A plane crash which killed a Red Arrows engineer could have been avoided, a coroner has ruled.
Corporal Jonathan Bayliss, 41, died when the Hawk T1 jet crashed into the runway at RAF Valley in Anglesey, North Wales, on March 20 2018.
Pilot Flight Lieutenant David Stark was injured but survived after ejecting moments earlier, a three-day inquest in Caernarfon heard in November.
At a hearing on Friday, acting senior coroner for North Wales (West) Katie Sutherland said she was making a report for the prevention of future deaths which would be sent to the Ministry of Defence (MoD) recommending action was taken to install stall warnings into the aircraft and to develop better simulator training.
She said it would not be in the interests of justice to reach a conclusion of unlawful killing.
Recording a narrative conclusion, she said the crash was caused by the aircraft stalling as the pilot attempted to fly out of a practice engine failure manoeuvre.
She said: “The stall probably occurred without warning to the pilot and at a height which did not allow the aircraft to be recovered from the stall and fly away.”
The coroner said Flt Lt Stark had not been able to anticipate the crash until the final moment because a buffet, a type of aerodynamic vibration which acted as a stall warning, did not always happen to the aircraft when a smoke pod was fitted.
She said: “The evidence shows the crash could have been avoided.”
Ms Sutherland said the MoD had considered installing a stall warning system on the jets following a crash in 2007, but the matter had been closed.
More analysis was being done on fitting the stall warnings following Cpl Bayliss’s death but a final decision had yet to be made, the coroner’s court at Gwynedd Council chamber heard.
Ms Sutherland said: “This does give rise to concern that future deaths will occur and action should be taken to reduce the risk of death.”
She said the family, including Cpl Bayliss’s father Michael and sister Gayle Todd, who watched proceedings via videolink, had asked for a conclusion of unlawful killing to be considered.
But she said the pilot had not breached his duty of care.
She said the MoD did breach its duty and fall below the standards required, but not so far below that a conclusion of corporate manslaughter could be reached.
Ms Sutherland said: “There was a breach of duty but it cannot be said to be so bad, so gross, to warrant a criminal sanction.”
She recorded Cpl Bayliss’s cause of death as smoke inhalation and low-grade head injury.
Giving evidence during the hearing, Flt Lt Stark said he did not give the usual command of “eject, eject, eject” but remembered swearing and then saying “eject” in the moments before the crash.
The inquest heard that the systems in the jet did not allow the pilot in the front seat to control the ejection of the rear seat passenger.
He said: “It is obviously my eternal regret that the command ejection system is not operated the other way round, in that if I had pulled the handle I could have taken Jon out as well.”
Cpl Bayliss, who was born in Dartford, Kent, joined the RAF in 2001 and in early 2018 was promoted to the Circus team, a small group of highly trained engineers who travel with the Red Arrows and provide technical support away from its base.