Source · Prevention of Future Deaths

Sean Cunningham

Ref: 2014-0087 Date: 26 Feb 2014 Coroner: S P Fisher Area: Lincolnshire (Central) Responses identified: 0 / 2 View PDF

A persistent design flaw in ejection seats allows strap misrouting, posing a significant risk, and manufacturers lack a robust system for urgently disseminating safety-critical information.

Date 26 Feb 2014
56-day deadline 23 Apr 2014 est.
Responses identified 0 of 2
Product related deaths

Coroner's concerns

AI summary
A persistent design flaw in ejection seats allows strap misrouting, posing a significant risk, and manufacturers lack a robust system for urgently disseminating safety-critical information.
View full 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 strapping-in process impacting negatively on the safe operation of 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 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:

Report sections

Investigation and inquest
On 22nd November 2011 commenced an investigation into the death of Sean James Cunningham, age 35. The investigation concluded at the end of the inquest on 29"h January 2014, The conclusion of the inquest was a narrative conclusion
Circumstances of the death
On the 11 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.

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Report details

Reference
2014-0087
Date of report
26 February 2014
Coroner
S P Fisher
Coroner area
Lincolnshire (Central)

Responses identified

Responses identified 0 of 2
2 responses not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 23 Apr 2014 (estimated).

Sent to

Martin-Baker
the MOD

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