A coroner today criticised the Ministry of Defence for failing to adequately maintain a helicopter which crashed and caught fire in Iraq, claiming the lives of two SAS soldiers.
Herefordshire Coroner David Halpern said that the primary cause of the RAF Puma's crash-landing near Baghdad in November 2007 had been pilot error.
But the coroner, who heard seven days of evidence about the deaths of Corporal Lee Fitzsimmons and Sergeant John Battersby, ruled that a faulty fuel valve had been a relevant factor in one of their deaths.
Mr Halpern, sitting at Hereford Town Hall, said it was "inexplicable" that the inoperative anti-spill valve had not the been the subject of any checks for almost 30 years.
Recording narrative verdicts on both men, Mr Halpern said he believed Sgt Battersby, a 31-year-old from Lancashire, died before the fire took hold, while Cpl Fitzsimmons, 26 and from Peterborough, died from a severe head injury and the inhalation of fumes.
Comrades of the two men battled for four minutes to free them from the burning aircraft but were eventually forced to withdraw due to the intense heat.
A pathologist told the inquest that Cpl Fitzsimmons' injuries were not survivable and it was inconceivable that they would not have rendered him unconscious.
Addressing the primary cause of the crash, which happened during a high-level mission to apprehend insurgents south of Baghdad, Mr Halpern said he did not wish to be "over-critical" of the pilot.
The coroner said: "He was faced with a very difficult task. Very sadly, things just went wrong for him on this particular occasion."
But Mr Halpern did identify failings made by the MoD, including its failure to foresee the risk of a fuel anti-spill valve "sticking" when an aircraft rolled over, a failure to fit display night-vision goggles to the Puma prior to the crash, and to enforce its policy for personnel to use restraints in aircraft.
"They really do need to implement, prosecute and police their policy regarding the use of restraints," Mr Halpern said, although he conceded that the soldiers killed would have been justified in not wearing them when the helicopter landed during a fast-moving mission.
Mr Halpern, who described the crash-landing in a furrowed field after its aftermath as "devastating", was told the anti-spill valves allowed fuel vapour to vent to the open air and should have closed if a Puma rolled over.
But the inquest heard that the valves, which operated by gravity, had not been checked or maintained for decades and were not listed on the aircraft's maintenance checklist.
Summing up the evidence, the coroner said: "They should have been part of a risk assessment and appropriate maintenance schedule.
"It was said by the pilot of the Puma that he would have considered the craft to be unairworthy if he had known that it had an inoperative anti-spill valve.
"For some inexplicable reason, for nearly 30 years the Puma anti-spill valve had just not been the subject of any maintenance checks."
After the hearing, Cpl Fitzsimmons' mother, Jacqui Auty, said she was reassured that the coroner had recognised the broad range of issues which contributed to the accident.
"We are asking ever more of our brave forces," she said. "When our sons lay their lives on the line for the greater good, I think they deserve better than this.
"Being a soldier isn't and never will be a risk-free business. However, all of our forces deserve to have the right equipment for the job, for it to be in good condition, and to have been fully trained for the situations we put them in."
Mrs Auty added: "It is of some comfort to hear that several of the failings have already been acted on and may prevent others from serious injury or death."
In a statement issued by her solicitor, Sgt Battersby's widow, Joanne, said he had died doing a job he loved and had been totally committed to his job.
Mrs Battersby said: "He knew the risk involved and we both were aware of the many dangers he would face every day.
"John loved life, he loved his family more than anything, but he also loved the Army and was so proud of what he had achieved and the standard of living he provided for his family.
"He died a hero for me, his children, his country and I hope that he will never be forgotten.
"I do not blame the RAF for his death, the pilot was doing his best under difficult circumstances. He and many like him can only work with the tools they are given and my thoughts about the role played by the MoD are best kept secret."
The inquest heard that an RAF board of inquiry had already investigated the crash, to learn lessons and improve the safety of its Puma fleet.
Speaking to the media following the inquest, Group Captain Jonathan Burr, the Station Commander at RAF Benson in Oxfordshire, offered his condolences to both men's families.
"I would like to thank the coroner for conducting this inquest so thoroughly," he said. "The verdict today reinforces the action we have already taken as a result of a review and our own board of inquiry.
"We constantly strive to improve our equipment to ensure the safety of our crews."
Barrister John Cooper, who represented the soldiers' families at the hearing, said he hoped the MoD had learned lessons from the tragedy.
"One hopes they have learned that equipment should be properly maintained," he said.
Rear Admiral Tony Johnstone-Burt, Commander Joint Helicopter Command, thanked the coroner for a thorough inquest and paid tribute to the "courage and dignity" of the soldiers' families.
He said: "We've learned the lessons from this incident and will do our utmost to ensure that such a tragic event does not happen again.
"These two brave men were involved in a highly complex and dangerous mission to apprehend insurgents.
"Restraints were available but as is common in such situations, the personnel onboard had removed them for landing so they could disembark quickly for the mission and return fire if necessary."
Since the fatal crash, he said, measures have been taken to make sure anti-spill valves are checked regularly and the Puma Force has been fitted with night vision goggles.
He added: "The loss of this aircraft again emphasises the risks that our people face daily on operations, and the inherently dangerous nature of our business.
"The lives and safety of our personnel are our highest priorities, and the Ministry of Defence is constantly striving to improve our equipment and processes to minimise risk as much as we possibly can."Reuse content