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By Caroline Wyatt
Defence correspondent, BBC News
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The Hercules exploded after its fuel tank caught fire
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The inquest into the deaths of 10 servicemen, killed when a Hercules was shot down over Iraq, is the latest in a series to highlight serious failings by the Ministry of Defence and, in this case, the RAF.
The coroner, David Masters, criticised what he called a "systemic failure" to implement internal RAF safety recommendations made several years before Hercules XV179 was lost in January 2005.
He highlighted the failure to fit Hercules planes with explosion suppressant foam (ESF) as a factor in the tragedy near Baghdad.
But he also highlighted mistakes made over the passing on of vital intelligence, a failure of internal communications, a loss of corporate memory and a failure to make or keep crucial records in order to track decision-making.
Mr Masters is seen as a diligent and fair coroner and his recommendations will be taken seriously.
His verdict made it clear that the cause of death was unlawful killing by insurgents, before he went on to criticise the MoD and RAF's contributory failings.
The coroner felt so strongly about those failings that he sent a long list of recommendations to the armed forces minister to try to help eliminate the risks the inquest uncovered and prevent any similar tragedy occurring in the future.
Among his recommendations were:
- The need for more joined-up communications within the MoD, RAF and armed forces
- That never again should a scientifically legitimate opinion on safety be ignored or not acted upon
- Fuel tank inerting systems such as ESF should be fitted on all RAF combat aircraft
- The fitting of a black box and cockpit voice recorder on all combat aircraft
- More pressure on the US to share information on military safety issues and known vulnerabilities of equipment
- All damage to RAF aircraft caused by enemy fire to be examined by experts, not just patched up
Apology
Armed Forces Minister Bob Ainsworth said he was determined to take rapid action to address all the issues raised at the inquest.
"I would like to apologise to the families for the inadequacy of our processes for passing on intelligence and tactical advice and for developing equipment to protect against likely vulnerabilities," he said.
"It is clear we should have acted more quickly to fit (ESF) to our Hercules fleet."
According to the MoD, 75% of the RAF's 44 Hercules have now been fitted with ESF, including all those now used on operations abroad.
Many relatives who sat through the inquest were visibly upset as the coroner completed his summing up, almost four years since their loved ones died.
John Cooper, a barrister representing three of the families, said they were considering suing for damages.
On the last day of evidence, when Wing Commander John Reid, president of the RAF's board of inquiry, repeated his own personal and heartfelt apologies to the families, many in court were moved to tears, including some barristers and journalists.
Wg Cdr Reid had been a friend and colleague of the crew of the downed aircraft, and he expressed his shame at his own lack of knowledge of ESF or the vulnerability of the planes' fuel tanks, which was described by some witnesses as a wider failing of knowledge "among the Hercules community".
As one witness put it: "We let ourselves down."
Resources stretched
Yet it is hard to draw one single conclusion from this latest inquest.
Unlike some other recent cases, the decision not to fit ESF had little to do with money. Witnesses said the budget for extra safety measures had been made available by the MoD.
The decision came about, with tragic consequences, because too few within the RAF appear to have fully understood the vulnerability of the Hercules' fuel tanks to small arms fire, while those who were aware of ESF did not believe it to be a "must-have" until after the loss of XV179.
"They felt it would be nice to have," as the coroner put it, "but not essential."
One comment from Richard Stead, the father of XV179's pilot, Flight Lt David Stead, summed up the feeling of many families at the inquest. "Everything was done in hindsight. There does not seem to have been much foresight."
The problem for the MoD and each individual service is that any such mistake, failure or misjudgement, from the smallest to the systemic, can prove lethal for servicemen and women in the current high tempo of operations.
Rarely since the world wars has so much been asked of Britain's armed forces over such a sustained period, leading to an ever-growing mismatch between tasks and resources.
There have already been warnings from senior commanders that the armed forces are at the very limit at what they can do, amid fears that overstretch is pushing them towards breaking point.
Current operations have also shone an increasingly harsh spotlight on the forces' equipment and the lack of certain safety measures for often ageing aircraft or armoured vehicles.
During the Cold War, or even in Northern Ireland, these rarely had to face such severe tests, nor such constant daily use as in the harsh climates of Iraq and Afghanistan.
After decades of cutbacks to personnel numbers in the RAF and other services, along with the outsourcing of many key functions including specialist engineering teams, Britain's armed forces - never configured to fight for this duration at this intensity - are now showing the strain.
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