these investigations are laid down in international protocols, specifically the standards and recommended practices defined in Annex 13 to the Convention on International Civil Aviation, Aircraft Accident and Incident Investigation, and published by the International Civil Aviation Organization (‘ICAO’). The CAA understands that the Department for Transport (‘DfT’) will, therefore, respond separately to those aspects of the Report which relate to aircraft accident investigation. We can confirm that we have exchanged responses with the DfT prior to filing this response with the court. Regulatory framework The UK’s aviation safety framework is designed to ensure that aircraft systems are developed and maintained to the highest safety standards. As the UK’s specialist aviation regulator, the CAA oversees compliance with domestic aviation safety regulations, including those covering the design, certification, operation, and ongoing maintenance of aircraft on the UK register. The CAA is also the UK’s competent authority for ensuring compliance with international obligations, including those issued by ICAO. The process of ensuring commercial aircraft are safe to operate begins with initial airworthiness1, referring to the design and certification phase, during which aircraft and their systems (including those which mitigate the risk of hazards onboard aircraft) must demonstrate compliance with detailed safety requirements before entering service. For large commercial aircraft, design standards are set out in Certification Specifications (‘CS’) (CS-252 applies to large aircraft). Although applied within individual international jurisdictions, CS are developed with close collaboration between regulators working across international jurisdictions, with extensive input from the wider aircraft design and manufacturing community. In practice, this results in a high degree of international consistency, ensuring that standards are technically robust and harmonised across regulatory systems. Once in service, aircraft must comply with the requirements within the UK Air Operations Regulation3 which are underpinned by a safety management system: a structured and proactive approach to managing safety risks that supports day-to-day safety management and operational decision making4. Alongside this, aircraft must continue to meet ongoing technical and maintenance requirements through a process known as continuing airworthiness5, including compliance with any Airworthiness Directives
1 UK Regulation (EU) No. 748/2012 (“UK Initial Airworthiness Regulation”) 2 CS-25 Amendment 28 3 UK Regulation (EU) No. 965/2012 (“UK Air Operations Regulation”) 4 UK Air Operations Regulation ORO.GEN.200; Annex 19 to the Convention on International Civil Aviation 5 UK Regulation (EU) No. 1321/2014 (“UK Continuing Airworthiness Regulation”)
OFFICIAL - Named Parties Only. This information is intended for HM Assistant Coroner, CAA and Interested Persons only OFFICIAL SENSITIVE - Named Parties Only: Legal Privilege (ADs) issued to address emerging concerns. Together, these requirements ensure that systems remain safe and effective over time, including systems for the prevention and management of operational risks including onboard fires. Fire prevention onboard commercial aircraft Oxygen systems and pressurisation Commercial aircraft are typically equipped with gaseous oxygen systems, which are designed to supply oxygen to passengers and crew in the event of emergencies such as cabin depressurisation or severe fume events. These systems play a critical safety role but are not used during routine flight operations, as the aircraft’s pressurisation system provides sufficient oxygen under standard conditions. Design and certification specifications for gaseous oxygen systems onboard commercial aircraft are designed to prevent a fire from occurring, noting the impact of fire risks on such systems, and include multiple safeguards and mitigations.6 These systems must meet stringent safety requirements; oxygen systems are required to be free from hazards, with design organisations required to demonstrate, through system safety assessments, that the likelihood of an uncontrolled oxygen fire at the aircraft level is extremely improbable and would not result from a single failure of any system or associated component7. Risk assessments are comprehensive and should cover equipment failures, operating conditions, components and materials, ignition mechanism and kindling chain. Current design standards for large commercial aircraft already require oxygen systems to be resilient against potential pressure surges and temperature effects8. The risk of overpressure in gaseous oxygen systems is addressed through design specifications, requiring oxygen equipment to be protected from rupture. These systems are built with proof and burst pressure factors, and all oxygen systems are required to have overpressure relief valves to safely vent excess pressure. Smoking and other flammable materials in the flight deck The Air Navigation Order 20169 and the UK Air Operations Regulation10 provide the legal framework for restricting smoking onboard commercial aircraft. The UK Air Operations Regulation enables the pilot-in-command to prohibit smoking anywhere on board in a range of operational scenarios and whenever considered necessary in the interest of safety.
While there is no specific reference to smoking in the flight deck within these regulations, the CAA is not aware of any UK aircraft operators that allow smoking in any part of an aircraft, including the flight deck. Flight crew receive extensive training in safety and risk management, with a strong emphasis on maintaining a controlled and hazard-free operating environment onboard aircraft. In addition, all safety related occurrences must be reported to the CAA, which enables data to be collected and analysed over time. Following a review of the coroner’s request, the UK CAA Safety Intelligence Team have confirmed that there have been no reported UK incidents involving smoking or vaping in the flight deck in the past decade.11 Whilst we recognise the legal framework does not expressly prohibit smoking in the flight deck, the CAA’s regulatory oversight derived from working closely with operators, and safety data derived from
6 CS 25.1441, CS 25.869 7 CS 25.1309(b) 8 CS 25.1453 9 Article 243 The Air Navigation Order 2016 10 UK Air Operations Regulation CAT.OP.MPA.240 11 Mandatory Occurrence Reporting data analysis for period 01/01/15 to 24/06/25
OFFICIAL - Named Parties Only. This information is intended for HM Assistant Coroner, CAA and Interested Persons only OFFICIAL SENSITIVE - Named Parties Only: Legal Privilege the UK Mandatory Occurrence Reporting Regulation12, does not currently indicate a safety risk or safety gap that would require regulatory change. Regarding other flammable materials, aircraft design standards require that all installed equipment in the flight deck and aircraft cabin are fire-resistant and meet specific fire-resistance criteria13. Operators are also expected to manage their risks associated with flight crew personal items and equipment, with specific Dangerous Goods approval required for the carriage of certain hazardous materials, in accordance with ICAO specifications. This approval is obtained by applying to the CAA and demonstrating compliance with safety requirements, including staff training and operational procedures14. Flight crew are also subject to aviation security screening15. The role of ongoing maintenance in prevention The CAA places significant emphasis on the continuing airworthiness of commercial aircraft as a further layer of safety risk mitigation. All CS systems, including oxygen systems and fire protection equipment, are subject to regular inspection, testing, and maintenance in accordance with approved maintenance programmes. This ensures that any degradation or malfunction is identified and addressed before it may contribute to an incident. Continuing airworthiness involves a structured programme of regular inspections, maintenance, repairs, and system checks, performed by licensed engineers and approved maintenance organisations. Operators are required to follow a maintenance schedule tailored to each aircraft type, which includes both routine servicing and in-depth checks at defined intervals, as well as specific pre- flight checks16. In addition, any defects or unusual findings must be reported, investigated, and resolved before an aircraft can return to service. This process is supported by detailed record-keeping, ensuring traceability and accountability for maintenance actions. The CAA is responsible for conducting compliance audits of approved maintenance organisations in accordance with the requirements set out in the UK Continuing Airworthiness Regulation. No new fire risks have been identified by the CAA as a result of this audit programme and the CAA remains satisfied that all known risks fall within existing design, certification and operational controls.
Managing fires onboard commercial aircraft The regulatory framework is designed to address both the prevention of onboard fires, as well as the ability to detect and respond effectively should they occur. Under the UK Air Operations Regulation, large transport category aircraft must carry fire extinguishers in the flight deck and cabin, with at least one located in the flight deck. The number of additional extinguishers required in the aircraft cabin are linked to passenger capacity17. Halon fire extinguishers have traditionally been used by commercial aircraft operators to meet these requirements due to their effectiveness in confined aircraft environments. However, their use is being phased out due to environmental concerns18, and from 31 December 2025, Halon-free extinguishers,
12 Occurrence Reporting | UK Civil Aviation Authority 13 CS 25.853, Appendix F to CS 25.853 14 SPA.DG.105 Approval to transport dangerous goods, UK Air Operations Regulation AMC3 ORO.MLR.100 15 Regulation (EC) No 300/2008 of the European Parliament (retained EU law) 16 UK Continuing Airworthiness Regulation Annex I (Part-M) GM M.A.301(i); UK Regulation (EU) 2018/1139 (‘UK Basic Regulation’) Annex V, 6.2 17 UK Air Operations Regulation CAT.IDE.A.250 18 Regulation (EC) No 1005/2009 (retained EU law)
OFFICIAL - Named Parties Only. This information is intended for HM Assistant Coroner, CAA and Interested Persons only OFFICIAL SENSITIVE - Named Parties Only: Legal Privilege which must meet the same minimum performance standards will be mandated by CS25.851(a) and the Minimum Operating Standards defined in FAA Advisory Circular AC20-42D. The CAA supports this transition. All flight crew onboard large commercial transport aircraft are required to undergo regular training on the handling and use of fire-fighting equipment, protective breathing equipment, and the effects of smoke on an enclosed area19. In the event of fire in the flight deck, flight crew must also have access to a crash axe or crowbar20 in order to access panels where fire sources may originate, as well as to portable oxygen to enable movement around the flight deck and aircraft cabin21. Conclusion The CAA’s review of the Assistant Coroner’s recommendations has concluded that no change to the existing aviation safety regulation framework is currently required. The CAA remains satisfied that the safeguards in place, which are underpinned by airworthiness and operational regulations, design and certification requirements and operator safety management systems provide adequate risk mitigation. As part of this review, subject matter experts have examined relevant safety data held by the CAA under the Mandatory Occurrence Reporting Scheme, which does not indicate there is a risk of fire onboard large commercial aircraft - or the consequences of a flight deck fire - necessitate changes to existing rules. The CAA is also mindful of international requirements directed by ICAO which do not support change to existing fire safety controls at the present time. However, given the specific concerns identified by the Assistant Coroner, the CAA will continue to carefully monitor safety data and future aviation safety investigation recommendations related to fire risks with a view to taking appropriate action where necessary.
Signed: Head of Design & Certification (Chief Engineer) Future Safety & Innovation Civil Aviation Authority 24 July 2025
19 UK Air Operations Regulation ORO.FC.230; AMC1 ORO.FC.230 20 UK Air Operations Regulation CAT.IDE.A.255 21 UK Air Operations Regulation CAT.IDE.A.235
The Civil Aviation Authority concluded that no changes to the existing aviation safety regulation framework for cockpit fire/smoke procedures are currently required, as current safeguards provide adequate risk mitigation. They will, however, continue to monitor safety data and future investigation recommendations.
AI summary
View full response
- Named Parties Only. This information is intended for HM Assistant Coroner, CAA and Interested Persons only OFFICIAL SENSITIVE - Named Parties Only: Legal Privilege
MR JONATHAN MARK LAYTON – HM ASSISTANT CORONER FOR CARMARTHENSHIRE & PEMBROKESHIRE CORONER’S COURT INVESTIGATION INTO THE DEATH OF RICHARD MOHAMED FEKRY OSMAN
CIVIL AVIATION AUTHORITY RESPONSE TO A REPORT ON ACTION TO PREVENT OTHER DEATHS PURSUANT TO REGULATIONS 28 & 29 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013
Introduction The UK Civil Aviation Authority (‘CAA’) would first like to express its sincere condolences to the family and friends of Mr. Osman. The CAA is a public corporation, established by Parliament in 1972 as an independent specialist aviation regulator. The CAA works so that:
• the aviation industry meets the highest safety standards,
• consumers have choice, value for money, are protected and treated fairly when they fly,
• through efficient use of airspace, the environmental impact of aviation on local communities is effectively managed and CO2 emissions are reduced,
• the aviation industry manages security risks effectively.
The CAA has carefully considered the Regulation 28 Report to prevent future deaths issued by the Assistant Coroner for Carmarthenshire & Pembrokeshire dated 5 June 2025 (‘the Report’), which includes the following recommendations that are relevant to the role and functions of the CAA, insofar as they apply only to aircraft registered and operated within the UK:
… That a full review of cockpit fire/smoke procedures be undertaken to include, but not limited to:
- the recognition of an oxygen fire (identifiable by a characteristic noise comparable to that of a blowtorch) and the immediate cutting off this oxygen supply.
- the installation or carrying of protective equipment to deal with any cockpit fires.
- a review of the effectiveness of Halon fire extinguishers to deal with onboard fires.
- a review of regulations (if required) to prevent the use of cigarettes in the cockpit and related flammable items and materials.
- the additional risk analyses to take into account the hypothesis of an overpressure in the oxygen distribution system. The CAA was not an Interested Person at this inquest. As such, it did not have access to the inquest evidence. When preparing this response, with a view to explaining the outcome of its review, the CAA has relied on the information contained in the Report, together with regulatory information and safety data held by the CAA and input from regulatory subject matter experts in civilian flight operations,
OFFICIAL - Named Parties Only. This information is intended for HM Assistant Coroner, CAA and Interested Persons only OFFICIAL SENSITIVE - Named Parties Only: Legal Privilege aircraft airworthiness and aeromedicine. The CAA’s Approach The CAA has acknowledged the concerns identified by the Assistant Coroner. In particular, those related to the risk of oxygen fire onboard a commercial aircraft, cockpit (‘flight deck’) fire/smoke procedures, the effectiveness of equipment for dealing with fire and how the current aviation safety regulation framework works to prevent such incidents. This response addresses the recommendations in the report, specifically in relation to large commercial aircraft. It outlines the relevant regulatory requirements, the measures in place to mitigate and respond to such risks, and the CAA’s role and function in overseeing these processes. The CAA is not responsible for the investigation of aircraft accidents or serious incidents on behalf of the UK, which falls to the Air Accidents Investigation Branch (‘AAIB’), a body who report directly to the Secretary of State for Transport. Procedures for these investigations are laid down in international protocols, specifically the standards and recommended practices defined in Annex 13 to the Convention on International Civil Aviation, Aircraft Accident and Incident Investigation, and published by the International Civil Aviation Organization (‘ICAO’). The CAA understands that the Department for Transport (‘DfT’) will, therefore, respond separately to those aspects of the Report which relate to aircraft accident investigation. We can confirm that we have exchanged responses with the DfT prior to filing this response with the court. Regulatory framework The UK’s aviation safety framework is designed to ensure that aircraft systems are developed and maintained to the highest safety standards. As the UK’s specialist aviation regulator, the CAA oversees compliance with domestic aviation safety regulations, including those covering the design, certification, operation, and ongoing maintenance of aircraft on the UK register. The CAA is also the UK’s competent authority for ensuring compliance with international obligations, including those issued by ICAO. The process of ensuring commercial aircraft are safe to operate begins with initial airworthiness1, referring to the design and certification phase, during which aircraft and their systems (including those which mitigate the risk of hazards onboard aircraft) must demonstrate compliance with detailed safety requirements before entering service. For large commercial aircraft, design standards are set out in Certification Specifications (‘CS’) (CS-252 applies to large aircraft). Although applied within individual international jurisdictions, CS are developed with close collaboration between regulators working across international jurisdictions, with extensive input from the wider aircraft design and manufacturing community. In practice, this results in a high degree of international consistency, ensuring that standards are technically robust and harmonised across regulatory systems. Once in service, aircraft must comply with the requirements within the UK Air Operations Regulation3 which are underpinned by a safety management system: a structured and proactive approach to managing safety risks that supports day-to-day safety management and operational decision making4. Alongside this, aircraft must continue to meet ongoing technical and maintenance requirements through a process known as continuing airworthiness5, including compliance with any Airworthiness Directives
1 UK Regulation (EU) No. 748/2012 (“UK Initial Airworthiness Regulation”) 2 CS-25 Amendment 28 3 UK Regulation (EU) No. 965/2012 (“UK Air Operations Regulation”) 4 UK Air Operations Regulation ORO.GEN.200; Annex 19 to the Convention on International Civil Aviation 5 UK Regulation (EU) No. 1321/2014 (“UK Continuing Airworthiness Regulation”)
OFFICIAL - Named Parties Only. This information is intended for HM Assistant Coroner, CAA and Interested Persons only OFFICIAL SENSITIVE - Named Parties Only: Legal Privilege (ADs) issued to address emerging concerns. Together, these requirements ensure that systems remain safe and effective over time, including systems for the prevention and management of operational risks including onboard fires. Fire prevention onboard commercial aircraft Oxygen systems and pressurisation Commercial aircraft are typically equipped with gaseous oxygen systems, which are designed to supply oxygen to passengers and crew in the event of emergencies such as cabin depressurisation or severe fume events. These systems play a critical safety role but are not used during routine flight operations, as the aircraft’s pressurisation system provides sufficient oxygen under standard conditions. Design and certification specifications for gaseous oxygen systems onboard commercial aircraft are designed to prevent a fire from occurring, noting the impact of fire risks on such systems, and include multiple safeguards and mitigations.6 These systems must meet stringent safety requirements; oxygen systems are required to be free from hazards, with design organisations required to demonstrate, through system safety assessments, that the likelihood of an uncontrolled oxygen fire at the aircraft level is extremely improbable and would not result from a single failure of any system or associated component7. Risk assessments are comprehensive and should cover equipment failures, operating conditions, components and materials, ignition mechanism and kindling chain. Current design standards for large commercial aircraft already require oxygen systems to be resilient against potential pressure surges and temperature effects8. The risk of overpressure in gaseous oxygen systems is addressed through design specifications, requiring oxygen equipment to be protected from rupture. These systems are built with proof and burst pressure factors, and all oxygen systems are required to have overpressure relief valves to safely vent excess pressure. Smoking and other flammable materials in the flight deck The Air Navigation Order 20169 and the UK Air Operations Regulation10 provide the legal framework for restricting smoking onboard commercial aircraft. The UK Air Operations Regulation enables the pilot-in-command to prohibit smoking anywhere on board in a range of operational scenarios and whenever considered necessary in the interest of safety.
While there is no specific reference to smoking in the flight deck within these regulations, the CAA is not aware of any UK aircraft operators that allow smoking in any part of an aircraft, including the flight deck. Flight crew receive extensive training in safety and risk management, with a strong emphasis on maintaining a controlled and hazard-free operating environment onboard aircraft. In addition, all safety related occurrences must be reported to the CAA, which enables data to be collected and analysed over time. Following a review of the coroner’s request, the UK CAA Safety Intelligence Team have confirmed that there have been no reported UK incidents involving smoking or vaping in the flight deck in the past decade.11 Whilst we recognise the legal framework does not expressly prohibit smoking in the flight deck, the CAA’s regulatory oversight derived from working closely with operators, and safety data derived from
6 CS 25.1441, CS 25.869 7 CS 25.1309(b) 8 CS 25.1453 9 Article 243 The Air Navigation Order 2016 10 UK Air Operations Regulation CAT.OP.MPA.240 11 Mandatory Occurrence Reporting data analysis for period 01/01/15 to 24/06/25
OFFICIAL - Named Parties Only. This information is intended for HM Assistant Coroner, CAA and Interested Persons only OFFICIAL SENSITIVE - Named Parties Only: Legal Privilege the UK Mandatory Occurrence Reporting Regulation12, does not currently indicate a safety risk or safety gap that would require regulatory change. Regarding other flammable materials, aircraft design standards require that all installed equipment in the flight deck and aircraft cabin are fire-resistant and meet specific fire-resistance criteria13. Operators are also expected to manage their risks associated with flight crew personal items and equipment, with specific Dangerous Goods approval required for the carriage of certain hazardous materials, in accordance with ICAO specifications. This approval is obtained by applying to the CAA and demonstrating compliance with safety requirements, including staff training and operational procedures14. Flight crew are also subject to aviation security screening15. The role of ongoing maintenance in prevention The CAA places significant emphasis on the continuing airworthiness of commercial aircraft as a further layer of safety risk mitigation. All CS systems, including oxygen systems and fire protection equipment, are subject to regular inspection, testing, and maintenance in accordance with approved maintenance programmes. This ensures that any degradation or malfunction is identified and addressed before it may contribute to an incident. Continuing airworthiness involves a structured programme of regular inspections, maintenance, repairs, and system checks, performed by licensed engineers and approved maintenance organisations. Operators are required to follow a maintenance schedule tailored to each aircraft type, which includes both routine servicing and in-depth checks at defined intervals, as well as specific pre- flight checks16. In addition, any defects or unusual findings must be reported, investigated, and resolved before an aircraft can return to service. This process is supported by detailed record-keeping, ensuring traceability and accountability for maintenance actions. The CAA is responsible for conducting compliance audits of approved maintenance organisations in accordance with the requirements set out in the UK Continuing Airworthiness Regulation. No new fire risks have been identified by the CAA as a result of this audit programme and the CAA remains satisfied that all known risks fall within existing design, certification and operational controls.
Managing fires onboard commercial aircraft The regulatory framework is designed to address both the prevention of onboard fires, as well as the ability to detect and respond effectively should they occur. Under the UK Air Operations Regulation, large transport category aircraft must carry fire extinguishers in the flight deck and cabin, with at least one located in the flight deck. The number of additional extinguishers required in the aircraft cabin are linked to passenger capacity17. Halon fire extinguishers have traditionally been used by commercial aircraft operators to meet these requirements due to their effectiveness in confined aircraft environments. However, their use is being phased out due to environmental concerns18, and from 31 December 2025, Halon-free extinguishers,
12 Occurrence Reporting | UK Civil Aviation Authority 13 CS 25.853, Appendix F to CS 25.853 14 SPA.DG.105 Approval to transport dangerous goods, UK Air Operations Regulation AMC3 ORO.MLR.100 15 Regulation (EC) No 300/2008 of the European Parliament (retained EU law) 16 UK Continuing Airworthiness Regulation Annex I (Part-M) GM M.A.301(i); UK Regulation (EU) 2018/1139 (‘UK Basic Regulation’) Annex V, 6.2 17 UK Air Operations Regulation CAT.IDE.A.250 18 Regulation (EC) No 1005/2009 (retained EU law)
OFFICIAL - Named Parties Only. This information is intended for HM Assistant Coroner, CAA and Interested Persons only OFFICIAL SENSITIVE - Named Parties Only: Legal Privilege which must meet the same minimum performance standards will be mandated by CS25.851(a) and the Minimum Operating Standards defined in FAA Advisory Circular AC20-42D. The CAA supports this transition. All flight crew onboard large commercial transport aircraft are required to undergo regular training on the handling and use of fire-fighting equipment, protective breathing equipment, and the effects of smoke on an enclosed area19. In the event of fire in the flight deck, flight crew must also have access to a crash axe or crowbar20 in order to access panels where fire sources may originate, as well as to portable oxygen to enable movement around the flight deck and aircraft cabin21. Conclusion The CAA’s review of the Assistant Coroner’s recommendations has concluded that no change to the existing aviation safety regulation framework is currently required. The CAA remains satisfied that the safeguards in place, which are underpinned by airworthiness and operational regulations, design and certification requirements and operator safety management systems provide adequate risk mitigation. As part of this review, subject matter experts have examined relevant safety data held by the CAA under the Mandatory Occurrence Reporting Scheme, which does not indicate there is a risk of fire onboard large commercial aircraft - or the consequences of a flight deck fire - necessitate changes to existing rules. The CAA is also mindful of international requirements directed by ICAO which do not support change to existing fire safety controls at the present time. However, given the specific concerns identified by the Assistant Coroner, the CAA will continue to carefully monitor safety data and future aviation safety investigation recommendations related to fire risks with a view to taking appropriate action where necessary.
Signed:
Head of Design & Certification (Chief Engineer) Future Safety & Innovation Civil Aviation Authority 24 July 2025
19 UK Air Operations Regulation ORO.FC.230; AMC1 ORO.FC.230 20 UK Air Operations Regulation CAT.IDE.A.255 21 UK Air Operations Regulation CAT.IDE.A.235
MR JONATHAN MARK LAYTON – HM ASSISTANT CORONER FOR CARMARTHENSHIRE & PEMBROKESHIRE CORONER’S COURT INVESTIGATION INTO THE DEATH OF RICHARD MOHAMED FEKRY OSMAN
CIVIL AVIATION AUTHORITY RESPONSE TO A REPORT ON ACTION TO PREVENT OTHER DEATHS PURSUANT TO REGULATIONS 28 & 29 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013
Introduction The UK Civil Aviation Authority (‘CAA’) would first like to express its sincere condolences to the family and friends of Mr. Osman. The CAA is a public corporation, established by Parliament in 1972 as an independent specialist aviation regulator. The CAA works so that:
• the aviation industry meets the highest safety standards,
• consumers have choice, value for money, are protected and treated fairly when they fly,
• through efficient use of airspace, the environmental impact of aviation on local communities is effectively managed and CO2 emissions are reduced,
• the aviation industry manages security risks effectively.
The CAA has carefully considered the Regulation 28 Report to prevent future deaths issued by the Assistant Coroner for Carmarthenshire & Pembrokeshire dated 5 June 2025 (‘the Report’), which includes the following recommendations that are relevant to the role and functions of the CAA, insofar as they apply only to aircraft registered and operated within the UK:
… That a full review of cockpit fire/smoke procedures be undertaken to include, but not limited to:
- the recognition of an oxygen fire (identifiable by a characteristic noise comparable to that of a blowtorch) and the immediate cutting off this oxygen supply.
- the installation or carrying of protective equipment to deal with any cockpit fires.
- a review of the effectiveness of Halon fire extinguishers to deal with onboard fires.
- a review of regulations (if required) to prevent the use of cigarettes in the cockpit and related flammable items and materials.
- the additional risk analyses to take into account the hypothesis of an overpressure in the oxygen distribution system. The CAA was not an Interested Person at this inquest. As such, it did not have access to the inquest evidence. When preparing this response, with a view to explaining the outcome of its review, the CAA has relied on the information contained in the Report, together with regulatory information and safety data held by the CAA and input from regulatory subject matter experts in civilian flight operations,
OFFICIAL - Named Parties Only. This information is intended for HM Assistant Coroner, CAA and Interested Persons only OFFICIAL SENSITIVE - Named Parties Only: Legal Privilege aircraft airworthiness and aeromedicine. The CAA’s Approach The CAA has acknowledged the concerns identified by the Assistant Coroner. In particular, those related to the risk of oxygen fire onboard a commercial aircraft, cockpit (‘flight deck’) fire/smoke procedures, the effectiveness of equipment for dealing with fire and how the current aviation safety regulation framework works to prevent such incidents. This response addresses the recommendations in the report, specifically in relation to large commercial aircraft. It outlines the relevant regulatory requirements, the measures in place to mitigate and respond to such risks, and the CAA’s role and function in overseeing these processes. The CAA is not responsible for the investigation of aircraft accidents or serious incidents on behalf of the UK, which falls to the Air Accidents Investigation Branch (‘AAIB’), a body who report directly to the Secretary of State for Transport. Procedures for these investigations are laid down in international protocols, specifically the standards and recommended practices defined in Annex 13 to the Convention on International Civil Aviation, Aircraft Accident and Incident Investigation, and published by the International Civil Aviation Organization (‘ICAO’). The CAA understands that the Department for Transport (‘DfT’) will, therefore, respond separately to those aspects of the Report which relate to aircraft accident investigation. We can confirm that we have exchanged responses with the DfT prior to filing this response with the court. Regulatory framework The UK’s aviation safety framework is designed to ensure that aircraft systems are developed and maintained to the highest safety standards. As the UK’s specialist aviation regulator, the CAA oversees compliance with domestic aviation safety regulations, including those covering the design, certification, operation, and ongoing maintenance of aircraft on the UK register. The CAA is also the UK’s competent authority for ensuring compliance with international obligations, including those issued by ICAO. The process of ensuring commercial aircraft are safe to operate begins with initial airworthiness1, referring to the design and certification phase, during which aircraft and their systems (including those which mitigate the risk of hazards onboard aircraft) must demonstrate compliance with detailed safety requirements before entering service. For large commercial aircraft, design standards are set out in Certification Specifications (‘CS’) (CS-252 applies to large aircraft). Although applied within individual international jurisdictions, CS are developed with close collaboration between regulators working across international jurisdictions, with extensive input from the wider aircraft design and manufacturing community. In practice, this results in a high degree of international consistency, ensuring that standards are technically robust and harmonised across regulatory systems. Once in service, aircraft must comply with the requirements within the UK Air Operations Regulation3 which are underpinned by a safety management system: a structured and proactive approach to managing safety risks that supports day-to-day safety management and operational decision making4. Alongside this, aircraft must continue to meet ongoing technical and maintenance requirements through a process known as continuing airworthiness5, including compliance with any Airworthiness Directives
1 UK Regulation (EU) No. 748/2012 (“UK Initial Airworthiness Regulation”) 2 CS-25 Amendment 28 3 UK Regulation (EU) No. 965/2012 (“UK Air Operations Regulation”) 4 UK Air Operations Regulation ORO.GEN.200; Annex 19 to the Convention on International Civil Aviation 5 UK Regulation (EU) No. 1321/2014 (“UK Continuing Airworthiness Regulation”)
OFFICIAL - Named Parties Only. This information is intended for HM Assistant Coroner, CAA and Interested Persons only OFFICIAL SENSITIVE - Named Parties Only: Legal Privilege (ADs) issued to address emerging concerns. Together, these requirements ensure that systems remain safe and effective over time, including systems for the prevention and management of operational risks including onboard fires. Fire prevention onboard commercial aircraft Oxygen systems and pressurisation Commercial aircraft are typically equipped with gaseous oxygen systems, which are designed to supply oxygen to passengers and crew in the event of emergencies such as cabin depressurisation or severe fume events. These systems play a critical safety role but are not used during routine flight operations, as the aircraft’s pressurisation system provides sufficient oxygen under standard conditions. Design and certification specifications for gaseous oxygen systems onboard commercial aircraft are designed to prevent a fire from occurring, noting the impact of fire risks on such systems, and include multiple safeguards and mitigations.6 These systems must meet stringent safety requirements; oxygen systems are required to be free from hazards, with design organisations required to demonstrate, through system safety assessments, that the likelihood of an uncontrolled oxygen fire at the aircraft level is extremely improbable and would not result from a single failure of any system or associated component7. Risk assessments are comprehensive and should cover equipment failures, operating conditions, components and materials, ignition mechanism and kindling chain. Current design standards for large commercial aircraft already require oxygen systems to be resilient against potential pressure surges and temperature effects8. The risk of overpressure in gaseous oxygen systems is addressed through design specifications, requiring oxygen equipment to be protected from rupture. These systems are built with proof and burst pressure factors, and all oxygen systems are required to have overpressure relief valves to safely vent excess pressure. Smoking and other flammable materials in the flight deck The Air Navigation Order 20169 and the UK Air Operations Regulation10 provide the legal framework for restricting smoking onboard commercial aircraft. The UK Air Operations Regulation enables the pilot-in-command to prohibit smoking anywhere on board in a range of operational scenarios and whenever considered necessary in the interest of safety.
While there is no specific reference to smoking in the flight deck within these regulations, the CAA is not aware of any UK aircraft operators that allow smoking in any part of an aircraft, including the flight deck. Flight crew receive extensive training in safety and risk management, with a strong emphasis on maintaining a controlled and hazard-free operating environment onboard aircraft. In addition, all safety related occurrences must be reported to the CAA, which enables data to be collected and analysed over time. Following a review of the coroner’s request, the UK CAA Safety Intelligence Team have confirmed that there have been no reported UK incidents involving smoking or vaping in the flight deck in the past decade.11 Whilst we recognise the legal framework does not expressly prohibit smoking in the flight deck, the CAA’s regulatory oversight derived from working closely with operators, and safety data derived from
6 CS 25.1441, CS 25.869 7 CS 25.1309(b) 8 CS 25.1453 9 Article 243 The Air Navigation Order 2016 10 UK Air Operations Regulation CAT.OP.MPA.240 11 Mandatory Occurrence Reporting data analysis for period 01/01/15 to 24/06/25
OFFICIAL - Named Parties Only. This information is intended for HM Assistant Coroner, CAA and Interested Persons only OFFICIAL SENSITIVE - Named Parties Only: Legal Privilege the UK Mandatory Occurrence Reporting Regulation12, does not currently indicate a safety risk or safety gap that would require regulatory change. Regarding other flammable materials, aircraft design standards require that all installed equipment in the flight deck and aircraft cabin are fire-resistant and meet specific fire-resistance criteria13. Operators are also expected to manage their risks associated with flight crew personal items and equipment, with specific Dangerous Goods approval required for the carriage of certain hazardous materials, in accordance with ICAO specifications. This approval is obtained by applying to the CAA and demonstrating compliance with safety requirements, including staff training and operational procedures14. Flight crew are also subject to aviation security screening15. The role of ongoing maintenance in prevention The CAA places significant emphasis on the continuing airworthiness of commercial aircraft as a further layer of safety risk mitigation. All CS systems, including oxygen systems and fire protection equipment, are subject to regular inspection, testing, and maintenance in accordance with approved maintenance programmes. This ensures that any degradation or malfunction is identified and addressed before it may contribute to an incident. Continuing airworthiness involves a structured programme of regular inspections, maintenance, repairs, and system checks, performed by licensed engineers and approved maintenance organisations. Operators are required to follow a maintenance schedule tailored to each aircraft type, which includes both routine servicing and in-depth checks at defined intervals, as well as specific pre- flight checks16. In addition, any defects or unusual findings must be reported, investigated, and resolved before an aircraft can return to service. This process is supported by detailed record-keeping, ensuring traceability and accountability for maintenance actions. The CAA is responsible for conducting compliance audits of approved maintenance organisations in accordance with the requirements set out in the UK Continuing Airworthiness Regulation. No new fire risks have been identified by the CAA as a result of this audit programme and the CAA remains satisfied that all known risks fall within existing design, certification and operational controls.
Managing fires onboard commercial aircraft The regulatory framework is designed to address both the prevention of onboard fires, as well as the ability to detect and respond effectively should they occur. Under the UK Air Operations Regulation, large transport category aircraft must carry fire extinguishers in the flight deck and cabin, with at least one located in the flight deck. The number of additional extinguishers required in the aircraft cabin are linked to passenger capacity17. Halon fire extinguishers have traditionally been used by commercial aircraft operators to meet these requirements due to their effectiveness in confined aircraft environments. However, their use is being phased out due to environmental concerns18, and from 31 December 2025, Halon-free extinguishers,
12 Occurrence Reporting | UK Civil Aviation Authority 13 CS 25.853, Appendix F to CS 25.853 14 SPA.DG.105 Approval to transport dangerous goods, UK Air Operations Regulation AMC3 ORO.MLR.100 15 Regulation (EC) No 300/2008 of the European Parliament (retained EU law) 16 UK Continuing Airworthiness Regulation Annex I (Part-M) GM M.A.301(i); UK Regulation (EU) 2018/1139 (‘UK Basic Regulation’) Annex V, 6.2 17 UK Air Operations Regulation CAT.IDE.A.250 18 Regulation (EC) No 1005/2009 (retained EU law)
OFFICIAL - Named Parties Only. This information is intended for HM Assistant Coroner, CAA and Interested Persons only OFFICIAL SENSITIVE - Named Parties Only: Legal Privilege which must meet the same minimum performance standards will be mandated by CS25.851(a) and the Minimum Operating Standards defined in FAA Advisory Circular AC20-42D. The CAA supports this transition. All flight crew onboard large commercial transport aircraft are required to undergo regular training on the handling and use of fire-fighting equipment, protective breathing equipment, and the effects of smoke on an enclosed area19. In the event of fire in the flight deck, flight crew must also have access to a crash axe or crowbar20 in order to access panels where fire sources may originate, as well as to portable oxygen to enable movement around the flight deck and aircraft cabin21. Conclusion The CAA’s review of the Assistant Coroner’s recommendations has concluded that no change to the existing aviation safety regulation framework is currently required. The CAA remains satisfied that the safeguards in place, which are underpinned by airworthiness and operational regulations, design and certification requirements and operator safety management systems provide adequate risk mitigation. As part of this review, subject matter experts have examined relevant safety data held by the CAA under the Mandatory Occurrence Reporting Scheme, which does not indicate there is a risk of fire onboard large commercial aircraft - or the consequences of a flight deck fire - necessitate changes to existing rules. The CAA is also mindful of international requirements directed by ICAO which do not support change to existing fire safety controls at the present time. However, given the specific concerns identified by the Assistant Coroner, the CAA will continue to carefully monitor safety data and future aviation safety investigation recommendations related to fire risks with a view to taking appropriate action where necessary.
Signed:
Head of Design & Certification (Chief Engineer) Future Safety & Innovation Civil Aviation Authority 24 July 2025
19 UK Air Operations Regulation ORO.FC.230; AMC1 ORO.FC.230 20 UK Air Operations Regulation CAT.IDE.A.255 21 UK Air Operations Regulation CAT.IDE.A.235
Report Sections
Investigation and Inquest
On 22 February 2017 I commenced an investigation into the death of Richard Mohamed Fekry Osman who was born on the 9 November 1975. The investigation concluded at the end of the inquest on 2 May 2025. The conclusion of the inquest was as follows: Richard Osman was a passenger onboard commercial flight MS804 travelling from Paris to Cairo which crashed into the Mediterranean Sea on 19 May 2016 following a fire onboard caused by an ignition source of unknown origin most likely associated with the first officer’s oxygen supply system, which either resulted from or was fed by an oxygen leak. The cause of death was 1(a) air incident
Circumstances of the Death
Richard Osman was a geologist on a business trip on flight MS804 which departed Paris bound for Cairo on 18 May 2016. In the early hours of 19 May 2016, as the aircraft was flying over the Eastern Mediterranean Sea, a fire broke out on the flight deck rendering the flight deck environment uninhabitable and causing the aircraft to be uncontrollable resulting in a crash. There were no survivors.
Inquest Conclusion
Richard Osman was a passenger onboard commercial flight MS804 travelling from Paris to Cairo which crashed into the Mediterranean Sea on 19 May 2016 following a fire onboard caused by an ignition source of unknown origin most likely associated with the first officer’s oxygen supply system, which either resulted from or was fed by an oxygen leak. The cause of death was 1(a) air incident
Similar PFD Reports
Reports sharing organisations, categories, or themes with this PFD
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Uniform policy for obtaining technical advice
Scottish Hospitals Inquiry
Major project lessons learned
Streamlining NHS construction quality procedures
Scottish Hospitals Inquiry
Major project lessons learned
Independent validation of hospital construction
Scottish Hospitals Inquiry
Major project lessons learned
Clarify whether HCRS and OCS assessment processes differ
Post Office Horizon Inquiry
Major project lessons learned
Reconsider Phase 1 recommendations in light of Phase 2
Grenfell Tower Inquiry
Major project lessons learned
Add legal requirements warning to statutory guidance
Grenfell Tower Inquiry
Major project lessons learned
Include academics on statutory guidance advisory bodies
Grenfell Tower Inquiry
Major project lessons learned
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.