A coroner today slammed safety pins in an ejector seat as "useless" as he criticised a manufacturer for failing to warn the RAF of defects which led to the death of a Red Arrows pilot.
Flight Lieutenant Sean Cunningham, 35, was killed after he was accidentally ejected 220ft into the air from his Hawk T1 aircraft while on the ground at RAF Scampton on November 8 2011.
The South African born pilot remained attached to his seat and fell unrestrained by the main parachute to the ground. He suffered non-survivable injuries, in particular to his brain and cardiovascular system, as a consequence of the high velocity impact with the ground, an inquest heard.
Recording a narrative verdict into the death today, Central Lincolnshire coroner Stuart Fisher criticised manufacturer Martin Baker for failing to inform the RAF of risks associated with the seat.
The inquest, held in Lincoln, heard that the ejection seat firing handle had been left in an unsafe position which meant it could accidentally activate the seat.
Mr Fisher said the safety pin mechanism was "entirely useless" and that it was "likely to mislead".
Tests of the MK 10 Martin Baker seat had showed that the safety pin could be inserted even when the seat was in an unsafe position; giving the impression the seat was safe, the coroner said.
However the coroner noted that the failure of the handle should not have proved fatal as the parachute should have opened when Flt Lt Cunningham was ejected.
Mr Fisher also criticised Martin Baker for a "serious failure of communication" relating to known risks associated with over-tightening of crucial nuts and bolts which could "hinder or prevent" the deployment of the main parachute.
Despite being aware of the risks since 1990, Martin Baker failed to warn the Ministry of Defence, the coroner said.
Matt Price was at Lincoln Corner's Court:
The family of RAF pilot Sean Cunningham have secured an undisclosed settlement from the Ministry of Defence in December 2013 following a full admission of liability for the incident in July that year.
Law firm Irwin Mitchell said:
"It was revealed during a three-week inquest that seat manufacturer Martin Baker warned air forces in other countries as far back as 1990 about a potential problem where the over tightening of a nut and bolt in the mechanism could cause the parachute to fail to deploy, but did not inform the RAF."
In a statement, the father of Flight Lieutenant Sean Cunningham says his son died doing what he loved, adding that the family are struggling to accept how many opportunities were missed which could have prevented his death.
Flight Lieutenant Cunningham's father Jim Cunningham said:
“Our son Sean died aged 35 doing what he loved which was flying with the Red Arrows. From the age of 17, he had wanted nothing more than to join the Royal Air Force and serve his country, which he did with utmost pride and sense of duty.
“He served a number of tours in Iraq flying Tornados in close air support of coalition forces. Sean’s death was a tragedy which we hope the evidence revealed in this Inquest, will help to avoid in the future.
“We still find it difficult to accept that so many people could have missed, between Sean’s last sortie on Friday and the following Tuesday, what should have been obvious to those having a duty to ensure the safety of the seat, and we remain unconvinced as to that aspect of the Coroner’s finding.
“Nevertheless, we accept that how the seat firing handle came to be in a position where it could be inadvertently activated may never be fully understood.
"We welcome the conclusions of the Coroner which confirm what we knew all along, which is that Sean was blameless and his tragic death was preventable.
"We therefore welcome the Coroner’s recommendations, which we hope and pray will ensure that no family such as ours, has to endure such a pointless and avoidable death."
The inquest heard that the ejection seat firing handle had been left in an unsafe position, meaning it could accidentally activate the seat.
Mr Fisher described a safety pin that goes through the firing handle as "entirely useless" and said its presence was "likely to mislead".
There were 19 checks carried out on the Hawk T1 between the final flight on November 4 and the incident.
The coroner said there was a repeated failure not to notice that the pin had been incorrectly housed and that the seat firing handle was in an unsafe position.
However, he said tests had showed that the pin could be inserted into the MK 10 seat even when it was in an unsafe position, giving the impression to RAF personnel that the seat was safe.
The coroner also said that Martin Baker was aware of issues with the over-tightening of crucial nuts and bolts in the mechanism of the seat which would cause the main parachute not to deploy properly.
However despite being aware of these issues since 1990, Martin Baker failed to pass on the warnings to the Ministry of Defence, the coroner said.
Mr Fisher said that, on the day of the incident, a shackle jammed and stopped the main parachute from opening and Flt Lt Cunningham being separated from the seat.
The coroner investigating the death of a Red Arrows pilot has branded part of the ejection seat on Sean Cunningham's plane as "entirely useless".
Cunningham was 35-years-old when he died in November 2011 from multiple injuries when he was catapulted nearly 300 feet into the air from his Hawk T1 aircraft, and then fell to the ground still strapped to his ejector seat.
Coroner Stuart Fisher said seven RAF personnel had 19 opportunities to check the ejection seat firing handle, but did not notice it was in the unsafe position.
He said "repeated failure to notice this" could only be due to the checks "not being done at all or not done sufficiently carefully by each individual".
The death of a Red Arrows pilot increased the "focus" needed on raising the number of engineers working for the team, an inquest has heard.
The process to assign more manpower to the display unit was already in motion but the shocking accident in which Flight Lieutenant Sean Cunningham was killed at RAF Scampton in Lincolnshire highlighted the need to rectify the shortfall in staff, a senior Royal Air Force (RAF) officer has said.
Air Commodore George Martin, who was chief air engineer at the time of Flt Lt Cunningham's death in November 2011, told Central Lincolnshire Coroner's Court that he had already received notice that the Red Arrows were short of around 19 engineers.
Flt Lt Cunningham was killed after he was ejected from his Hawk T1 aircraft while on the ground at the Lincolnshire air base and propelled 200 to 300ft in the air, on November 8 2011.
He was a highly regarded and experienced pilot with the RAF's aerial display team as well as an Iraq war veteran.
The parachute on the ejector seat did not deploy and the 35-year-old South African-born airman later died in hospital as a result of multiple injuries.
Asked at the inquest by Tom Kark QC, representing Flt Lt Cunningham's family, if the tragedy had been the catalyst for an increase in manning, Air Cdre Martin said work was under way by in the autumn of 2011 to justify and present a case further up the hierarchy as to why levels should increase.
The inquest, which began last week, has already heard evidence from witnesses who said workload meant engineers had little opportunity to get their hands on the planes, and in 2007 there were more experienced staff at corporate level.
Staff on the team had also expressed concerns about a lack of training in some crew and "dilution" in roles.
The inquest continues.
An RAF engineer has told an inquest on Tuesday of how a dream posting to the Red Arrows turned into a nightmare after he discovered he was expected to carry out his new job without training.
Chief Technician Norman Briggs, who joined the crack aerobatics team in April 2011 said he had no previous experience of working on Hawk jets used by the Arrows but was left to his own devices after simply being shown round the hangar at their base at RAF Scampton, Lincs.
The inquest at Lincoln is examining the circumstances surrounding the death of Red Arrows' pilot Flt Lt Sean Cunningham, 35, who lost his life in November 2011 after his ejection seat went off while he was on the ground preparing to take off.
He was thrown 300 feet into the air and suffered fatal injuries when he fell back down to earth still strapped in his seat after his parachute failed to open.
The hearing has been told that at the time the ground crew team was up to 30% short of the numbers needed to operate efficiently with many of those arriving on the team straight from their basic training.
Mid Lincolnshire Coroner Stuart Fisher is also looking at what part problems with the ejection seat played in the fatal incident.
Chief Technician Briggs told an inquest that he was appointed to a supervisory role as avionics trade manager with the team but was not given the training he needed to carry out the job.
The inquest into the death of Red Arrow Sean Cunningham heard how ground crew ran for safety after the pilot was thrown 300 feet into the air when his ejection seat went off while he prepared for take-off.
Cpl David Morris:
"The canopy filled with smoke and then Flt Lt Cunningham went with his seat through the canopy. As the canopy blew it took a couple of seconds to register what had happened.
"Then we ran to avoid parts of the canopy hitting us. I knew at some point the ejection seat was going to separate and it was going to fall to the ground.
"It looked like Flt Lt Cunningham was trying to stabilise himself. I could see his limbs moving. It looked as if he was trying to get his balance. The parachute didn't open. The seat came down and hit the floor, I could feel the thud. I saw the whole thing."
SAC Joseph Tiley, who had helped Flt Lt Cunningham prepare his aircraft for take-off said the ejection seat went off as he was carrying out last minute checks said:
"I was taking a step back to do the air brakes when I saw a flashy and black smoke. At that point I tucked myself up unto a ball, put my hands over my head and closed my eyes. I didn't see any of the ejection."
Sgt Chris Clarkson:
"I caught the flash from the ejection out of the corner of my eye. I turned to look and I saw Sean leaving the aircraft. I watched him go over my head. Then we started getting hit by canopy so I turned away.
"I saw Joe Tiley on the floor. Being so close to the aircraft I thought he was possibly dead. "
An inquest has heard how in the immediate period before Flt Lt Cunningham's death the Red Arrows had been concentrating on learning lessons from the death of another pilot, Jon Egging, who lost his life three months earlier when his Hawk Jet crashed while taking part in an air show at Bournemouth.
Sqdrn Ldr Martin Higgins, who was Red 10 at the time of the tragedy said:
"Due to the fact of Jon Egging's crash the priority would have focused on the lessons identified from the crash rather than administering the air safety management plan."
The hearing in Lincoln continues and is expected to last three weeks.
The hectic schedule of the Red Arrows display team meant that engineers barely had time to carry out work on their Hawk jets, an inquest heard today.
The number of engineers available to the team had been reduced over the previous four years but there was no reduction in the work load.
The inquest into the death of pilot Sean Cunningham, who died after his ejection seat fired while he was preparing for take off sending him 300 feet into the air, was told that the team was up to 20 engineers short and many were inexperienced.
It heard that a number of mechanics were on their first RAF posting after completing their basic training.