Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0087, written 26 Feb 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Feb 2014 |
|---|---|
| Reference | 2014-0087 |
| Deceased | Sean Cunningham |
| Coroner | Stuart Fisher |
| Coroner area | Lincolnshire (Central) |
| Category | Product related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Managing Director Martin-Baker Lower Road Higher Denham Br Uxbridge Middlesex UB9 5AJ CORONER lam S P G Fisher, senior coroner, for the coroner area of Central Lincolnshire CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. [HYPERLINKS] INVESTIGATION and INQUEST On 22" 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"" 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. CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. — 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 the 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 safety 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. ACTION SHOULD BE TAKEN YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 23" April 2014. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons, Irwin Mitchell Solicitors, Lincolnshire Police, HSE, BAE Systems and the MOD | am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your 7 response, about the release or the publication of “your response by the Chief Coroner. C y * DATE [ale “ISHED BY CORONER _
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