A coroner has described a safety pin on an ejection seat that threw a Red Arrows pilot to his death as "entirely useless" and criticised its manufacturer for failing to warn the RAF of the defect.
Flt Lt Sean Cunningham, 35, was killed at RAF Scampton in Lincolnshire on November 8th 2011 after he was accidentally ejected from his Hawk T1 aircraft while it was on the ground.
Flt Lt Cunningham, who was born in South Africa and grew up in Coventry, was propelled 220ft in the air from the cockpit of the plane.
The inquest heard that the ejection seat firing handle was left in an unsafe position meaning it could accidentally activate the seat.
The court heard that testing of the Mk.10 Martin-Baker seat showed it was still possible to insert a safety pin into the seat even when it was in an unsafe position.
Coroner Stuart Fisher described the pin mechanism as "entirely useless".
The failures associated with the ejection handle should not have proved fatal as Flt Lt Cunningham should have been saved by his parachute.
However, Mr Fisher told the hearing that the main chute failed to deploy because a nut and bolt had been fastened too tightly.
The court heard that seven RAF personnel had 19 opportunities to check the ejection seat firing handle between the final flight on November 4 and the incident.
All personnel failed to notice the seat was in the wrong position.
The coroner said there was a repeated failure not to notice that the pin had been incorrectly housed and that the seat firing handle was in an unsafe position.
The court heard that Martin-Baker knew the parachute mechanism could jam if the nut and bolt were too tight as early as January 1990.
However despite being aware of these issues Martin- Baker failed to pass on the warnings to the Ministry of Defence, the coroner said.
Following the three-week inquest, Central Lincolnshire coroner Stuart Fisher recorded a narrative verdict.
Mr Fisher said: "There was a very serious failure of communication by Martin- Baker (the manufacturer) in my view. It is unexplained by the evidence. It seems there is no logic to warn and inform some but not others."
In a statement released after the hearing today, Air Commodore Terry Jones, speaking on behalf of the MoD, said: "The tragic loss of Flight Lieutenant Sean Cunningham at RAF Scampton in November 2011 is still keenly felt by the Royal Air Force, the Red Arrows and all of Sean's former colleagues.
"Our thoughts have always been and continue to be with his mother and father Monika and Jim and sister Nicolette and his extended family and friends. They remain in our thoughts and prayers as always.
"We are grateful to the Coroner for his thorough examination of the facts and to the preceding thorough inquiry conducted by the Military Aviation Authority. There have been a number of lessons for us and others to absorb and correct and we have made and will continue to make every effort to ensure that such a tragic accident cannot occur again. The Red Arrows in particular will be a stronger, safer and better team as a result."