The company that manufactured the ejection seat in which Red Arrows pilot Sean Cunningham was thrown to his death has been fined £1.1 million after admitting a breach of health and safety regulations.
Martin-Baker Aircraft Company Ltd, which is a world leader in the production of ejection seats, apologised for the incident in which the parachute failed to open after the ejection seat was inadvertently activated while Flt Lt Cunningham, 36, was preparing for take-off from the aerobatics team's base at RAF Scampton on November 8, 2011.
He was thrown 200 feet into the air and fell to the ground still strapped into his seat suffering fatal injuries.
The court heard that Flt Lt Cunningham's two biggest fears in life were being ejected from an aircraft and the injuries that would be sustained, and dying at a young age.
His sister Nicolette, in a victim impact statement, told how the family has suffered "six years of hell" since Sean's death.
She said her brother's interest in flying began when he was a teenager.
He gained his private pilot's licence at the age of 17 having saved up from a Saturday job to pay for lessons and went on to join the RAF in 2000.
"His first love was to fly," she said. "He loved life and lived it to the full. He was the perfect son and brother."
Mrs Justice Carr, passing sentence, said: "In the words of his [Flt Lt Cunningham's] father this was an entirely preventable tragedy.
"Today's victim personal statement shows how raw and painful the family's grief remains, describing six years of hell and all that they have lost for the future."
She said the company had been put on notice as long ago as 1990 that there was a potential problem with the ejection seat after the American firm McDonnell Douglas raised the matter with them.
Over the following two decades hundreds of pilots and their passengers, including many celebrity guests, were put at risk when flying with the aerobatics team.
The judge said: "A significant number of pilots and also potential passengers were exposed to the risk of harm over a very lengthy period.
"Martin-Baker Aircraft Company Ltd admits that in about 1990 it should have issued a written warning to RAF engineers. There should have been a warning to guard technicians against overtightening the drogue shackle locknut. For reasons that are not explained this never happened, at least so far as the MoD/RAF are concerned.
"By this breach Martin-Baker Aircraft Company Ltd exposed each pilot and passenger to a material risk."
Rex Tedd QC , prosecuting, told an earlier hearing: "The ejection was inadvertent. The perspex canopy shattered and the ejection seat was propelled to a height of over 200 feet with Flt Lt Cunningham still strapped in the seat.
"He was 200 feet in the air without a parachute as the shackles had jammed. The impact was non-survivable.
"This tragic incident was the eventuation of the risk that the shackles could jam at low speed or in zero-zero situations."
Mr Tedd said that the subsequent investigation revealed issues with the ejection seat if it activated when the pilot was travelling at low speed or was either preparing for take-off or landing.
The prosecutor told the court that in admitting a breach of health and safety regulations the ejection seat manufacturer Martin-Baker Aircraft Company Ltd accepted that its breach was a substantial or significant cause of the death of Flt Lt Cunningham.
Mr Tedd said: "Martin-Baker provided ejection seats fitted to all Hawk aircraft in the RAF.
"The company exposed all RAF pilots who flew the Hawk to a material risk. That includes all pilots who flew with the Red Arrows. On occasions the pilot would take a passenger with him. When this was the case the passenger would be exposed to the same risk as the pilot. The risk persisted from the early 1970s through to November 2011.
"The issue was that if the pilot was ejected from his or her Hawk at zero-zero or low speed conditions the shackles would not release but would jam together. The result would be that the main parachute would not deploy or open.
"If that occurred, the pilot having started the ejection process would be several hundred feet in the air. There could be only one result and that would be the death of the pilot."
Mr Tedd said that a claim by the company made in a press statement that events that led to Flt Lt Cunningham's death was an "isolated incident" was inaccurate.
"The failure exposed to risk many pilots over a lengthy period. It was not isolated."
Martin-Baker Aircraft Company Ltd admitted a charge brought under section 3(1) of the Health and Safety at Work Act 1974 that on or before November 8, 2011, it failed to conduct its undertaking in relation to the design, manufacture, supply and support of the Mark 10b ejection seat in a way that did not expose non-employees , including Flt Lt Cunningham, to risk.
The charge particularised the non-deployment of the main parachute attached to the ejection seat during low speed or zero-zero ejections as a risk.
The company has already paid £550,000 prosecution costs.
Richard Matthews QC, representing the company, told the hearing: "The company accepts its responsibility for the significant contribution its failings made to the death of Flt Lt Cunningham.
"No words of a lawyer or any other person can convey the sadness, the regret and the apology on behalf of the company and all who stand behind it. The regret is enormous.
"The ethos of the company from the inception has been that the ejection seat is a lifeboat that should operate effectively in every situation."
Flt Lt Cunningham had just completed his first season with the Arrows and held the position of Red 5 in the formation team at the time of his death. He had completed several operational tours of Iraq before joining the Arrows.
In a statement issued at the conclusion of the proceedings, a spokesperson for Martin-Baker Aircraft Company Limited said: "Our thoughts remain foremost with the family and friends of Flt Lt Sean Cunningham, to whom the company conveys its sadness, regret and apology.
"This tragic accident was the result of an inadvertent ejection and main parachute deployment failure due to the over-tightening of the drogue shackle bolt.
"In November 2017, the HSE confirmed that the inadvertent ejection was not caused by any fault attributable to the company. Upon receiving clarification of the HSE’s case, the company accepted a breach of s.3(1) of the Health & Safety At Work Act 1974, on the basis that it failed to provide a written warning to the RAF not to over-tighten the drogue shackle bolt.
"Martin-Baker’s ethos has always been to design and manufacture the highest quality ejection seats and that the maintenance should be carried out to the highest possible standards, under effective supervision and by regularly trained and qualified personnel.
"Martin-Baker has designed and manufactured ejection seats for 73 years and in that time they have been flown by 92 air forces. Our seats have saved the lives of 1,050 RAF and Royal Navy aircrew with a further 6,510 aircrew lives saved around the world."