Death of Sean Cunningham

Cunningham was born in Johannesburg, South Africa, in 1976.

His family moved to the United Kingdom in 1986 when he was nine years old and settled in the Ernesford Grange area of Coventry.

Cunningham attended Ernesford Grange School 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 Royal Air Force in 2000; it had been his boyhood dream to fly with the Red Arrows, the RAF's aerobatic display team.

Flight Lieutenant Sean Cunningham (1976 – 8 November 2011) was a Royal Air Force pilot on the Red Arrows aerobatics display team, who died when his ejection seat 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, RAF Scampton in Lincolnshire, 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 ft to his death 66 m away from the motionless aircraft.

He had flown with No. 617 Squadron and No. 100 Squadron of the Royal Air Force before being selected to join the Red Arrows as 'RED 5' in May 2011.

On 8 November 2011, Cunningham (who was to fly as RED 5), was crewing-in to his aircraft, a Hawk T1, registration XX177, to undertake a training flight and a transit to RAF Valley in North Wales.

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 ejection seat 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 ft the drogue parachutes deployed (one was 22 in across and the other 5 ft) 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 Lincoln County Hospital 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.

This model of ejection seat is a zero-zero seat; that is, it has no minimum speed or minimum height above ground to deploy fully.

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 (Mk.10B1) 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.

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 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.

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 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.

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 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 Lincolnshire Police 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.

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 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 promethazine, 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.

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".

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 on their first tour.

There had also been pressure on the pilots to perform at a greater number of events.

In January 2018, in the prosecution brought by the Health and Safety Executive, Martin-Baker, the manufacturers of the seat, pleaded guilty to a breach of health and safety law regarding Cunningham's death.

On 23 February 2018, Martin-Baker were fined £1.1million.