An ejector seat maker has been heavily fined for a Health & Safety failing that resulted in the death of a Red Arrows pilot.

The pilot fell hundreds of feet after unintentionally ejecting from his aircraft while carrying out pre-flight checks on the ground.

The seat manufacturer had a duty to make sure pilots were not exposed to a Health & Safety risk.

Faulty equipment

An investigation found two seat shackles, designed to deploy the main parachute, would not release from one another. The jam stopped the seat’s parachute mechanism from working.

Investigators discovered a crucial ‘drogue shackle bolt’ had been over-tightened.

Health & Safety Executive (HSE) inspectors found two aircraft manufacturers had made the ejection seat firm aware of issues with the shackles.

The seat’s design was also such that at zero speed and zero altitude it could fail to operate as intended.

No written warning

Although the HSE had stated the ‘inadvertent ejection was not caused by any fault attributable to the company’ the manufacturer accepted it broke the Health & Safety at Work etc Act 1974 by failing to provide a written warning to the RAF not to over-tighten the bolt.

The prosecution said there was a risk ‘to many pilots over a lengthy period’.

Martin-Baker Aircraft Company Ltd admitted failing to ensure the safety of non-employees.

It was handed a £1.1m fine and must also pay £550,000 in prosecution costs.

Just failed

The court heard the Ministry of Defence assessed such incidents as happening only once in more than 100 years.

It was also told the firm had a ‘good system’ in place and that it ‘just failed in this instance’.

However, the judge said the company ‘fell short of the appropriate standard’ in what was ‘an entirely preventable tragedy’.

The judge commented ‘A significant number of pilots and also potential passengers were exposed to the risk of harm over a lengthy period’.

It was stressed the risk of harm was of the highest level – death.

The HSE said its investigation found the manufacturer had ‘failed to take all reasonably practicable steps to protect users from the risk of harm after it was told of concerns regarding the shackles which deployed the main parachute’.

The death was therefore ‘avoidable’.