Aviation Anthology Vol 1 2026 - Digital Version - Flipbook - Page 22
The April 2026 Publication Policy
The Chief Coroner (Her Honour Judge Alexia Durran)
sets out the position in clear terms:
“The decision to issue a PFD report is a judicial one. To
comply with the principle of open justice, the public must
be able to access PFD reports and responses, unless
there is a compelling reason to restrict access… There is
therefore a presumption that PFD reports and responses
will be published by the Chief Coroner.”
There are three principal aspects of note:
O First, it gives formal effect to the principle of open
justice by establishing a clear presumption in favour
of publication. Reports and responses are accessible
unless a compelling justification for restriction arises.
O Secondly, it provides a clear framework governing
the exercise of the Chief Coroner’s discretion
introducing consistent criteria for publication,
redaction and (in exceptional cases) non-publication.
The aim is to promote transparency, predictability,
and principled uniformity in decision making as
regards publication.
O Thirdly, it strengthens the accountability and
preventative function of the PFD regime by ensuring
that reports and responses are accessible and so
available for scrutiny. This facilitates the identification
and dissemination of lessons of wider relevance.
Aviation related PFD reports
Most PFD reports concern sectors outside aviation,
including healthcare, workplace fatalities, road transport
and deaths in custody and detention. Only a small
proportion relate, directly or indirectly, to aviation.
These include reports arising from air accident fatalities,
incidents at aerodromes or airports, and fatalities
connected with aircraft maintenance, ground operations,
or aviation related occupational activity. In the context
of air accident fatalities, coroners do not revisit technical
causation, which falls within the statutory remit of the
AAIB. Instead, the focus is on broader risks disclosed by
the death, including systemic or regulatory issues and
whether steps should be taken to mitigate the risk of
recurrence.
crashed on the A27 adjacent to the airshow ground
resulting in eleven fatalities and injuring some
sixteen others. PFD reports addressed risks within
the regulatory framework governing flying displays.
These reports contributed to significant revisions to
CAA regulatory guidance CAP 403.[6]
O PFD reports have also featured in an aviationadjacent context. In 2025, the Senior Coroner for
Inner West London issued a PFD report following
the repatriation of victims of the Air India 2025
fatal accident. The report identified a serious and
previously under-recognised public health risk
arising from the repatriation of human remains. The
report addressed risks arising from elevated levels of
toxic substances (including formalin) within coffins.
The report led to clarification of procedures and
strengthened protective measures for UK mortuary
staff and others handling repatriated remains.
Conclusion
The April 2026 Publication Policy confirms that
publication and transparency are now central features of
the PFD regime.
For aviation stakeholders, this carries implications.
Although PFD reports arising from aviation fatalities
remain uncommon, their potential impact is significant.
They may concern regulatory issues, operational
practices and organisational decision making. Secondly,
they can attract public, media and regulatory scrutiny
beyond the conclusions and recommendations of the
AAIB investigation into accident cause or associated
coronial inquests establishing how, when and where the
deceased came to their death.
Accordingly, PFD reports, where they do arise, should
be understood as an additional aspect of post-incident
exposure. They introduce a further layer of legal,
reputational, and operational risk which requires active
management, alongside existing post-loss investigative,
regulatory and claims processes. Consideration of
potential PFD engagement, and the associated time,
cost and resourcing implications, should therefore form
part of the broader response and risk management
strategy adopted by aviation industry parties in the
aftermath of a fatal accident.
Illustrative examples
The following examples demonstrate how PFD reporting
have arisen and in an air accident context, have done so
alongside but separately from AAIB investigation:
O A fatal hot air balloon accident in June 2023 led to
an AAIB final report in May 2024. Separately, a PFD
report issued in August 2024 addressed concerns
regarding regulatory oversight and competitive
ballooning practices. This contributed to subsequent
CAA activity and the publication of safety guidance
for balloon events and competitions (CAP 1739) in
April 2026.[5]
O In the Shoreham Airshow accident (2015), a Hawker
Hunter aircraft crashed during a display. The aircraft
22
DAC Beachcroft
[1] Chief Coroner of England and Wales, Prevention of Future Deaths
Reports – Publication Policy (2026), Courts and Tribunals Judiciary, April
2026.
[2] Air Accidents Investigation Branch, Annual Safety Review 2025 (AAIB,
4 June 2026).
[3] Coroners and Justice Act 2009, c. 25, Coroners and Justice Act 2009,
c. 25, and the Coroners (Investigations) Regulations 2013 (SI 2013/1629).
[4] Ministry of Justice, Coroners Statistics 2023: England and Wales
(published 10 May 2024).
[5] Civil Aviation Authority, CAP 1739: Safety Guidance for Balloon
Events and Competitions (2026).
[6] Civil Aviation Authority, CAP 403: Flying Displays and Special Events
(as amended).
Aviation Anthology 2026 - Volume I
