The inquest into the death of Red Arrows pilot Sean Cunningham has revealed that a number of “serious communication failures” were at fault.
Flight Lieutenant Cunningham died on November 8 2011, aged 35, at RAF Scampton when his Mk10 ejector seat fired whilst the Hawk T1 aircraft was still on the ground.
Senior Coroner for Central Lincolnshire Stuart Fisher, who has heard almost three weeks of evidence, described ejector seat manufacturer Martin-Baker Aircraft Co failure to pass on a “risk to life warning” about ejector seat bolts.
The company issued seat maintenance safety warnings to foreign air forces – but not to the RAF.
The inquest also heard that his parachute did not deploy because a shackle jammed.
The Iraq War veteran was shot 220ft into the air and suffered fatal injuries at ground impact.
The court heard that seven RAF personnel missed 19 opportunities to check that the seat firing handle had been left in a safe position.
Coroner Stuart Fisher also said the safety pin mechanism was “entirely useless” and gave the impression that the seat was safe.
The inquest heard that Flt Lt Cunningham took Night Nurse medication the night before his accident. Mr Fisher was satisfied this did not impair his abilities.
The court has heard that all 59 recommendations in the military aviation authority’s air safety service inquiry into the incident have been adopted by the RAF.
The Ministry of Defence have paid an undisclosed damages settlement to the family of Sean Cunningham after admitting full liability for his death.
Lincolnshire Police Supt Shaun West said: “We hope this inquest has explained the circumstances surrounding Mr Cunnigham’s death to his family and in some sense enables them to move forward.
“Lincolnshire Police conducted an extensive investigation into this matter and the work of my team was praised by the coroner during the inquest.”