A coroner has said a Red Arrows jet crash in which an RAF engineer in the rear cockpit had died “could have been avoided.”
Acting North West Wales senior coroner Katie Sutherland at Caernarfon issued a prevention of future deaths report to the Ministry of Defence, seeking action to avoid future tragedies.
Corporal Jonathan Bayliss, aged 41, from Ingham, Lincolnshire, was killed in March 2018 when a Hawk crashed at RAF Valley in Anglesey after it stalled. The pilot had been conducting a practice engine failure after take-off (PEFATO).
However, the aircraft’s command ejection system was in the rear cockpit, and couldn’t be activated from the front to save the engineer.
Pilot, Flight Lt David Stark, who ejected 0.52 seconds before impact and sustained major injury, told the inquest: “It’s obviously my eternal regret that the command ejection system isn’t operated the other way around and if I pulled the handle I could have taken Jon out as well.
“I take no pride in surviving.”
Home Office pathologist Dr Brian Rodgers said Corporal Bayliss died from inhaling smoke and low-grade head injury.
The coroner said in 2007 a student pilot had crashed a Hawk at RAF Mona in Anglesey – near Valley – after a stall. A military inquiry had recommended consideration of fitting a stall warning system.
The Hawk trainer was due to remain in service until at least 2030.
Mrs Sutherland said, nearly four years after Corporal Bayliss’s death and two years after a service inquiry, there was still no decision by the MOD.
There had been “systemic failings” before the tragedy, she remarked.
The coroner said Corporal Bayliss’s family, who watched the proceedings on a video-link, had suggested a conclusion of “unlawful killing.” But the coroner ruled out gross negligence or corporate manslaughter conclusions.
“The pilot didn’t himself breach the duty incumbent on him,” Mrs Sutherland declared.
“The pilot was not pre-warned as to the stall, he was not able to eject his passenger, there was no flight simulation training of the manoeuvre previously and no adequate risk assessment regarding the passenger.”
She said: “The pilot flew the PEFATO manoeuvre in accordance with his training and within all safety parameters made known to him at the time.”
The evidence didn’t support corporate manslaughter, too, although “following previous accidents and near-misses, the Ministry of Defence was aware of the significance of the risk of stalling, as evidenced by its commissioning of a feasibility study in 2010 to investigate the installation of a stall warning system.”
There was also a failure to conduct a thorough risk assessment for engineers during PEFATOs.
“It was foreseeable that Corporal Bayliss lacked the experience to determine when he should independently initiate his own ejection,” the coroner pointed out.
The coroner said: “This is a complex and important inquest. There has been a lot of evidence for me to consider and weigh up.”
She remarked: “Jon’s family have spent several years waiting for this inquest and naturally want answers as to how Jon died.”
Recording her narrative conclusion, Mrs Sutherland said: “The stall probably occurred without warning to the pilot and at a height which didn’t allow the aircraft to be recovered from the stall and then flown away.”
PEFATO was a “difficult and high-risk” manoeuvre.
“The evidence shows the crash could have been avoided,” she added.