33:
273:
safety pin had been incorrectly inserted or that the firing handle was in an unsafe position. One senior aircraftman who was working that day gave evidence at the inquest stating that he had confirmed the firing handle safety pin was in position, which meant it was supposed to be safe according to his training. He said "I still believe it's not possible, or shouldn't be possible, for those other positions. To me, an ejection seat should have two settings: safe or in use."
248:
safety pin of her ejection seat firing handle leaving her at risk of accidental ejection. Stewart said the firing handle had accidentally been moved to the wrong position during flight by her seat straps, and that she believed the handle being in the wrong position prevented full insertion of the safety pin. The inquest was heard at
Lincoln Cathedral Centre in January 2014. This had been delayed due to
277:
would not be. This means that the yellow and black strap that sits between the pilots legs (the SFH) can be pulled upwards sharply and the seat will deploy. The SFH can also be pushed accidentally into a downward position, so that any amount of downward pressure upon it will allow the ejection to activate.
238:
The
Service Inquiry into the accident found that the seat firing handle (SFH) safety pin, had been displaced on an earlier flight (4 November 2011) and re-inserted incorrectly so as to appear that it was in the safe position, especially if viewed vertically from above, which is the normal stance when
210:
initiated at 11:06 am, which resulted in the canopy being shattered and the seat with
Cunningham strapped into it being jettisoned into the air. After reaching a height of 220 feet (67 m) the drogue parachutes deployed (one was 22 inches, 560 mm across and the other 5 feet, 1.5 m)
317:
According to Martin-Baker's solicitors (Clyde &Co) they were advised to plead guilty to 'avoid upsetting MoD'. As part of the guilty plea, Martin-Baker agreed to pay court costs amounting to over £550,000 but refuted the prosecution's allegation that what happened was "not an isolated incident".
285:
or the Royal Air Force. An assessment carried out by the
Ministry after the incident stated that the event would occur only every 115 years. It was revealed prior to sentencing that Martin-Baker had passed this information to MoD before 1990, so had no obligation to do so again in 1990. In court, it
247:
A pre-inquest hearing was held in August 2013, where the coroner heard that Flight
Lieutenant Kirsty Stewart, a fellow pilot on the Red Arrows, had a related incident working as an instructor at RAF Valley. After landing following a training flight, Stewart noticed she had failed to fully insert the
280:
The coroner was critical of Martin-Baker, who knew about how the bolt that retained the drogue parachute was not to be over-tightened as far back as
January 1990. Martin-Baker had informed some operators of the Mk10B1 seat (including many military air forces worldwide) not to over-tighten the bolt,
268:
The inquest also heard how a squadron leader who had returned to the Red Arrows after being away for four years was surprised by the lack of engineers for the squadron, the operational tempo (especially given the age of the aircraft) and the relative inexperience of the engineers, some of whom were
256:
The inquest heard about the incident and the events leading up to it, including how
Cunningham had taken Night Nurse, a brand of cold relief, as an oral suspension the night before and how moments before crewing-in, he accepted a 49-second call on his mobile phone from an estate agent about a house
294:
Martin-Baker have since designed a small metal plate to go over the SFH which prevents accidental firing. This had been proposed a number of times but always rejected by MoD. Additionally they have created a new bolt that cannot be over-tightened and will hold the main parachute in place until the
272:
The coroner described the safety pin of the ejection seat's firing handle as "entirely useless". Seven personnel had nineteen opportunities to check the position of the firing handle between its final flight on 4 November and the incident, and none of them, including
Cunningham, had determined the
276:
One of the last things that a pilot does when crewing-in before take-off, is to remove the safety pin(s) so that the seat is "live". The safety pin on the seat could also be mis-aligned, which when viewed from a normal vertical downward angle, means that it looks to be in the 'safe' position, but
234:
The seat did not act in the sequence that it was supposed to; after ejection from the canopy and a ceiling height is attained, the seat is supposed to drop away and a main parachute deploy to allow the pilot to drift back down to the ground. A bolt had been over-tightened which meant that the
239:
looking at the ejection seat for both aircrew and groundcrew, but actually it was in an unsafe position. As the aircraft was not used between 4 November and 8 November 2011, the cockpit was unsafe for four days. It was believed that straps from a previous sortie had pulled the SFH loose.
264:
Before crewing-in, Cunningham and some of the other aircrew were waiting for the engineering paperwork to be completed and it was stated that
Cunningham appeared "in good spirits", and that he was "buzzing with excitement at flying to RAF Valley and an overnight stay with four friends".
122:, England. The initiation of the ejection seat was assumed to be by accident. The parachute on the seat did not deploy and Cunningham fell, still strapped to the seat, 220 feet (67 m) to his death 217 feet (66 m) away from the motionless aircraft. In January 2018, in the
330:
Hawk aircraft, reads "...they have slipped the surly bonds of Earth / Put out their hands and touched the face of God... / In memory of / Flt Lt Jon Egging – 20th August 2011 / Flt Lt Sean
Cunningham – 8th November 2011". The wording paraphrases part of the poem "High Flight" by
211:
which were designed to allow the seat to stabilize itself in mid-air. As the seat fell back to earth the main parachute failed to deploy to slow the descent to a safe speed, and he fell to his death in the malfunctioning ejection seat. Cunningham was airlifted to
252:
conducting their own criminal investigation in the incident and passing the case file to the Crown Prosecution service (CPS) who decided that no-one would be prosecuted as there was insufficient evidence to suggest anyone had breached their duty of care.
286:
was claimed MoD never had this information, from 1952 on. An RAF training film, MoD Air Publications and aircrew & engineer witnesses, proved otherwise; but the Health and Safety Executive advised the judge that this was irrelevant.
314:. A pre-trial hearing was conducted in February 2017, where the company pleaded not guilty. A trial was scheduled to commence in January 2018, at which Martin-Baker pleaded guilty to a breach of the Health and Safety at Work Act 1974.
206:. As the team were out of the display season (which normally ends in September), they flew up to three times a day, five days a week for continual professional training. During Cunningham's aircraft's pre-flight checks the
295:
ejection seat is initiated and stabilised. This shoulder bolt had previously been removed from the Mk9 seat design, with the MoD's agreement. Training on ejection seats in the Royal Air Force was changed after this event.
343:
235:
sequence could not complete properly. It was noted that the initiation of the ejection seat was almost impossible to do accidentally, with senior officers from the RAF at a loss to explain how it happened.
261:, which can cause "drowsiness, poor vision, loss of concentration and cognitive impairment". The other stated that it was "highly unlikely" that the dose taken would have had any effect the following day.
231:) was also fitted to other aircraft besides the Hawk, though many were cleared as being fit to fly in the days after the event. The Red Arrows were given their airworthiness back by early December 2011.
1235:
1616:
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on their first tour. There had also been pressure on the pilots to perform at a greater number of events. For the 2012 season, the number of hours flown had been dropped from 3,000 to 2,500.
227:
The incident led to a grounding of many aircraft that the Royal Air Force were operating at that time, including all variants of the Hawk aircraft. The Martin-Baker ejection seat used (
1209:
257:
sale. Two medical officers submitted testimony that disagreed with each other about the effect of Night Nurse on Cunningham's alert state. One stated that Night Nurse contains
215:
by air ambulance, but was declared dead there at 12:14 pm. Cunningham died after what the coroner called "non-survivable injuries" to his brain and cardiovascular system.
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initiated whilst the aircraft he was in was stationary on the ground and he was conducting pre-flight checks. The incident occurred at the Red Arrows' home base,
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588:
326:
There is a memorial at RAF Scampton to Cunningham and fellow Red Arrows pilot, Flight Lieutenant Jon Egging. A brass plaque, on a wooden plinth in front of a
135:
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might pursue a prosecution. In September 2016, The Health and Safety Executive announced that they would be pressing ahead with a prosecution of
1324:
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311:
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and learnt to fly, gaining his pilot's licence at the age of 17. Despite a promising career in football, after university Cunningham joined the
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154:, South Africa, in 1976. His family moved to the United Kingdom in 1986 when he was nine years old and settled in the
37:
Three of the Red Arrows departing RIAT 2011. XX177 is on the left of this image taken four months before the incident
1571:
Service Inquiry Investigating the Accident Involving Hawk XX177 on 8 Nov 2011 Part 1.3 Narrative of Events
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1462:
Mitchinson, James, ed. (13 February 2018). "Ejector seat firm put lives of pilots at risk".
302:(CPS) announced in May 2013 that no-one would be prosecuted over the incident, but that the
190:
On 8 November 2011, Cunningham (who was to fly as RED 5), was crewing-in to his aircraft, a
182:
of the Royal Air Force before being selected to join the Red Arrows as 'RED 5' in May 2011.
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8:
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seat; that is, it has no minimum speed or minimum height above ground to deploy fully.
1210:"Red Arrows pilot was not warned about ejector seat danger before death, says coroner"
1467:
96:
155:
344:
List of fatal accidents and incidents involving Royal Air Force aircraft from 1945
506:
167:
103:
1449:
RED 5 – An Investigation into the death of Flt Lt Sean Cunningham (David Hill)
1404:"Ejector seat firm to stand trial over death of Red Arrows pilot from Coventry"
1285:
Red 5 – An investigation into the death of Flt Lt Sean Cunningham (David Hill)
563:"Ejector seat manufacturer criticised after death of Coventry Red Arrows pilot"
138:
regarding Cunningham's death. On 23 February 2018, Martin-Baker were fined £1.1
1600:
1471:
327:
207:
111:
1512:"75 Years of High Flight Beloved aviator poem's 75th anniversary celebrated"
307:
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151:
131:
119:
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441:"Joining Red Arrows was boyhood dream for pilot killed in ejector tragedy"
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863:"Red Arrows pilot fell from about 300ft following ejection from aircraft"
203:
123:
1429:"Red Arrows ejector seat firm pleads guilty to RAF Scampton pilot death"
1128:"Red Arrows pilot Sean Cunningham inquest: 'Problem with ejection seat'"
1158:"Inquest into Red Arrows pilot death told 'resources were a big issue'"
1045:"Red Arrows 'lacked experienced engineers' ejection seat inquest hears"
199:
171:
107:
1236:"Inquest into death of Red Arrows pilot Sean Cunningham finds ejector"
1100:"Red Arrows crews missed 19 chances to spot deadly ejection seat risk"
1325:"Ejector seat-maker to be prosecuted over death of Red Arrows pilot"
810:"Red Arrows pilot Sean Cunningham inquest: Seat mechanism 'useless'"
1074:"Red Arrows inquest: coroner criticises ejection seat manufacturer"
725:"Martin-Baker vows to learn lessons from fatal Red Arrows accident"
351:- another Red Arrows pilot, who died a few months before Cunningham
191:
159:
698:"Red Arrows ejector seat death: CPS to review Red Arrows fatality"
589:"Manufacturer to be prosecuted over death of RAF Red Arrows pilot"
1184:"Ejection seat firm failed to warn MOD of Red Arrows safety flaw"
134:, the manufacturers of the seat, pleaded guilty to a breach of
1617:
Aviators killed in aviation accidents or incidents in England
1378:"Firm to face trial after RAF Red Arrows ejection seat death"
415:"Coventry Red Arrows pilot death: Ejector seat firm in court"
948:"Red Arrows pilot death: Ejector seat firm to be prosecuted"
922:"Work culture of Red Arrows to be probed at pilot's inquest"
893:"Red Arrows pilot Sean Cunningham 'died in 300ft ejection'"
318:
In February 2018, the company was fined £1.1 million.
672:"Red Arrows pilot death: No charges over fatality say CPS"
1351:"Ejection seat firm in court over Red Arrows pilot death"
993:"Red Arrows pilot ejected 300 feet into air to his death"
837:"Red Arrows display pressure investigated in pilot death"
170:
in 2000; it had been his boyhood dream to fly with the
971:
969:
174:, the RAF's aerobatic display team. He had flown with
1541:
Warwickshire & Birmingham Wing Air Training Corps
507:"Red Arrows pilot killed in incident at RAF Scampton"
489:
487:
312:
Section 3(1) Health and Safety at Work etc. Act 1974
1537:"2028 Squadron Realise A Dream With The Red Arrows"
966:
587:Eleftheriou-Smith, Loulla-Mae (26 September 2016).
1632:Victims of aviation accidents or incidents in 2011
484:
370:"Red Arrows death: Ejection seat firm fined £1.1m"
198:, to undertake a training flight and a transit to
860:
617:"Red Arrows pilot 'killed when parachute failed'"
586:
1598:
1486:"Pilot death ejection seat firm fined £1.1m"
1299:"Red Arrows pilot death: Report due in June"
388:"Former Coventry schoolboy joins Red Arrows"
289:
1155:
110:aerobatics display team, who died when his
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854:
785:. Royal Air Force. 15 May 2013. p. 23
751:"No charges over Red Arrows pilot's death"
31:
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1580:(Report). Royal Air Force. 15 May 2013.
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1451:https://www.amazon.co.uk/dp/B07VTN8NVZ
1287:https://www.amazon.co.uk/dp/B07VTN8NVZ
1261:"Pilot death a 'once a century' event"
1207:
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1097:
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1016:
990:
975:
834:
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1592:Full service report into the incident
1376:Clementine, Katherine (17 May 2017).
1156:Bogustawski, Lucy (10 January 2014).
1146:
981:
911:
537:"Second tragedy hits Red Arrows team"
16:2011 British Royal Air Force accident
1072:Siddique, Haroon (29 January 2014).
1062:
861:Press Association (9 January 2014).
723:Learmount, David (3 February 2014).
635:
606:
534:
525:
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1017:Cooper, Matthew (1 December 2011).
646:"Coroner hits out over pilot death"
561:Williams, Steve (29 January 2014).
413:Gibbons, Duncan (17 January 2017).
13:
1208:Carter, Claire (29 January 2014).
535:Ward, Victoria (8 November 2011).
321:
14:
1643:
1585:
1234:Williams, Rob (29 January 2014).
1019:"Hundreds mourn Red Arrows pilot"
776:"Service Inquiry into Hawk XX177"
439:Bingham, John (9 November 2011).
218:This model of ejection seat is a
466:"RAF – The Red Arrows Team News"
281:but had not informed either the
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1182:Farmer, Ben (20 January 2014).
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1098:Farmer, Ben (23 January 2014).
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1043:Farmer, Ben (10 January 2014).
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749:Hopkins, Nick (30 April 2013).
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102:(1976 – 8 November 2011) was a
1402:Eccleston, Ben (17 May 2017).
991:Farmer, Ben (9 January 2014).
835:Farmer, Ben (22 August 2013).
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1622:Deaths by person in England
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304:Health and Safety Executive
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128:Health and Safety Executive
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47:Johannesburg, South Africa
300:Crown Prosecution Service
290:Aftermath and prosecution
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333:John Gillespie Magee Jr.
213:Lincoln County Hospital
164:Ernesford Grange School
150:Cunningham was born in
162:. Cunningham attended
136:health and safety law
25:Sean James Cunningham
1547:on 13 September 2017
1331:. 26 September 2016
954:. 26 September 2016
376:. 23 February 2018.
349:Death of Jon Egging
283:Ministry of Defence
250:Lincolnshire Police
1492:. 23 February 2018
1464:The Yorkshire Post
1408:Coventry Telegraph
1267:. 13 February 2018
928:. 22 November 2013
873:on 15 January 2024
623:. 22 November 2011
567:Coventry Telegraph
419:Coventry Telegraph
392:Coventry Telegraph
1431:. 22 January 2018
1357:. 16 January 2017
1134:. 10 January 2014
816:. 29 January 2014
652:. 29 January 2014
513:. 8 November 2011
472:. 9 November 2011
97:Flight Lieutenant
94:
93:
87:Years active
60:(aged 34–35)
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899:. 9 January 2014
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869:. Archived from
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168:Royal Air Force
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126:brought by the
104:Royal Air Force
100:Sean Cunningham
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56:8 November 2011
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