The Nimrod Review - Official Documents

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PART I: INTRODUCTION
Chapter 1 – Introduction and Summary CHAPTER 1 – INTRODUCTION AND EXECUTIVE SUMMARY Introduction Loss of XV230 on 2 September 2006 1.1 1.2 1.3 On 2 September 2006, RAF Nimrod XV230 was on a routine mission over Helmand Province in Southern Afghanistan in support of NATO and Afghani ground forces when she suffered a catastrophic mid-air fire, leading to the total loss of the aircraft and the death of all those on board. XV230 had a full crew complement of 12 on board, together with two mission specialists: Flight Lieutenant A J Squires (Captain), Flight Lieutenant S Johnson, Flight Lieutenant L A Mitchelmore, Flight Lieutenant G R Nicholas, Flight Lieutenant S Swarbrick, Flight Sergeant G W Andrews, Flight Sergeant S Beattie, Flight Sergeant G M Bell, Flight Sergeant A Davies, Sergeant B J Knight, Sergeant J J Langton, Sergeant G P Quilliam, Lance Corporal O S Dicketts and Marine J D Windall. This was an unusually experienced crew with two of the Nimrod Force’s most capable and knowledgeable aviators, Flight Lieutenant Squires and Flight Sergeant Davies, on the flight deck. 1 XV230 had taken off from the Deployed Operational Base (DOB) at 09:13 hours that morning. All went according to plan until 11:11:33 when, some 1½ minutes after completion of Air-to-Air Refuelling (AAR) from a Tristar tanker, the crew were alerted that something was amiss by two almost simultaneous warnings: a fire warning in the bomb bay and a smoke/hydraulic mist warning in the elevator bay. At 11:12:26 the aircraft depressurised. At 11:13:45 the camera operator reported “we have flames coming from the rear of the engines on the starboard side”. Upon receiving the first warning, the crew immediately commenced emergency drills and at 11:14:10 transmitted a MAYDAY whilst diverting to Kandahar airfield. Faced with a life-threatening emergency, every member of the crew acted with calmness, bravery and professionalism, and in accordance with their training. They had no chance, however, of controlling the fire. At 11:16:54 the Nimrod was observed by a Harrier GR7 pilot in a descent with flames emitting from the starboard wing root and the starboard aft fuselage. Shortly thereafter, several members of ‘A’ Squadron Royal Canadian Dragoons (RCD) observed the aircraft as it passed to the south of their position; the fire appeared to them to be on the port side of the aircraft, although it was in other respects similar to that seen by the GR7 pilot. At 11:17:39, the Harrier GR7 pilot reported that the aircraft had exploded, at what he believed to be 3000 feet above ground level, and he observed wreckage striking the ground. The RCD also witnessed the explosion, although they reported it as being at a lower altitude. XV230 came down in open fields, close to the village of Farhellah, in an area called Chalaghor in the Panjwaye District of Kandahar, Afghanistan. Immediate Aftermath 1.4 A Scene of Action Commander was established over the crash site and a Combat Search and Rescue (SAR) team was immediately deployed. No survivors were found. The crash site was secured by the RCD unit supplemented by members of 34 Squadron RAF Regiment from Kandahar airfield. The crash site was in a known area of Taliban activity and proximate to combat operations. Initial priorities were the recovery of the crew’s bodies, personal effects, classified documentation, flight recorders and other equipment. The Canadian unit was withdrawn the following day. Several hundred local nationals, including Taliban elements, began to enter the site. The remaining RAF Regiment personnel formed a defensive position in an irrigation ditch crossing the site. Shortly thereafter, in an increasingly unstable and hostile situation, they were withdrawn by air, 21 hours after the initial arrival of ground forces. Fortunately, a detailed photographic record of some key parts of the wreckage had been made by (Officer Commanding (OC) 904 EAW2 , which proved invaluable. Subsequently, most of the aircraft wreckage was removed from the site by the Taliban and local villagers. 1 See Comments on BOI Report by Station Commander, Group Captain Jerry Kessel, paragraph 15 [3-4]. 2 Expeditionary Air Wing. 5
Page 1 and 2: THE NIMROD REVIEW An independent re
Page 3 and 4: © Crown Copyright 2009 The text in
Page 5 and 6: THE LOSS OF RAF NIMROD XV230 A FAIL
Page 7 and 8: XV230
Page 9: 2 The Nimrod Review Section Two: Re
Page 13 and 14: The Nimrod Review Offices and Team
Page 15 and 16: Executive Summary Introduction Loss
Page 17 and 18: Chapter 1 - Introduction and Summar
Page 19 and 20: Coroner’s Inquest Chapter 1 - Int
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Page 39 and 40: PART II: PHYSICAL CAUSES
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The Nimrod Review 56 (3) Inadequate
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The Nimrod Review 58 (1) Breach of
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The Nimrod Review 60 4.64 4.65 4.66
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The Nimrod Review 62 4.72 4.73 haza
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The Nimrod Review 66 Prevailing App
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The Nimrod Review 68 18. Targeted f
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The Nimrod Review 70 Figure 5.3: Ni
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The Nimrod Review 72 Description of
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The Nimrod Review 74 Figure 5.8: Fu
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The Nimrod Review 76 5.17 determine
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The Nimrod Review 78 5.27 to have b
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The Nimrod Review 80 of one second,
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The Nimrod Review 82 Maintenance re
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The Nimrod Review 84 Ignition/Leak
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The Nimrod Review 86 Fuselage Leaks
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The Nimrod Review 88 would generate
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The Nimrod Review 90 5.75 5.76 5.77
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The Nimrod Review 92 The Manufactur
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The Nimrod Review 94 The Procuremen
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The Nimrod Review 96 Contractual ch
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The Nimrod Review 98 5.111 Comment
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The Nimrod Review 5.134 102 The ave
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The Nimrod Review 108 6. I have con
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The Nimrod Review 6.6 110 this inta
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The Nimrod Review Analysis 6.19 112
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The Nimrod Review 6.28 114 limitati
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The Nimrod Review 6.40 116 Impingem
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The Nimrod Review 6.44 6.45 118 The
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The Nimrod Review Gap between fairi
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The Nimrod Review 6.60 6.61 6.62 6.
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The Nimrod Review 6.72 Cognisant of
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The Nimrod Review 6.83 126 on its o
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The Nimrod Review 6.96 128 I have c
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The Nimrod Review Causation general
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The Nimrod Review 6.113 132 of fuel
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The Nimrod Review 134 Causation 9.
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The Nimrod Review 7.10 136 Followin
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The Nimrod Review 7.20 138 When XV2
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The Nimrod Review 7.39 142 combinat
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The Nimrod Review 7.47 Causation 14
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The Nimrod Review 7.53 Dealing with
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The Nimrod Review 7.67 Conclusion 1
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The Nimrod Review Introduction 8.1
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The Nimrod Review 8.23 154 Again, e
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The Nimrod Review 156 or destructio
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The Nimrod Review 8.44 158 It is no
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PART III: NIMROD SAFETY CASE Introd
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CHAPTER 9 - BACKGROUND TO SAFETY CA
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9.7 9.8 Chapter 9 - Background to S
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Guiding Principles of Lord Cullen
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9.22 9.23 Chapter 9 - Background to
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Military Regulation of Safety Cases
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9.44 Chapter 9 - Background to Safe
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9.52 9.53 9.54 Chapter 9 - Backgrou
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White Booklet 9.67 Chapter 9 - Back
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Philosophy of the SMP 9.72 9.73 Cha
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The Safety Committees and Hazard Ma
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Chapter 9 - Background to Safety Ca
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CHAPTER 10A - NIMROD SAFETY CASE: T
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Chapter 10A - Nimrod Safety Case: T
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Chronology - three phases 10A.8 Cha
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10A.19 Chapter 10A - Nimrod Safety
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10A.39 10A.40 Chapter 10A - Nimrod
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Worksheets 10A.60 10A.61 10A.62 Cha
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10A.66 10A.67 10A.68 10A.69 Chapter
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DCP 0221.jpg DCP 0312.jpg Chapter 1
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8 May 2003: Third PSWG Meeting 10A.
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1 March 2004: BAE Systems strategy
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Initial ‘pro-forma’ template to
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June 2004: slow progress on zonals
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Fire & Explosion Report completed C
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Switch in strategy for meeting Chap
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Chapter 10B - Nimrod Safety Case: T
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10B.15 10B.16 Chapter 10B - Nimrod
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10B.31 Bronze Award 10B.32 Chapter
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10B.75 10B.76 “Change 17 Mar 2005
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Chapter 11 - Nimrod Safety Case: An
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Criticism of individuals Chapter 11
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Introduction Background - Chapters
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(2) BAE Systems failed to carry out
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Sketchy details and inadequate phot
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Delays resulted 11.51 Chapter 11 -
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11.61 Chapter 11 - Nimrod Safety Ca
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Primary sentencing source was MRA4
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Purpose of meeting 11.77 Dilemma 11
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11.85 11.86 Chapter 11 - Nimrod Saf
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Ethics 11.95 Causation 11.96 Chapte
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Review’s audit of the Pro-Formas
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(3) Erroneous or poor mitigation an
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‘Zone 7.23’ Chapter 11 - Nimrod
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(3) Leaving the NSC task incomplete
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Detailed analysis and criticisms of
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Joint working group never set up Ch
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George Baber’s lack of care and a
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(8) QinetiQ was too compliant and e
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Failure to ask intelligent question
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PART IV: ORGANISATIONAL CAUSES
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The Nimrod Review 342 6.2 1994-1999
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The Nimrod Review 344 Figure 12.2:
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The Nimrod Review 12.9 IPTs 346
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The Nimrod Review ‘Partnering’
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The Nimrod Review 2007: formation o
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The Nimrod Review 356 ‘change’
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The Nimrod Review 358 (2) Demise of
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The Nimrod Review 13.4 13.5 13.6 13
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The Nimrod Review 13.14 362 In my v
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The Nimrod Review 13.23 De-layering
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The Nimrod Review McKinsey recommen
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The Nimrod Review 13.44 ‘CUTS’
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The Nimrod Review 13.54 370 13.53.1
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The Nimrod Review 372 or organisati
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The Nimrod Review ‘Reduction in o
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The Nimrod Review 13.83 376 lines (
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The Nimrod Review (2) Increased ope
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The Nimrod Review Realpolitik 13.10
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The Nimrod Review DLO Business Plan
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The Nimrod Review Chief Engineer RA
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The Nimrod Review 13.126 AD(Eng)Pol
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The Nimrod Review 388 D Tech AD(Eng
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The Nimrod Review Conclusion on MOD
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The Nimrod Review 13.148 392 apex,
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The Nimrod Review 13.158 394 (4) Fe
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The Nimrod Review 13.169 396 with A
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The Nimrod Review Evidence of Nimro
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The Nimrod Review 13.188 13.189 Con
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The Nimrod Review 402 5. The immedi
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The Nimrod Review 2003: ISD ‘slip
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The Nimrod Review 14.16 14.17 406 F
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The Nimrod Review 14.25 408 forces
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The Nimrod Review Conclusion 14.30
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PART V: AFTERMATH Introduction to P
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Chapter 15 - BOI Recommendations an
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15.8 Chapter 15 - BOI Recommendatio
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Fuel Seal Replacement Programme 15.
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The Process 15.32 15.33 Chapter 15
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The Cost 15.44 15.45 Chapter 15 - B
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Appendix A to Chapter 15 AIRCRAFT:
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Serial Recommendations Status Numbe
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CHAPTER 16 - INQUEST Contents Chapt
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Chapter 16 - Inquest 16.4.2 Second,
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PART VI: LESSONS AND RECOMMENDATION
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The Nimrod Review 446 (7) A new Pro
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The Nimrod Review NASA Space Shuttl
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The Nimrod Review (2) ‘Torrent of
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The Nimrod Review (10) ‘Normalisa
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The Nimrod Review 454 who are gover
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The Nimrod Review 456 17.39.3 “It
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The Nimrod Review 462 The three yea
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The Nimrod Review 466 ‘Bow Tie’
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The Nimrod Review The ‘organisati
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The Nimrod Review 18.38 470 1 Accid
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The Nimrod Review Current position
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The Nimrod Review (6) There is a bi
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The Nimrod Review 476 by the IPT an
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The Nimrod Review 478 trails’ rat
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The Nimrod Review 480 Meeting / Wor
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The Nimrod Review 482 operational t
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The Nimrod Review 484 19.34.16 ”A
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The Nimrod Review Four Key Principl
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The Nimrod Review 20.12 20.13 490 1
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The Nimrod Review 20.24 20.25 492 S
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The Nimrod Review 494 (8) Mandatory
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The Nimrod Review 496 I. Clarificat
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The Nimrod Review 498 issues person
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The Nimrod Review 500 Recommendatio
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The Nimrod Review 502 Head of the M
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The Nimrod Review 504 Defence Airs
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The Nimrod Review 506 those who are
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The Nimrod Review 21.37 Paragraph 6
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MAA The Nimrod Review Head of the M
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The Nimrod Review 512 will also mai
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The Nimrod Review 21.59 21.60 Objec
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The Nimrod Review 21.80 21.81 Objec
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The Nimrod Review 520 Recommendatio
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The Nimrod Review Recommendations E
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The Nimrod Review 21.110 524 The BO
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The Nimrod Review 21.119 526 in a p
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The Nimrod Review 21.129 21.130 Obj
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The Nimrod Review 530 provide overs
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The Nimrod Review 21.152 532 nd I w
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The Nimrod Review 22.12 Third, Safe
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The Nimrod Review 538 22.16.1 First
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The Nimrod Review Genesis of Safety
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The Nimrod Review Six Principles fo
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The Nimrod Review 546 (2) Common se
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The Nimrod Review Life Extension Pr
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The Nimrod Review 554 not represent
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The Nimrod Review 23.35 556 I consu
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The Nimrod Review Lesson Learned -
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The Nimrod Review 24.12 562 nor per
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The Nimrod Review Conclusions 25.16
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The Nimrod Review Professor Reason
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The Nimrod Review Safety Managers 2
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The Nimrod Review The critical role
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The Nimrod Review 29.6 XV230 29.7 5
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The Nimrod Review FI Fatigue Index
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ACKNOWLEDGEMENTS Acknowledgements A
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