The Nimrod Review - Official Documents

The Nimrod Review
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It is not entirely clear exactly what investigations, if any, the Nimrod IPT carried out following receipt of BAE
Systems’ report of 17 February 2006, and the MOD Form 761. In a letter dated 3 March 2006 entitled: “Hot Air
Ducts” – Nimrod Hazard NM/H66”, the IPT Leader, George Baber, wrote to BAE Systems, referring to the second
duct failure on XV229 and stating, inter alia, as follows:
“Following consideration by the relevant subject matter experts within the Nimrod IPT, Nim
(ES)AV(A)3 and Nim(ES)Safety , the effect of the failure is to remain at Catastrophic but
the probability is to be raised to Improbable (Remote likelihood of occurrence to just one
or two aircraft during the operational life of a particular fleet).
You are requested to amend hazard NM/H66 accordingly and set it to Managed.”
8.45 As I explain further in Chapter 11, it is important to note that this change in probability was only applied to the
hazard linked to the aircraft engine bay (Hazard H66) and not to any other area with hot air ducts. The No. 7
Tank Dry Bay was of course an area particularly vulnerable, should a hot air leak occur. However, neither this area
nor any of the other areas containing hot air ducts are recorded as having been reassessed in the light of the
new concerns over the second duct failure. In my judgment, the decision process remained myopic and failed to
consider all the implications arising from the incident, and the earlier duct failure on XV227.
Conclusion
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In conclusion, the above represented significant incidents in the years before the loss of XV230 which contained
warning signs of some of the problems and issues which were to affect XV230.
These incidents represented missed opportunities to spot risks, patterns and potential problems, and for these
lessons to be read across to other aircraft.
No-one was taking a sufficient overall view.