Ms Sutherland said the MoD had considered installing a stall warning system on the jets following a crash in 2007, but decided not to invest in the systems.

“The evidence shows the crash could have been avoided,” she added.

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.”

Family had asked for ‘unlawful killing’ conclusion

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.

However, she concluded the pilot had not breached his duty of care.

She said the MoD did breach its duty and fell 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.

“There were systemic failings as accepted by the Service Inquiry such as no warning system for pre-stall buffet, no flight simulation training nor ejector capability of the pilot for his passenger.

“I do not assess these as gross.”

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 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.