Investigation and inquest
On 22nd November 2011 I commenced an investigation into the death of Sean James Cunningham, age 35. The investigation concluded at the end of the inquest on 29th January 2014. The conclusion of the inquest was a narrative conclusion.
Circumstances of the death
On the 11th November 2011, the deceased ejected from an aircraft. His parachute failed to deploy and he suffered fatal injuries as a result of a fall to the ground.
Coroner’s concerns
Martin Baker (the manufacturers of the ejection seat) continue to manufacture, and the MOD continue to operate aircraft incorporating ejection seats in respect of which there continues to be a significant risk of the strap-ring process impacting negatively on the safe operation of the ejection seat, principally in consequence of strap misrouting. This risk continues despite pilot instruction, training and specific warning to seek to ensure that it does not occur. My concern is that no design solution, to a well-established problem in this regard, has yet been found.
It is not clear to me at the end of this inquiry as to whether Martin Baker Aircraft have a sufficiently comprehensive, robust and auditable system in place that will ensure that in the event of a need for a safety warning or a safety critical alteration to maintenance procedures being issued in the future, it will be sent to and received by all end users of the applicable seat or seats within an appropriate timescale. My concern relates the companies process for the urgent dissemination of safety critical information in this respect.