The Nimrod Review - Official Documents

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6.111 Chapter 6 – Overflow or Pressure from Air-to-Air Refuelling (5) The blow-off valve is only 2.1 metres directly forward of the fairing in way of starboard No. 7 Tank Dry Bay. (6) There is ample empirical evidence of the likelihood of blow-off fuel migrating back along the fuselage and entering panels. 52 (7) Gaps in the fairing could allow fuel to ingress the starboard No. 7 Tank Dry Bay, come into contact with the SCP elbow, and pool. (8) One is certain to get fuel in the vent lines before blow-off occurs. (9) There is a recorded incident of fuel leaking from the No. 1 tank vent connections in 2006. 53 (10) The recent XV235 fault signal shows that No. 1 Tank Cell 4 rear vent connection was the probable cause of fuel wetting the SCP elbow muff below. 54 (11) Recent experiments have confirmed that fuel from No. 1 Tank Cell 4 rear vent drops onto and pools on the panel at the bottom of the starboard No. 7 Tank Dry Bay. (12) The No. 1 Tank Cell 4 rear vent pipe connection was designed for air not fuel, is a poor design, and could have leaked under even low fuel pressure. 55 (13) No. 1 Tank Cell 4 rear vent could have been weakened by blow-offs on previous XV230 sorties. (14) Fuel could also have leaked from the couplings in the vent pipe connections. The following reasons militate against overflow during AAR being the source of fuel: (1) There have been only three known incidents of blow-off on Nimrods in 25 years. (2) It is not straightforward for blown-off fuel to pool on the lower panel in the starboard No. 7 Tank Dry Bay. (3) The crew were operating a 15,000lbs limitation in relation to Tank No. 1. (4) No venting from XV230 was observed at the time by the Tristar tanker. Balance of probabilities of overflow during AAR being the source of fuel 6.112 I have carefully weighed up all these factors, and all the evidence I have heard and read, and have concluded that the balance of probabilities favour overflow during AAR being the source of the fuel which led to the fire in the starboard No. 7 Tank Dry Bay which caused the loss of XV230 (i.e. (b) above). In my view, four factors tip the balance in favour of overflow during AAR being the cause: 6.122.1 First, the recent evidence of the fault signal for XV235 which shows that fuel found in the SCP elbow muff probably originated from No. 1 Tank Cell 4 rear vent. 6.122.2 Second, the recent careful examination of the No. 1 Tank Cell 4 rear vent shows it is a poor design for fuel and could leak when under fuel pressure. 6.122.3 Third, the recent evidence of the dye experiments on MRA4 which show the likelihood of fuel tracking straight back along the fuselage and entering the SCP elbow of the MR2. 6.122.4 Fourth, the fact that fuel could have emanated from the two sources simultaneously during AAR and both ended up in the starboard No. 7 Tank Dry Bay, i.e. both: (i) fuel blown off from No. 1 blow-off valve and tracking two metres down the starboard fuselage into the fairing over the SCP elbow; and (ii) fuel simultaneously entering the vent system and leaking out of No. 1 Tank Cell 4 rear vent and pouring down onto the SCP elbow muff and panel at the bottom of No. 7 Tank Dry Bay below. An initial splash 52 AEW3, MRA4 experiments, XV249, XV232 etc. 53 Air Incident Report KIN/59/06 (BOI Report, Exhibit 57). 54 Serious Fault Signal 181300 May 09, raised on 20 April 2009, during maintenance of XV235 at RAF Kinloss. 55 See QinetiQ’s Fault Report: QINETIQ/MS/SES/TR0902158/1, dated 2 July 2009, during the Ageing Aircraft Audit conducted on Nimrod XV236. 131
The Nimrod Review 6.113 132 of fuel on the SCP elbow from (i) could have initiated a fire which could then have been fuelled by fuel dropping down and pooling as a result of (ii) (or vice-versa). It it important to note that much of this crucial evidence has been very recent and has not been available to others who have previously considered the question of causation, in particular the BOI, the AAIB and the United States Air Force Safety Center (AFSC).
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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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Nimrod 2000/MRA4 2.23 2.24 Chapter
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2.37 Chapter 2 - History of the Nim
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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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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 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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Page 97 and 98: The Nimrod Review 92 The Manufactur
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Page 103 and 104: The Nimrod Review 98 5.111 Comment
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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 10A - NIMROD SAFETY CASE: T
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Chronology - three phases 10A.8 Cha
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1 March 2004: BAE Systems strategy
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Chapter 11 - Nimrod Safety Case: An
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Introduction Background - Chapters
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(2) BAE Systems failed to carry out
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Primary sentencing source was MRA4
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Purpose of meeting 11.77 Dilemma 11
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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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PART IV: ORGANISATIONAL CAUSES
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The Nimrod Review 342 6.2 1994-1999
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The Nimrod Review 358 (2) Demise of
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The Nimrod Review Realpolitik 13.10
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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 13.169 396 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 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 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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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 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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