Fatal Somerset plane crash: Seven safety recommendations made
Investigators have made seven safety recommendations after a plane crashed killing the pilot and his passenger.
Pilot Jonathan Mann and his passenger Margaret Costa died when their light aircraft crashed in August 2021.
The Air Accident Investigation Branch (AAIB) said it wants guidance published as a result to help new pilots cope with deteriorating weather conditions.
It also said there was an "absence of active decision making" among air traffic controllers trying to help him.
Its report found the crash had exposed "shortcomings" in emergency procedures when ground staff were dealing with a pilot in distress.
It has recommended training for air traffic controllers so they can understand how stress affects pilots.
It also said ground staff needed more rules about the type of information they should record when responding to aircraft in an emergency.
Mr Mann, 69, and Ms Costa, 74, an artist from Lancercombe, Devon, were on a private flight travelling from the plane's base at Watchford Farm in Somerset to the Isles of Scilly.
The plane, a Mudry Cap 10B low-wing aerobatic aircraft - took off just after 07:00 BST on 12 August, but after flying over Cornwall it then turned back.
Mr Mann made an emergency call at 09:05, the AAIB said, using the words "PAN, PAN, PAN", indicating he needed urgent assistance.
He said he could not land at Watchford Farm as he was stuck above cloud and made a second call at 09:11 BST saying he was in "real trouble".
"Several witnesses in other aircraft who heard the call described the pilot sounding anxious and stressed," the AAIB report said.
Weather 'had deteriorated'
Various air traffic control (ATC) staff tried to help Mr Mann, the report said, including staff at the Distress and Diversion (D&D) facility in London, which is a military air traffic unit.
He was eventually transferred to a controller at Exeter Airport.
While communicating with staff at Exeter Airport about his altitude and heading for a landing, Mr Mann hit a tree, measuring about 25m (82ft) tall, near Buckland St Mary in Somerset.
He crashed at about 09:17 BST destroying the plane and killing both occupants.
Mr Mann, who lived near Sidmouth in Devon, was qualified under Visual Flight Rules (VFR) meaning he was only allowed to fly in good, clear weather.
After examining a tablet computer found in the wreckage, investigators were able to conclude he had checked the weather forecast before take off, and witnesses had said conditions locally were "clear skies with good visibility".
However there had been a "marked deterioration" in conditions throughout the morning, the AAIB said, and there had been enough doubt in some forecasts "to merit reconsidering the flight".
'Breakdown in communication'
Mr Mann had a valid pilot's license, he had more than 1,400 flying hours on his record, and investigators found no mechanical faults with the aircraft.
After examining records of conversations between the various controllers on the ground and Mr Mann, AAIB investigators said he was transferred to Exeter "before anyone with controlling authority" knew it was an emergency diversion.
The weather conditions at Exeter had not been discussed when D&D staff handed the plane over either, they added.
The AAIB said during the contact Mr Mann had with both the D&D staff and Exeter Airport, the level of support he was given "was not sufficient" given that he was "in a state of distress".
"A breakdown in communication and teamwork occurred between the D&D Cell, Exeter ATC and the pilot, which led to miscommunication, incorrect assumptions and omission of critical information," it added.
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