Dear Mr Thompson, Re: Andrew Paul Westlake Deceased Further to your Report to Prevent Future Deaths made under Schedule 5, paragraph 7 Coroners and Justice Act 2009 and Regulation 28 Coroners (Investigations) Regulations 2013, dated 3 December 2020 (“the PFD Report"), I am writing to provide you with Jet2.com’s response as required by 27 January 2021.

Please find enclosed:
1. PDF document which explains our Ground Handling procedures and training review, conclusions and action plan.
2. Ground Operations Instruction document which update Jet2.com’s Ground Handling Manual.
3. Email from the CAA to Jet2.com dated 15.01.21 confirming approval of Jet2.com’s amended procedures.

In the PFD Report your concerns were centred on the following:

• Training for airline and ground staff (employed by UK Airlines) on vulnerability of lone passengers when disembarked overseas.
• Procedures for safeguarding vulnerable passengers such as Mr Westlake.

Jet2.com has a strong reputation for providing excellent customer service and a genuine desire to look after all customers. In addition, there is an established and robust training programme in place for colleagues across the Ground Operations environment. In the light of the case of Mr Westlake, we have taken the opportunity to review and update our existing policies, procedures, and training.

In addition, we have liaised with the CAA, for approval of the updates made. This is detailed below.

Ground Handling Manual

As is the case with all airlines, Jet2.com maintain a Ground Handling Manual - a comprehensive document approved by the CAA - which is available to ground crew at all stations, and which details the procedures to facilitate an aircraft turnaround, including those relating to passengers.

Current Jet2.com policies contained within the manual refer to medical, physical, and mental health conditions in the context of supporting customers throughout their journey, whether pre-notified or otherwise. There is a strong focus on ensuring customers with medical conditions and hidden disabilities are supported appropriately and that their needs are met to the extent possible throughout their journey.

We have reviewed and updated the content to address the fact that a passenger who is disembarked from an aircraft for any reason may equally be suffering from a hidden disability, such as a mental health condition or crisis. In such circumstances the passenger may be vulnerable, and we have provided guidance on what additional assistance should be considered where such behaviour is evident or otherwise identified.

Section 4.2 of the Ground Handling Manual - Assistance Customers & Hidden Disabilities

This section of the Ground Handling Manual applies to passengers who require assistance with air travel, for conditions including hidden disabilities. The section setting out common types of hidden disability has been updated to encompass an acute mental health issue, such as that suffered by Mr Westlake, as an example of a mental health condition and to note that an acute mental health crisis may require special additional assistance. The revised section is attached and, following positive feedback from the CAA, has already been published.

Section 3.3.19 of the Ground Handling Manual – Denied Boarding

Section 3.3.19 of the Ground Handling Manual addresses the procedures to be followed by ground crew should a passenger be denied boarding. Denied boarding can take place for a number of reasons including disruptive behaviour, as was the case with Mr Westlake. The procedure now contains a provision that if a passenger is denied boarding, then ground crew should consider the immediate customer needs and assist the passenger to the extent practical in the circumstances. In situations where the passenger may have become distressed, or is potentially vulnerable or displaying vulnerable behaviour, then the procedure now provides that (to the extent practical in the circumstances) ground crew should consider whether it is possible to arrange additional support, such as assistance to the passenger in contacting family and friends (as occurred in the case of Mr Westlake), the appropriate Embassy or Consulate, or other services such as Police, medical services, or the airport chaplain. The revised procedure is attached and has also already been published.

Training

To further support our colleagues, training will be updated in line with the revised procedures set out above, and we will additionally use the case of Mr Westlake as a case study in our initial and recurrent training to ground crew. We also plan to introduce a further suitable external course for trainers on Mental Health Awareness. We have set a deadline of 29 January 2021 to update the relevant training

material, and 21 March 2021 to deliver the updated training material, but this is of course subject to the recovery of the aviation industry and the return to flying operations in light of the current Covid- 19 pandemic.

CAA

Finally, we have liaised with the CAA in respect of our procedures and the matter of Mr Westlake. The CAA’s Consumers and Markets Group (consumer protection), and Safety and Airspace Regulation Group (aviation safety) have now reviewed our updated procedures. They have confirmed in the attached email dated 15.01.21, that the approach adopted by Jet2.com is what the CAA would expect from a responsible operator in terms of dealing with vulnerable passengers.

We would like to take this opportunity to express our sincere condolences to Mr Westlake’s family and friends, for their loss.

I trust that this response is to your satisfaction, but please do not hesitate to contact me with any queries.

1

JAMES E. THOMPSON – HM ASSISTANT CORONER FOR COUNTY DURHAM AND DARLINGTON

INVESTIGATION INTO THE DEATH OF ANDREW PAUL WESTLAKE CIVIL AVIATION AUTHORITY RESPONSE TO A REPORT ON ACTION TO PREVENT OTHER DEATHS PURSUANT TO REGULATIONS 28 & 29 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013

The Civil Aviation Authority (CAA) has considered carefully the report of the Assistant Coroner to prevent future deaths and the concerns raised:
• Training for airline and ground staff (employed by UK airlines) on vulnerability of lone passengers when disembarked overseas.
• Procedures for safeguarding vulnerable passengers such as Mr Westlake.

Introduction The CAA was not an Interested Person at this inquest. As such, we did not have access to the evidence. To understand the background to this case, we have relied on knowledge gained from reviewing press articles and information contained in the Regulation 28 Report received from the Assistant Coroner. The CAA has no direct regulatory oversight of UK airline operators’ overseas passenger disembarkation training and procedures. There is no specific aviation legislation that supports the CAA’s formal intervention concerning safeguarding vulnerable passengers. Nevertheless, the CAA does recognise the significance of its role regulating to safety and consumer protection in UK aviation, including the statutory requirement to have due regard to further certain societal objectives relating to equality when carrying out its functions.1

1 Equality Act 2010 section 149(1).

2

We consider that it may be of assistance to the Assistant Coroner for the CAA to provide comment on Jet2.com’s decision to disembark Mr Westlake from the aircraft on or about 28 May 2018. Colleagues in the CAA’s Safety and Airspace Regulation Group can see no reason to question that decision. It is a basic tenet of aviation safety that an aircraft Captain has absolute control of the aircraft and must take appropriate action to ensure the safety of the aircraft and the passengers on board. Furthermore, upon receipt of the Regulation 28 report the CAA contacted Jet2.com to discuss the steps the airline operator intended to take to respond to the concerns raised by the Assistant Coroner (set out above). Representatives in the CAA’s Safety and Airspace Regulation Group (aviation safety) and Consumers and Markets Group (consumer protection) then reviewed the Jet2.com Ground Operations Policy Update that we are instructed will be sent separately to the Assistant Coroner by Jet2.com in response to his report. We are now able to confirm the approach now adopted by Jet2.com is what the CAA would expect from a responsible operator in terms of dealing with vulnerable passengers such as Mr Westlake. Vulnerable Consumers The CAA’s Consumer Panel2 recently invited the CAA to take steps to improve the support that is provided to those consumers who are vulnerable in order to gain a better experience whilst they interact with UK airlines and airports. The CAA’s accepted definition of consumer vulnerability is set out below: “When a consumer’s personal circumstance or characteristics combine with the way the aviation market operates to mean they are less likely to be able to engage effectively in the market and more likely to be more severely affected or suffer greater detriment. Industry actions can reduce or exacerbate consumer vulnerability in aviation.” The Consumer Panel has also provided the following key points to add context to the definition:
• It is clear that circumstance can affect a consumer’s vulnerability, not just their characteristics, so anyone can be vulnerable in particular circumstances;
• A consumer’s vulnerability can be either visible or invisible: this does not solely capture those with reduced mobility;

2 The CAA Consumer Panel is a non-statutory body established, amongst other things, to help the CAA to understand fully, and take account of, the interests of consumers in its policy development and decisions. More information here: https://www.caa.co.uk/Our-work/About-us/CAA-consumer-panel/

3

• Vulnerability can be temporary or transient, it doesn’t have to be permanent to be captured by the definition;
• It is very clear that industry has a role to play in improving the situation for vulnerable passengers, and it is equally clear that industry can make it worse by their actions. There is substantial overlap between the concept of consumer vulnerability (and the Consumer Panel’s ambitions for the CAA in this area) and the requirements imposed on the CAA under the Public Sector Equality Duty. This tragic case has emphasised the need for the CAA to further the initiative proposed by the CAA Consumer Panel and encourage those we regulate to respond appropriately to the needs of a wide range of vulnerable people at all stages of their interaction with the UK aviation industry. The CAA is confident that working with the UK aviation industry will lead to a better understanding of the potential needs of passengers like Mr Westlake, whether they are traveling alone or with others. Our aim is to encourage all sectors in the UK aviation industry to adopt procedures that recognise and respond effectively to those who may require enhanced individual support. The CAA Executive will receive a report from colleagues during the first quarter of 2021, using the adopted definition above on proposed improvements to the treatment of vulnerable consumers by the UK aviation industry. The report will include initial proposals for the CAA Executive to consider increasing our engagement with industry, starting with the CAA Chair, , raising this issue with larger regulated organisations. This report will also emphasise the need for the CAA to encourage its own staff, and in the case of front-line staff, receive training on the needs of vulnerable individuals when engaging with our stakeholders. The CAA’s intention is for this initiative to be regularly reviewed by the CAA Executive so that we can learn the lessons from our progress and ensure that the focus of this work is maintained. We anticipate this work will lead to real progress on improvements to the care of those who are more vulnerable in our society when engaging, at all stages, with the UK aviation industry. Conclusion There are no regulations that would enable the CAA to mandate changes to UK airline procedures and training for the disembarkation of vulnerable lone passengers overseas. We will however continue our work to support the UK aviation industry make improvements to the treatment of vulnerable consumers. The CAA is actively taking steps to increase our engagement with UK aviation stakeholders including airline operators, to enhance the

4

support they offer to all consumers who may be considered vulnerable, whether that be from a known condition or as a result of unexpected circumstances.

CAA 22 January 2021