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Failures Blamed For Red Arrows Pilot's Death
Red Arrows pilot Sean Cunningham died because of "serious communication failures" by an ejector seat maker, as well as RAF training issues, an inquest has found.
Giving a narrative verdict, a coroner criticised manufacturer Martin Baker's failure to pass on a "risk to life warning" about ejector seat bolts to the Ministry of Defence (MoD).
Flight Lieutenant Cunningham died because he did not separate from the Mk10 ejector seat and his parachute did not deploy because a shackle jammed, the verdict said.
He suffered fatal injuries when he was propelled 200-300ft in the air from his Hawk T1 aircraft while it was on the ground at RAF Scampton, Lincolnshire, in November 2011.
Central Lincolnshire coroner Stuart Fisher said: "There was a very serious failure of communication by Martin Baker in my view.
"It is unexplained by the evidence. It seems there is no logic to warn and inform some but not others."
The company had been aware since 1990 that over-tightening certain nuts and bolts could cause the parachute not to deploy properly. However, it had not informed all its clients.
The RAF's failure to ensure crew were aware that the ejector seat handle could be in an unsafe position, even when a safety pin was inserted, also contributed to the tragedy, said the coroner.
He described the pin as "entirely useless" and "likely to mislead".
There had been a repeated failure to notice that the pin had been incorrectly replaced, leaving the ejector handle raised, the coroner said.
The inquest heard how Flight Lieutenant Cunningham was doing pre-flight checks when he accidentally fired the ejector seat.
Describing the incident, Mr Fisher said: "Automatic separation from the ejection seat and main parachute deployment failed to occur.
"Very shortly thereafter and when still retained in seat there followed a high-velocity impact with the ground from which he suffered no survivable injuries."
Reacting to the verdict, Flight Lieutenant Cunningham's father Jim said his son "died doing what he loved".
He added: "Sean's death was a tragedy which we hope the evidence revealed in this inquest will help to avoid in the future."
The coroner said that the RAF had made significant improvements to prevent a similar incident.
Ejector seat manufacturer Martin Baker expressed "sincere condolences" and said it was "deeply saddened" by the pilot's death.
It said warnings about the seat how had now been passed on to all aircraft still using it, and that a new bolt and firing handle mechanism had also been designed.
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