Red Arrows pilot Sean Cunningham inquest
The coroner was told a small metal plate has been designed to fit over the ejection seat firing handle (pictured), to prevent the seat from being activated accidentally.
A new type of bolt, which cannot be over tightened, converse sklep has also been designed for the parachute drogue shackle at the top of the seat.
How dangerous is life as a Red Arrow?
Mr Fisher said the RAF had failed to take “sufficient steps” to bring the risk to the attention of air and ground crew, and said this had contributed to the pilot’s death.
Flt Lt Cunningham’s parachute should have saved his life, but the main chute failed to deploy because a nut and bolt had been fastened too tightly, the inquest heard.
Mr Fisher said none of the engineers who worked on the parachute mechanism can be criticised.
Martin Baker knew the parachute mechanism could jam if the nut and bolt were too tight as early as January 1990, the inquest was told.
The manufacturer warned some air forces but did not warn the MoD.
Mr 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 CPS concluded that no manslaughter charges should be brought, due to “insufficient evidence”.
However, the Health and Safety Executive (HSE) could still prosecute Martin Baker and/or the MoD, and will consider whether to do so now the inquest has concluded.
Flt Lt Cunningham’s parents agreed an undisclosed settlement with the MoD in December, after the MoD admitted liability for the incident.
Customers alertedMartin Baker issued a statement extending “sincere condolences” to Flt Lt Cunningham’s family and friends.
“On this occasion, converse skor online uniquely in the entire history of Martin Baker ejection seats using this particular feature, it [the parachute] failed due to a shackle bolt being too tight.
“In light of this incident, lessons have been learned and we have taken steps to alert all our customers worldwide who still use this type of seat, of the risk of over tightening the shackle.”
Flt Lt Cunningham took Night Nurse medication the night before the accident, but Mr Fisher was satisfied this did not impair his abilities.
Speaking after the inquest, his father Jim Cunningham said: “We welcome the conclusion of the coroner which confirmed 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 no family such as ours has to endure such a pointless and avoidable death.”