SYSTEMIC failure is a term that somehow gives the impression that no human agency is involved. Yet although the inquest into the shooting down of an RAF Hercules plane with the loss of ten servicemen in Iraq in 2005 uses that term it is clear that several individuals in the Ministry of Defence, and perhaps even in the RAF, were responsible. The Hercules crashed after its right wing was hit by Iraqi fire and a fuel tank exploded. There had been several recommendations that an explosion suppressant foam should be used in all Hercules planes; the US Air Force Hercules aircraft have been fitted with the foam for 40 years. Many of the RAF crews flying Hercules planes were unaware of the potential danger.
In an inquest lasting three years the Wiltshire coroner, David Masters, has unearthed a disgraceful story of carelessness and disinterest both in the RAF itself and the Ministry of Defence in dealing with a known hazard. In his judgement Mr Masters said it was unbelievable that no record existed of who was responsible for failing to give the problem the necessary priority since it was first raised in the early 1990s.
Sometimes UK coroners have seemed unduly harsh in making judgements on deaths under the extreme pressures of the battlefield. But the Hercules crash was different. Its cause was unforgivable inefficiency.