The Nimrod Review - Official Documents

Section Three: Previous Incidents
Chapter 8 – Previous Incidents and Missed Opportunities
CHAPTER 8 – PREVIOUS INCIDENTS AND MISSED OPPORTUNITIES
Contents
Chapter 8 answers the following questions:
Were there any previous incidents which highlighted the fire risks of fuel coupling leaks and hot air ducts?
What was the response to those previous incidents?
Were opportunities missed?
Were lessons learned?
Summary
1. There were a number of significant incidents in the years before the loss of XV230 which contained
warning signs of some of the problems and issues which were potentially relevant to XV230:
(1) The risk of an airborne fire from misaligned FRS couplings: Harrier XW921 (1988);
(2) The potential for leaks from fuel couplings to migrate: Nimrod XV249 (1999);
(3) The risks from split fuel seals: Nimrod XV245 (2000);
(4) The fire risks from fuel coupling leaking onto a hot duct: Nimrod XV229 (2000);
(5) The risks of a fuel coupling leak being ignited by a hot duct despite insulation: Tornado ZA599
(2002);
(6) The risks of the rupture of bleed-air ducting destroying adjacent fuel seals: Nimrod XV227
(2004); and
(7) The potential increase in risk following a second bleed-air duct failure: Nimrod XV229 (2005).
2. These incidents represented missed opportunities to spot risks, patterns and potential problems,
and for these lessons to be read across to other aircraft.
3. Most tended to be treated in isolation as ‘one-off’ incidents with little further thought being given
to potential systemic issues, risks or implications once the particular problem on that aircraft was
dealt with. Rarely did anyone attempt to grasp the wider implications of a particular incident for the
future, or spot trends or patterns or read across issues to other aircraft. There was a corresponding
lack of corporate memory as to related incidents which had occurred in the past.
4. There is a danger in dealing with an incident as a ‘one-off’ without considering its potential wider
ramifications.
5. No-one was taking a sufficient overall view. This re-enforces the need for a New Military Airworthiness
Authority as recommended in Chapter 21.
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