RACHEL FISK: WHITEWASH?
By Mike Bravo CMIOSH
Any reputable company or organisation will have in place established suitable and concise procedures and protocols with regards to Major Incident Announcements –– such as fatal accidents. These procedures and protocols will be subject to and compliant with Health and Safety, Corporate Communications and Legal Counsel advice.
The basis for such an approach is obvious; many of the matters relating to a fatal accident are sub judice and, as such, must remain confidential until investigations and enquiries are concluded, because enforcement action including prosecution may be pursuant and there is likely to be insurance claims or litigation for damages and loss.
The object of any official announcement is to inform stakeholders and to provide only the necessary facts to the general public in a clear articulate manner. The two main imperatives are:
- not to cause further distress to the casualty’s already distraught family
- not to prejudice or unduly influence enquires and investigations or otherwise adversely impact upon any form of legal process
In Part 1 of this article, Bravo Three Zero CMIOSH raises these very issues.
- What was the motivation of British Parachuting Associate Ltd (BPA) trading as British Skydiving (BS) for issuing this ‘Interim Report’ regarding Sgt Helen Fisk’s death?
- Has the BS action unduly influenced or otherwise adversely impacted upon the investigation of Sgt Fisk’s death?
- Who gave this amateur sports body and its officials –– who apparently hold no officially awarded, relevant qualifications –– permission to issue such a poorly constructed and speculative report?
- In so doing, has BPA/BS now rendered the Ministry of Defence (MOD) liable to a lawsuit by Sgt Fisk’s family?
- Has BPA/BS exposed Royal Air Force senior staff officers of 22 Group to prosecution by the Police?
Any information disclosed into the public domain at this juncture, should only be via official sources such as the Police, Health and Safety Executive (HSE) and/or the MOD, probably subsequent to consultation with all stakeholders, prior to Coroners Court hearings. Such information should be limited solely to the established fact that Sgt Fisk’s parachutes did not deploy, as per the various news media reports based upon MOD press office statements.
Sgt Fisk was a serving member of HM Forces, on duty at an MOD establishment or otherwise at work, whose employer was the RAF. The BPA/BS officials who released this interim report had no business doing so and some observers are wondering why this charlatan organisation is even involved to begin with.
It is highly arguable that BPA/BS is not a credible witness in the first instance as its representatives do not meet the recognised criteria of professional experts. Furthermore, BPA/BS does not operate a parachute training organisation and thus has no experience in day-to-day skydiving activities and the running of a business delivering such services.
However, BPA/BS is the Civil Aviation Authority’s delegated parachuting regulator, a status that has demonstrably enabled this amateur sports association to establish a lucrative commercial monopoly over parachuting in the United Kingdom since the Exposition drawn up in 1996 with the CAA. With these vested interests in play, BPA/BS is not an impartial party.
Some critics suggest that in publishing this interim report, BPA/BS intended to prepare the ground for a cover-up relating to Sgt Fisk’s death and extricate themselves from any form of culpability.
 |
| Tony Butler: BPA Ghost Director |
Any opinion offered by BPA/BS to the Coroner’s Court should be deemed inadmissible not just because of this strong likelihood of bias but because the BPA/BS officials participating in the investigation have never produced any credible credentials. Indeed, the firm’s Chief Operating Officer Tony Butler’s only experience seems to be his investigation of numerous fatalities – with no tangible improvements in safety as a result. Meanwhile, the death toll simple keeps rising.
None of these investigations has prompted BPA/BS officials –– some of whom receive six-figure salaries –– to raise the firm’s safety-related expenditure from its annual average of £5,000. This well-documented fact alone is enough to undermine BPA/BS’ self-promoting propaganda and its smoke-and-mirrors act.
Many people within the sector pose the questions:
- Does the £30,000 annual fee paid by BPA/BS to the CAA quango for its Approved Person status equate to a sale by the CAA of an illegal commercial monopoly?
- Has the CAA sold BPA/BS exemption from laws like The Health and Safety at Work etc Act 1974 and permission for BPA/BS officials to act illegally with no regulatory oversight or sanction?
- Has the CAA quango overreached its powers in transforming BPA/BS into a quango in its own image? BPA Watch has published several articles about BPA/BS –– and CAA –– lawbreaking.
The BPA/BS monopoly is the subject of a lawsuit by a majority of the BPA/BS-affiliated PTOs, who formed the Parachute Training Organisation Association Ltd for just this purpose.
There is unequivocal evidence that the BPA is the controlling mind within the CAA-BPA cartel and, therefore, the organisation is at the very minimum vicariously liable if not directly culpable for all skydiving accidents. In some instances, this may engage the Corporate Manslaughter and Corporate Homicide Act 2007. Indeed, BPA Ltd officials have narrowly escaped corporatemanslaughter charges in the past.
Just one example is the series of static line student deaths within a 12-month period in the early 2000s. Four students died after becoming entangled in their parachute equipment (rigging lines), a long-known hazard associated with the type of aircraft exit used at that time.
The Chair of the working group ––an ex-RAF Parachute Jump Instructor (PJI), 2 Group, No. 1 Parachute Training School, RAF Brize Norton –– resigned in disgust at the BPA attitude and its failure to adequately address the specific risk issues.
 |
| Grant Shapps: responsible for CAA-BPA cartel |
These are important underlying matters that the HSE and MOD investigators –– the Police –– need to focus upon: the systemic management control, system and procedural failures that reside within the construct of the BPA/BS framework and its Operations Manual, touted as a safety gold standard by various parties with vested interests.
One reason why the BPA has not previously been the focus of HSE investigations is because its ghost directors and officials habitually coerce BPA-affiliated Parachute Training Organisations (PTOs) into not reporting accidents under Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (SI 1471) (RIDDOR).
The coercive tactics applied include threats –– behind closed doors –– of punitive action such as suspending their BPA/BS affiliate status or their instructor ratings. Unfortunately, many BPA-rated instructors believe that these ratings are valid qualifications when, in fact, there is nothing official about them. They are not worth the paper upon which they are printed.
Failure to report accidents under RIDDOR is a criminal offence under the Health and Safety at Work etc Act 1974. The BPA/BS modus operandi is clearly in direct contravention of statutory requirements to report parachuting accidents not involving an aircraft under RIDDOR as stipulated by the HSE and the CAA’s own document CAP 1484.
The CAA directorate –– traditionally headed by former high-ranking RAF officers appointed by the Transport Minister –– is equally implicated because of its sanctioning of BPA/BS policy –– the head of the firm is on written record as describing the HSE as “a danger” to its operations –– so is the Minister responsible for the CAA quango also of the belief that the HSE is a danger?
In cases like Sgt Fisk’s death at RAF Weston-on-the-Green on September 2nd 2021, the MOD is required to report parachuting accidents to the HSE in compliance with OC 801/2 Supplement 1. This raises the following questions:
- Is the CAA acting outside its authority and in breach of constitutional law by exempting the BPA from overarching legislation?
- Has the CAA deliberately misled the HSE and HM Government Ministers in pretending to be the parachuting regulator?
- Why has the HSE failed to produce a Code of Practice for Parachuting?
- When will the HSE realise what has been occurring over a 25 year period and take back its regulatory oversight function from the CAA quango?
Detailed investigations into the true root causes of accident events has never been a primary motivation for BPA/BS. BPA-rated instructors appointed as lead investors have often been threatened when their reported findings did not align with BPA/BS intentions, which usually involve blaming any Chief Instructor in charge of the drop zone for contravening the rules rather than questioning and testing those rules to ensure that they were correctly formulated in the first place.
BPA/BS rules tend to be formulated and adopted in a reactive rather than proactive manner. In other words, the firm locks the stable door after the horse has bolted or, as one BPA/BS Advanced Instructor put it:
“The BPA Operations Manual has developed over a long period of time on an ad hoc basis and needs to be completely rewritten.”.
The Health and Safety at Work etc Act 1974 introduced the concept of reducing risk “so far as is reasonably practicable”. The Management of Health and Safety at Work Regulations, which came into force in 1992, builds upon this concept with the requirement to carry out a “suitable and sufficient risk assessment” with the aim of developing “adequate control measures” - prompting businesses to adopt a Safety Management Systems approach during the 1990s.
However, BPA/BS has not kept pace with the rest of the world, sticking defiantly with their inflexible approach as encapsulated in their Operations Manual. This defiance is facilitated by the failure of the CAA to challenge its –– illegally –– delegated regulatory overseer, a failure shared by, at the time of writing, Transport Minister Grant Shapps and by the HSE.
The BPA/BS Operations Manual is touted as the “gold standard” and “the only operations manual accepted by the CAA", assertions that go unchallenged because the CAA refuses, in effect, to process other organisations’ safety management documentation as part of its facilitation of the BPA/BS commercial monopoly over skydiving and parachuting.
BPA/BS pay the CAA £30,000 per annum for its Approved Person
status, an exorbitant fee by any governmental or even quango standards. In
return, the CAA ensures that the illegality of the CAA-BPA CAP 660 document is not exposed by any properly-composed and Heath and Safety-compliant parachuting CAPs presented by other organisations that would reveal, for instance, CAP660’s non-compliance with Health and Safety law and regulation.
This blog is not alone in raising concern, as one instructor examiner and former BPA director stated on social media: “The BPA Operations Manual is not based upon a robust risk management approach and is not fit for purpose.”.
Active Monitoring – inspection and audit, and Reactive Monitoring – accident and incident investigation form integral parts of the Measuring and Reviewing Performance elements of any recognised Safety Management System, and thus provides particular drivers as part of the overall continuous improvement process.
HSE publication HSG245 Investigating Accidents and Incidents establishes the minimum requirements and provides guidance on the systematic approach that should be adopted in determine why an accident or incident has occurred and the steps needed to ensure it does not happen again.
However, BPA COO Tony Butler views any HSE involvement inskydiving as a “danger” and prefers to attribute any accident to a single cause; in Sgt Fisk’s case, the BPA/BS cites the burble. Typically with most BPA/BS accident reports, the intention is to attribute blame in terms of a technical failure or human error – the smokescreen to obscure the complexity of accident causation.
This serves to conceal the fundamental contributors to the event from investigatory overseers and the general public by creating the impression that the accident causes are beyond the scope of management control or, in other words, the BPA/BS directorate and the firm’s Operations Manual.
The ‘technical failure’ finding thus lays the blame on an inanimate item of hardware and on human error –– the rule-breaking Chief Instructor or the reckless skydiver at the scene of the accident. This approach serves to conceal the fact that such accidents are the result of management failures in the areas of organisation, procedure and risk control.
As BPA Watch has previously noted, senior BPA/BS official like Tony Butler receive reported six-figure salaries –– and generous expenses allowances –– whilst the firm’s annual safety-related expenditure hovers around £5,000.
When Mr Butler was BPA Ltd’s National Safety Officer, he spoke to a coroner’s court –– and to the press –– of investigating more than sixty skydiving fatalities. That was in 2003 during the confusion over BPA member Stephen Hilder, whose death was initally treated as murder. The death toll has remained constant since then, Rachel Fisk merely being the latest, which indicates that BPA/BS has done nothing to improve its appalling safety record. Mr Butler is currently the firm’s COO and named Person with Significant Control, and generally regarded as a ghost Director and Chief Executive Officer.
The categorisations of accident underlying and root cause factors, based on risk control principles, include but are not limited to the following;
- Safety management failures
- Human factors
- Technical failures
As an integral part of the overall enquiries, investigators will normally want to review and analyse previous accident data and statistics in order to identify any patterns or trends. However, the BPA has never reported accidents to the HSE nor categorised any accidents in accordance with RIDDOR criteria.
Consequently, the data available to other investigators –– in this case, the MOD, the RAF, the HSE and Thames Valley Police –– is incomplete and unreliable and thus inhibits the undertaking of any meaningful analysis.
Investigators will also want to review reports and findings relating to previous, similar accidents to establish any links or patterns in terms of root causes and underlying risk control failures. However, as this blog has clearly established, any report emanating from BPA/BS is highly likely to be unreliable.
The only adequate investigation into a skydiving fatality to be found in the public domain is the Service Inquiry into the death of a solider whilst parachuting at Bad Lippspringe, Germany – Document: 1 Rifles parachuting accident 29 September 2015.
It would appear that none of the significant findings and recommendations within this report have been addressed, implemented or otherwise adhered to by BPA/BS and, in this case, the RAF organisations in partnership with BPA/BS, which include The RAF Robson Academy of Resilience.
This is because BPA/BS is an arrogant, corrupt, insular,
self-serving mini-me quango –– created illegally by the CAA quango in its own
image –– whose directors consider themselves above any laws, a belief
underscored by CAA protection and, we must not forget, the patronage of no less
a figure than HRH The Prince of Wales.
Of course, this Royal patronage was granted when the British Parachute Association was a bona fide amateur sports association staffed and run by retired military officers, before the likes of Tony Butler and his cronies took it over.
As for the senior RAF staff officers from 22 Group who
oversee the RAF partnership with BPA/BS, BPA Watch has seen evidence that they
were warned about BPA/BS and its dangerous practices earlier this year but they
seem to be just as arrogant and careless as their civilian partners. And why not? They are all covered by the CAA, which is chaired by retired RAF officers.
Sgt Rachel Fisk’s death was eminently avoidable but BPA Watch
doubts that their consciences will be troubled. And putting its seal of
approval on this toxic fellowship is the CAA quango, headed by retired RAF
bigwigs like Air Chief Marshall Sir Stephen Hillier. And supporting the CAA
quango is Transport Minister Grant Shapps. Jobs for the boys: CAA Chair Sir Stephen Hillier
BPA/BS subterfuge and misdirection –– the art of lying with an element of truth as in the ‘burble’ axiom purported by the BPA Board of Inquiry – once again clouds the issue through this ‘interim report’.
Several parachute riggers have commented that, the javelin skyhook combination is notoriously difficult to pack; at most, the burble merely exacerbated an equipment functionality failure or packing mistake or otherwise is the equipment simply not fit for purpose?
As video footage shows, there was a clear 3-second delay between Sgt Fisk’s activation of her reserve parachute and the camera shot of her drogue deploying; what happened during these three seconds?
Commenting to BPA Watch on condition of anonymity –– for obvious reasons –- a well-respected skydiving instructor and examiner stated: “The BPA should not have issued this report before the coroners court hearing. I can only hope that the family of Sgt Fisk finds a team of experts to legally challenge what appears to be an attempted whitewash. Not for the first time when it comes to the BPA.”.
A long-serving former BPA Director or more than 25 years’ standing told us: “There should be a lot of very nervous members of the BPA Council at this time, as they will be held culpable for all the illegal actions of the BPA over many years. This accident is different. It is a serving member of the RAF that has died and the HSE are involved.
The BPA have been evading HSE scrutiny and regulation for years and got away with until now. Hopefully justice will eventually prevail and the HSE will see through the smokescreen with this accident and prosecute the BPA.”.
The question now being asked across the sector in both civilian and military circles is: does the BPA/BS and CAA rhetoric about BPA/BS being the “gold standard”, “world class” and “safest in the world” constitute misrepresentation in legal terms and is there an intent to mislead external authorities and the general public, including its customers, with regard to inherent and inadequately controlled risks relating to the sport of skydiving?
It is an important question for the 60,000-plus members of the public who participate in tandem skydiving each year and who are at risk. Of course, BPA/BS would say that an average of two or three deaths a year is low but the fact is that many of those deaths could have been avoided, just like Sgt Rachel Fisk’s death if the CAA-BPA/BS cartel took skydiving safety seriously.
This blog has asked the question before: how many people need to die before the authorities take heed of the situation and adequate interventions and action are forthcoming?
Secretary of State for Transport Grant Shapps MP should be taking a closer look at the CAA quango, its usurpation from the HSE
of regulatory control, its delegation of those stolen powers to an amateur
sporting association run by unqualified charlatans and the shocking death and
injury toll over which the CAA-BPA cartel has presided since 1996.
