The Nimrod Review - Official Documents

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Return to an Address of the Honourable the House of Commons dated 28th October 2009 for AN INDEPENDENT REVIEW INTO THE BROADER ISSUES SURROUNDING THE LOSS OF THE RAF NIMROD MR2 AIRCRAFT XV230 IN AFGHANISTAN IN 2006 Charles Haddon-Cave QC Ordered by the House of Commons to be printed 28th October 2009 HC 1025 London: The Stationery Office £63.00
© Crown Copyright 2009 The text in this document (excluding the Royal Arms and other departmental or agency logos) may be reproduced free of charge in any format or medium providing it is reproduced accurately and not used in a misleading context. The material must be acknowledged as Crown copyright and the title of the document specified. Where we have identified any third party copyright material you will need to obtain permission from the copyright holders concerned. For any other use of this material please contact the Office of Public Sector Information, Information Policy Team, Kew, Richmond, Surrey TW9 4DU or e-mail: licensing@opsi.gsi.gov.uk. ISBN: 9780102962659 Printed in the UK by The Stationery Office Limited on behalf of the Controller of Her Majesty’s Stationery Office ID P002325264 10/2009 476 Printed on paper containing 75% recycled fibre content minimum.
Page 1: THE NIMROD REVIEW An independent re
Page 5 and 6: THE LOSS OF RAF NIMROD XV230 A FAIL
Page 7 and 8: XV230
Page 9 and 10: 2 The Nimrod Review Section Two: Re
Page 11 and 12: Chapter 1 - Introduction and Summar
Page 13 and 14: The Nimrod Review Offices and Team
Page 15 and 16: Executive Summary Introduction Loss
Page 17 and 18: Chapter 1 - Introduction and Summar
Page 19 and 20: Coroner’s Inquest Chapter 1 - Int
Page 21 and 22: Chapter 2 - History of the Nimrod A
Page 23 and 24: 2.8 2.9 Chapter 2 - History of the
Page 25 and 26: Nimrod 2000/MRA4 2.23 2.24 Chapter
Page 27 and 28: 2.37 Chapter 2 - History of the Nim
Page 29 and 30: 2.45 2.46 Chapter 2 - History of th
Page 31 and 32: CHAPTER 3 - THE BOARD OF INQUIRY RE
Page 33 and 34: Chapter 3 - The Board of Inquiry Re
Page 35 and 36: Chapter 3 - The Board of Inquiry Re
Page 37 and 38: 3.22 Chapter 3 - The Board of Inqui
Page 39 and 40: PART II: PHYSICAL CAUSES
Page 41 and 42: The Nimrod Review 36 (2) The escape
Page 43 and 44: The Nimrod Review 38 because Nimrod
Page 45 and 46: The Nimrod Review 40 7. The Cross-F
Page 47 and 48: The Nimrod Review 42 Addition of SC
Page 49 and 50: The Nimrod Review 44 No. 7 Tank Dry
Page 51 and 52: 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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The Nimrod Review 64
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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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The Nimrod Review 80 of one second,
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The Nimrod Review 82 Maintenance re
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The Nimrod Review 84 Ignition/Leak
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The Nimrod Review 86 Fuselage Leaks
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The Nimrod Review 88 would generate
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The Nimrod Review 90 5.75 5.76 5.77
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The Nimrod Review 92 The Manufactur
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The Nimrod Review 94 The Procuremen
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The Nimrod Review 96 Contractual ch
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The Nimrod Review 98 5.111 Comment
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The Nimrod Review 5.123 5.124 5.125
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The Nimrod Review 5.134 102 The ave
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The Nimrod Review 5.145 5.146 104 T
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The Nimrod Review 108 6. I have con
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The Nimrod Review 6.6 110 this inta
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The Nimrod Review Analysis 6.19 112
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The Nimrod Review 6.28 114 limitati
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The Nimrod Review 6.40 116 Impingem
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The Nimrod Review 6.44 6.45 118 The
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The Nimrod Review Gap between fairi
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The Nimrod Review 6.60 6.61 6.62 6.
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The Nimrod Review 6.72 Cognisant of
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The Nimrod Review 6.83 126 on its o
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The Nimrod Review 6.96 128 I have c
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The Nimrod Review Causation general
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The Nimrod Review 6.113 132 of fuel
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The Nimrod Review 134 Causation 9.
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The Nimrod Review 7.10 136 Followin
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The Nimrod Review 7.20 138 When XV2
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The Nimrod Review 7.39 142 combinat
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The Nimrod Review 7.47 Causation 14
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The Nimrod Review 7.53 Dealing with
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The Nimrod Review 7.67 Conclusion 1
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The Nimrod Review Introduction 8.1
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The Nimrod Review 8.23 154 Again, e
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The Nimrod Review 156 or destructio
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The Nimrod Review 8.44 158 It is no
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PART III: NIMROD SAFETY CASE Introd
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CHAPTER 9 - BACKGROUND TO SAFETY CA
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9.7 9.8 Chapter 9 - Background to S
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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.67 10B.68 Chapter 10B - Nimrod
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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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Page 295 and 296:
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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 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 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 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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