The deaths of 10 British servicemen killed when their RAF Hercules was shot down in Iraq was the result of "serious systemic failures", a coroner said today.
The fact that the Ministry of Defence and RAF had not fitted the Hercules fleet with ESF (explosion-suppressant foam) was a factor in the tragedy, coroner David Masters said.
The Wiltshire coroner also highlighted a failure to communicate intelligence about insurgents who had already fired on two US helicopters in the same area earlier the same day in January 2005.
Mr Masters said: "The failure to fit ESF was on the facts found a serious systemic failure and a contributory factor in the loss of the aircraft.
"There was a loss of opportunity for the survival of the crew by that failure."
The Hercules C130k aircraft, 47 Squadron Special Forces flight XV179, was flying at low-level (about 150ft) in daylight from Baghdad to Balad to await further tasking orders when it was downed by insurgents.
The coroner, ruling that the 10 men were unlawfully killed, highlighted the way intelligence was not passed on about a previous attack by insurgents on the US Blackhawks on the same day in the same sector.
He described this as another "failure."
But he said XV179's decision to fly at low level was not a failure because the Hercules flying community at the time had no idea of their vulnerability to small arms fire, which they were in range of at 150ft.
Among Mr Masters' recommendations, made under Rule 43 of the Coroners Rules, was for all RAF combat aircraft to be fitted with fuel tank inerting systems - which do the same job as ESF.
He said, in particular, the Hercules' successor, the Airbus A400M, must all be fitted.
The coroner then turned to the intelligence failure - US Blackhawk helicopters came under fire in the same area shortly before Hercules XV179 was shot down.
This should "never be allowed to happen again," the coroner said, recommending a review of coalition intelligence systems.
All aircraft in theatre should be visible on this system to all teams at coalition HQ. Probable flight paths and any changes to them should be made known too.
This recommendation was made in the light of XV179's flight path not being known by British ground-base intelligence officers because it was a Special Forces flight.
The coroner also recommended a review of weapon classification taught by staff at the Air Warfare Centre at RAF Waddington.
This came in the wake of RAF witnesses not having a thorough awareness of the different types of projectile-firing weapons in theatres like Iraq.
Mr Masters said all combat aircraft must be fitted with black boxes or other such flight data recording devices so as to better assist investigators in the event of an incident. XV179 did have one.
He said, from now on, all suspected battle damage on all aircraft must be examined and reported upon to appropriate figures "to inform the risk/threat analysis".
On the failure of US soldiers to assist the inquest, Mr Masters said that despite it arguably being outside the remit of Coroner's Rule 43, he would recommend that America helped in future.
"Who knows, lives could be saved by the assistance of any force, be it from America or elsewhere," he said.
Concluding the two-month inquest, Mr Masters said he would also tell the relevant Government Minister that family members should be allowed legal aid to fund lawyers to represent them at future inquests.
This issue dates back to before the start of the XV179 inquest in April, when families of the 10 dead men were denied funding, before being granted it at the 11th hour. Most families were unrepresented at the hearing.
Mr Masters told the families before ending the inquest: "We shall shortly be approaching Remembrance Day. These men will never be forgotten. They were so brave, but so unlucky to die."Reuse content