Coroner criticises MoD over fatal 'copter crash.
PILOT error and an "inexplicable" failure to conduct safety checks on an RAF helicopter were factors in the deaths of two SAS soldiers, a coroner ruled yesterday.
Herefordshire coroner David Halpern said the Ministry of Defence's failure to perform any maintenance on a fuel anti-spill valve for almost 30 years was a relevant factor in the death of Corporal Lee Fitzsimmons.
Cpl Fitzsimmons died near Baghdad in November 2007 after the RAF Puma caught fire shortly after it crash-landed in a furrowed field during a "high level" mission to apprehend insurgents.
His comrade, Sergeant John Battersby, is thought to have died before the fire took hold after suffering multiple injuries when the Puma crashed.
Mr Halpern, who heard seven days of evidence about the deaths, ruled that a faulty fuel valve had been a relevant factor in Cpl Fitzsimmons' death. Recording narrative verdicts on both men, Mr Halpern said pilot error - albeit under extreme pressure - had been the primary cause of the crash.
The coroner, who stressed he did not wish to be "over-critical" of the pilot, said: "He was faced with a very difficult task.
"Very sadly, things just went wrong for him on this particular occasion."
But Mr Halpern did identify failings made by the MoD, including its failure to foresee the risk of a fuel anti-spill valve "sticking" when an aircraft rolled over, a failure to fit display night-vision goggles to the Puma prior to the crash, and to enforce its policy for personnel to use restraints in aircraft.
"They really do need to implement, prosecute and police their policy regarding the use of restraints," Mr Halpern said, although he conceded that the soldiers killed would have been justified in not wearing them when the helicopter landed during a fast-moving mission. Mr Halpernwas told the anti-spill valves allowed fuel vapour to vent to the open air and should have closed if a Puma rolled over.
But the inquest heard the valves, which operated by gravity, had never been maintained and were not listed on the aircraft's maintenance checklist. Summing up the evidence, the coroner said: "They should have been part of a risk assessment and appropriate maintenance schedule.
"It was said by the pilot of the Puma that he would have considered the craft to be unairworthy if he had known that it had an inoperative anti-spill valve.
"For some inexplicable reason, for nearly 30 years the Puma anti-spill valve had just not been the subject of any maintenance checks."
A pathologist told the inquest that Cpl Fitzsimmons died from a severe head injury and the inhalation of fumes, although the injuries he suffered in the initial impact would not have been survivable.
Fellow soldiers battled for four minutes to free Sgt Battersby, a 31-year-old from Lancashire, and Cpl Fitzsimmons, who was 26 and from Peterborough, from the burning aircraft.
But the men, who were praised by the coroner for placing themselves at great personal risk, were eventually forced to withdraw due to the intense heat.
The inquest heard that an RAF board of inquiry had already investigated the crash to learn lessons and improve the safety of its Puma fleet.
In a statement after the hearing, Rear Admiral Tony Johnstone-Burt, the Commander of Joint Helicopter Command, paid tribute to the "courage and dignity" of the soldiers' families.
He said: "These two brave men were involved in a highly complex and dangerous mission to apprehend insurgents.
"Restraints were available but as is common in such situations, the personnel onboard had removed them for landing so they could disembark quickly for the mission and return fire if necessary."
Since the crash, he said, measures have been taken to make sure anti-spill valves are checked regularly and the Puma Force has been fitted with night vision goggles.
Cpl Fitzsimmons' mother, Jacqui Auty, said she was reassured that the coroner had recognised the broad range of issues which contributed to the accident.
"When our sons lay their lives on the line for the greater good, I think they deserve better than this," she said. "Being a soldier isn't and never will be a risk-free business. However, all of our forces deserve to have the right equipment for the job, for it to be in good condition, and to have been fully trained for the situations we put them in."