Two SAS soldiers died in Iraq because the Ministry of Defence failed to adequately maintain a helicopter which crashed and caught fire.
Pilot error was the primary cause of the RAF Puma's crash-landing near Baghdad in November 2007, said Herefordshire coroner David Halpern, but a faulty fuel valve that had not been checked for almost 30 years had been a relevant factor. Mr Halpern, who heard seven days of evidence about the deaths of Corporal Lee Fitzsimmons and Sergeant John Battersby, described the failure as "inexplicable".
Recording narrative verdicts, Mr Halpern said Sgt Battersby, 31, from Lancashire, died before the fire took hold, while Cpl Fitzsimmons, 26, from Peterborough, died from a severe head injury and inhaling fumes.
Their comrades had battled for four minutes to free them from the burning aircraft. The anti-spill valves allow fuel vapour to vent to the open air and should have closed if a Puma rolled over. But the inquest heard the valves had not been checked for decades and were not listed on the aircraft's maintenance checklist.
Mr Halpern 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."
Mr Halpern identified several failings made by the MoD, including its failure to foresee the risk of a fuel anti-spill valve "sticking" when an aircraft rolled over; 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."Reuse content