The Nimrod Review - Official Documents

The Nimrod Review
Introduction
8.1 In Chapter 2 I explain that, prior to the loss of XV230, in all the Nimrod’s 35 years of service, there had been
only four accidents resulting in the loss of an aircraft, namely, XV256 on 17 November 1980; XV257 on 3 June
1984; XW666 on 16 May 1995; and XV239 on 1 September 1995. Of these accidents, only one (XW666)
could be attributed to a failure of the aircraft’s systems and none of them are directly relevant to the loss of
XV230, or illustrate any pattern of faults with the aircraft. I therefore do not discuss these incidents further in
this Chapter.
8.2
8.3
8.4
8.5
8.6
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There are, however, a number of incidents prior to XV230 which, whilst not resulting in the loss of an aircraft,
may, on analysis, be said either to corroborate the findings of the BOI and this Report in relation to the most
probable physical causes of the fire onboard XV230, or to have provided a warning or indication of the risks
inherent in the Nimrod MR2 Cross-Feed/SCP system.
In the course of its investigations, the Review has examined numerous reports in relation to previous Nimrod and
other aircraft incidents, including Boards of Inquiry, Unit Inquiries, Flight Safety Investigations, Air and Ground
Incident Reports and Serious Fault Reports.
With the benefit of hindsight, it is of course possible to observe in many of these potential indicators of the
hazard that resulted on XV230. The aim of this Chapter, however, is not to consider each and every one of these
reports with the benefit of hindsight, but rather to identify those previous incidents which I consider could have
been of particular significance as warning signs for the future, or which are, in my view, indicative of a more
general failure to grasp implications or to learn lessons for the future.
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.
I turn to consider and analyse seven previous incidents which I consider relevant and significant.
(1) August 1988: Harrier GR3 XW921 Accident – Fuel leak leading to airborne fire.
8.7
8.8
8.9
An early indication of the potential problem of an FRS coupling failing and leading to a fire came in 1988, when
a Harrier GR3 XW921 suffered an airborne fire as a result of a fuel leak. Although unable to be conclusive in
their findings, the Board of Inquiry into the incident (Harrier BOI) determined that the fuel could have come from
two possible sources, one of which was an FRS coupling failure.
In light of its findings, the Harrier BOI recommended that :
“The Harrier EA instigate an investigation into the integrity of this type of FRS coupling.
The investigation should include consideration of introducing geometric checks of the
coupling on fitment, and the introduction of a lifing policy for the coupling seal.” (emphasis
added)
In a letter dated 31 May 1989 entitled “Harrier GR3/T4 – FRS Coupling Servicing – Schedule Amendment”1, the
Harrier Director of Aircraft Engineering 1 (Harrier EA) stated:
1 D/DD Air Eng(RAF)56/2/10, dated 31 May 1989.