Red Arrows pilot Sean Cunningham died because of "serious communication failures" and RAF training issues, an inquest has decided.
Giving a narrative verdict, the coroner described as "very serious" ejector seat manufacturer Martin Baker's failure to pass on a "risk to life warning" about ejector seat bolts to the Ministry of Defence (MoD). It had warned other users.
Flight Lieutenant Cunningham died because he did not separate from the Mk10 ejector seat and his parachute did not deploy because a shackle jammed, the verdict said.
The 35-year-old Iraq War veteran suffered fatal injuries when he was propelled 200-300ft in the air from his Hawk T1 aircraft while it was on the ground at RAF Scampton, Lincolnshire, in November 2011.
Central Lincolnshire coroner Stuart 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."
Mr Fisher has heard nearly three weeks of evidence concerning the death.
In his verdict, he described how a shouldering bolt fitted by Martin Baker in 2013 to fix the problem that caused the accident could have been fitted as long ago as 1991.
The RAF's failure to ensure crew were aware that a pin could be in seat firing handle but still be unsafe had also clearly contributed to Flt Lt Cunningham's death, said Mr Fisher
He added that there was a repeated failure to notice that a pin had been incorrectly replaced, leaving the ejector handle raised.
Flt Lt Cunningham also missed in his checks that the pin was not correctly housed and the seat firing handle was unsafe.
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