The Nimrod Review - Official Documents

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6.34 6.35 6.36 Chapter 6 – Overflow or Pressure from Air-to-Air Refuelling investigations be carried out by way of in-flight dye tests. Unfortunately, it appears this was never followed up following the subsequent shelving of the Nimrod AEW3. This was regrettable. Such dye tests would very probably have led to a realisation of the risks posed by the starboard blow-off valve. In this regard, I agree with the comment on the BOI by the Air Member for Materiel: “It is particularly disturbing that the undesirable overflow characteristic of the AAR system design appears to have been identified during development trials in the mid 1980s for the Nimrod Airborne Early Warning (AEW) aircraft, yet (although corrective action was taken for No 5 Tank) no corrective action was taken for the No 1 Tank despite recommendations that it be investigated further.” 21 If the dye test had been carried out, it is likely that, not only would the risk of fuel possibly tracking back into No. 7 Tank Dry Bay have been identified and addressed, but it is also possible that the ignition risk posed by the SCP elbow would have been highlighted by the dye penetrating the ‘muff’ insulation and, thus, the danger posed by the bleed-air system exposed. In my view, responsibility for failure to follow up the question of dye tests after 1985 or read across this issue to the MR2 and R1 fleets must be jointly shared by BAE Systems as the Design Authority (DA) and the MOD. 2006: Dye tests for MRA4 6.37 6.38 6.39 Dye tests were, however, carried out by BAE Systems in 2006 in relation to the MRA4 programme, these have provided clear visual evidence of the manner in which liquid expelled from an aircraft can cover a significant area. 22 and Flight tests were conducted on the MRA4 prototype PA3 in June 2006 to check whether water discharged from the forward and aft waste water drain masts would track back and impact on the wings and fuselage causing an ice problem. The test was carried out by pouring 0.5 gallons of coloured fluid into both the toilet and galley waste water systems during flight and evacuating it. The colour of the fluid, ‘Desert Sand’, 23 provided a strong contrast with the standard Nimrod grey external paint scheme. The test on the forward mast was carried out just prior to landing at a speed of 192 knots for the forward mast and 170 knots for the rear mast. This speed range was calculated as most likely to allow fluid to impact the aircraft fuselage. The aircraft avoided cloud and rain following the trial to prevent the dyed fluid being washed off. After landing, a photographic record was made of all the areas where the impingement of fluid on the wings and fuselage had occurred. The results are instructive. They show the fluid fanning out and tracking back over and under the wing and entering parts of the fuselage. The toilet mast protrudes several inches from the aircraft. A boundary layer of air exists close to the aircraft structure. The air immediately proximate to the aircraft structure will travel at an extremely slow speed because of surface friction, relative to the aircraft, but this speed will increase as the distance from the aircraft structure increases, until the air is travelling at the same speed relative to the aircraft as the surrounding free-flow air. The thickness of this boundary layer varies, but is of minimal width. The significance of this is that the mast from the forward toilet protrudes directly into this freeflow air. Despite this, the fluid had clearly impacted the aircraft fuselage, as can be seen from the photograph below. The blow-off outlet of No. 1 tank is flush with the aircraft fuselage. Fuel exiting the blow-off will have to negotiate the boundary layer before it reaches the free-flow air. Thus, it would appear even more likely to track along the fuselage. It should be noted that there would be significantly more fuel involved in blow-off than liquid in this experiment. Furthermore, the higher speeds which the aircraft would be flying during AAR would make it more, not less, difficult for the fuel to reach the free-flow air. As BAE Systems’ witnesses have made clear, the diagrams supplied to the BOI24 reflect the flow of air around a particular section of the fuselage, rather than any likely fluid flow. That the fluid flow is likely to be more complex is suggested by the wide dispersal of the dyed fluid in the photographs below. 21 Comment on the BOI by the Air Member for Materiel, Air Marshal Sir Barry Thornton dated 8 October 2007. 22 BAE/D/NIM/RP/173496 and BAE/P/NIM/RP/162811. 23 The fluid used was temporary camouflage coating (1314GB0361E) diluted with water. 24 BOI Report, Exhibit 60. 115
The Nimrod Review 6.40 116 Impingement on Forward Fuselage & Inner Wing Fwd Drain Mast Figure 6.4: MRA4 Showing Dispersal of Dyed Fluid 1. Impingement on Bomb Bay Doors & Hinges Impingement on Bomb-Bay Doors and Hinges Figure 6.5: MRA4 Showing Dispersal of Dyed Fluid (close-up of wing root) If one extrapolates the results of this trial to the No. 1 blow-off valve operating, it is very easy to envisage fuel tracking back only 2.1 metres into the fairing of the SCP elbow and potentially the No. 7 Tank Dry Bay. The prospect becomes even more likely given the fact that if the blow-off valve activated during AAR, the quantities of fuel expelled would be very considerable.
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THE NIMROD REVIEW An independent re
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© Crown Copyright 2009 The text in
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THE LOSS OF RAF NIMROD XV230 A FAIL
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XV230
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2 The Nimrod Review Section Two: Re
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Chapter 1 - Introduction and Summar
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The Nimrod Review Offices and Team
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Executive Summary Introduction Loss
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Chapter 1 - Introduction and Summar
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Coroner’s Inquest Chapter 1 - Int
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Chapter 2 - History of the Nimrod A
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2.8 2.9 Chapter 2 - History of the
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Nimrod 2000/MRA4 2.23 2.24 Chapter
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2.37 Chapter 2 - History of the Nim
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2.45 2.46 Chapter 2 - History of th
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CHAPTER 3 - THE BOARD OF INQUIRY RE
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Chapter 3 - The Board of Inquiry Re
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Chapter 3 - The Board of Inquiry Re
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3.22 Chapter 3 - The Board of Inqui
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PART II: PHYSICAL CAUSES
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The Nimrod Review 36 (2) The escape
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The Nimrod Review 38 because Nimrod
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The Nimrod Review 40 7. The Cross-F
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The Nimrod Review 42 Addition of SC
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The Nimrod Review 44 No. 7 Tank Dry
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The Nimrod Review 46 4.17 4.18 Tria
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The Nimrod Review 48 4.24 Figure 4.
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The Nimrod Review 50 Shrouds 4.32 b
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The Nimrod Review 52 4.36 This conf
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The Nimrod Review 54 4.42 Gaps 4.43
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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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Page 71 and 72: The Nimrod Review 66 Prevailing App
Page 73 and 74: The Nimrod Review 68 18. Targeted f
Page 75 and 76: The Nimrod Review 70 Figure 5.3: Ni
Page 77 and 78: The Nimrod Review 72 Description of
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Page 81 and 82: The Nimrod Review 76 5.17 determine
Page 83 and 84: The Nimrod Review 78 5.27 to have b
Page 85 and 86: The Nimrod Review 80 of one second,
Page 87 and 88: The Nimrod Review 82 Maintenance re
Page 89 and 90: The Nimrod Review 84 Ignition/Leak
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Page 93 and 94: The Nimrod Review 88 would generate
Page 95 and 96: The Nimrod Review 90 5.75 5.76 5.77
Page 97 and 98: The Nimrod Review 92 The Manufactur
Page 99 and 100: The Nimrod Review 94 The Procuremen
Page 101 and 102: The Nimrod Review 96 Contractual ch
Page 103 and 104: The Nimrod Review 98 5.111 Comment
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Page 107 and 108: The Nimrod Review 5.134 102 The ave
Page 109 and 110: The Nimrod Review 5.145 5.146 104 T
Page 111 and 112: The Nimrod Review 5.155 5.156 106 T
Page 113 and 114: The Nimrod Review 108 6. I have con
Page 115 and 116: The Nimrod Review 6.6 110 this inta
Page 117 and 118: The Nimrod Review Analysis 6.19 112
Page 119: The Nimrod Review 6.28 114 limitati
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Page 125 and 126: The Nimrod Review Gap between fairi
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Page 129 and 130: The Nimrod Review 6.72 Cognisant of
Page 131 and 132: The Nimrod Review 6.83 126 on its o
Page 133 and 134: The Nimrod Review 6.96 128 I have c
Page 135 and 136: The Nimrod Review Causation general
Page 137 and 138: The Nimrod Review 6.113 132 of fuel
Page 139 and 140: The Nimrod Review 134 Causation 9.
Page 141 and 142: The Nimrod Review 7.10 136 Followin
Page 143 and 144: The Nimrod Review 7.20 138 When XV2
Page 147 and 148: The Nimrod Review 7.39 142 combinat
Page 149 and 150: The Nimrod Review 7.47 Causation 14
Page 151 and 152: The Nimrod Review 7.53 Dealing with
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Page 155 and 156: The Nimrod Review Introduction 8.1
Page 159 and 160: The Nimrod Review 8.23 154 Again, e
Page 161 and 162: The Nimrod Review 156 or destructio
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Page 165 and 166: PART III: NIMROD SAFETY CASE Introd
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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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10A.172 10A.173 10A.174 Chapter 10A
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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.42 Chapter 10B - Nimrod Safety
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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 12.33 12.34 12.35
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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 Introduction 18.1
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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 22.27 22.28 542 T
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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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