The Nimrod Review - Official Documents

The Nimrod Review
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The six-man BAE Systems zonal inspection team comprised Richard Oldfi eld (Project Engineering Team
Leader – Nimrod), Witness G [BAE Systems] (Structures Group Leader), Witness H [BAE Systems] (Senior
Systems Engineer), Witness I [BAE Systems] (Senior Systems Engineer), Witness J [BAE Systems] (Senior
Systems Engineer), Witness C [BAE Systems] (Flight Safety Specialist). The BLSC Phase 1 Report said that the
BAE Systems’ zonal inspection team had been chosen for “both their extensive Nimrod knowledge and to give
full representation on the Team of the relevant Specialist Departments within the [Design Authority]”. BAE
Systems’ claim to have a full spectrum of specialist knowledge was justifi ed: the team included a Flight Safety
Manager, a Mechanical Systems Specialist, an Electrical Systems Specialist, an Avionic Systems Specialist, and
a Structural Specialist. The claim that the team had extensive knowledge of the Nimrod was only justifi ed in
the sense that all members of the team had worked with Nimrods over the years (Witness H [BAE Systems]
and Witness J [BAE Systems], for 40 and 35 years respectively, and Richard Oldfi eld for 15 years, as well as
being appointed BAE Systems Assistant Chief Engineer Nimrod in 2000). However, this sort of design/offi cebased
experience is markedly different from the detailed, practical, hands-on experience that engineers on
the line at RAF Kinloss and RAF Waddington would have had. Witness C [BAE Systems] explained in evidence
that he had never actually worked on a Nimrod. Thus, prior to the visits, the BAE Systems team needed to
‘familiarise themselves’ using the illustrated parts catalogue and the Aircraft Maintenance Manual. This is not
something that line engineers would have needed to have done.
All six BAE Systems individuals who took part in the R1 and MR2 zonal hazard inspections had attended
an internal ZHA course on 17 October 2002 given by a BAE Systems System Safety Technologist and a
BAE Systems Eurofi ghter System Safety specialist. 43 This was no doubt a useful introductory course which
explained the background to ZHA and broadly the process involved. It did not, however, cover how in practice
a ZHA should be conducted, i.e. precisely what steps by way of inspection, recording and analysis should
be carried out during the inspection phase. It is noteworthy that at a System Safety Practices Meeting on 4
September 2002, Witness C [BAE Systems] raised the need for more in depth “level 2” ZHA and FT courses.
It is not clear that this suggestion was ever taken up.
44 The BLSC Phase 1 Report indicates that the team undertook an ‘on-aircraft’ examination of XV227, XV236
and XV248 and a visual assessment of each zone allocated to them, using a checklist similar to that used for
the RAF Jaguar ZHA. The checklist highlighted e.g.: “FIRE/EXPLOSION. Fuel Leaks/ vapour...LEAKS. Junctions
in pipes, couplings, ‘V’ band clamps, manifold blocks/ seals...Fuel tanks...HOT SURFACES. Pipes...”. The Report
said that worksheets were drawn up recording “the nature of the equipment and hazard within each zone
and the likely interactions between them in the event of failures occurring”, accompanied in many cases by
photographs. 45 The results from the worksheets were subsequently entered (by Witness C [BAE Systems]) into
the CASSANDRA database. 46
Zonal inspections of the No. 7 Tank Dry Bays
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At both the R1 and the MR2 inspections, the six BAE Systems personnel were divided into three two-man
teams, each allocated different sections of the aircraft based on the aircraft maintenance zones. Richard
Oldfi eld and Witness C [BAE Systems] covered the wing-to-wing zones, Witness G [BAE Systems] and Witness
H [BAE Systems] examined the cabin and the inside of the fuselage, and Witness I [BAE Systems] and Witness
J [BAE Systems] inspected the pannier from nose to tail. A member of the Nimrod IPT was present during the
R1 inspection at RAF Waddington to give general assistance but played little, if any, part in the actual zonal
inspections.
47 The No. 7 Tank Dry Bays, port and starboard, are located at the wing root and are known as Zones 514 and
614, respectively. These zones appear to have been inspected twice: once by Richard Oldfi eld and Witness
C [BAE Systems] when inspecting XV236 and XV248, and once by Witness I [BAE Systems] and Witness J
43 For at least one member of the BAE Systems team (Witness I [BAE Systems]) this was a refresher course, as he had previously attended a longer
Zonal Hazard Analysis course.
44 Paragraph 2.2 BLSC (Phase 1) Report.
45 Paragraph 2.3 and 2.4 BLSC (Phase 1) Report.
46 Reproduced at Appendix F of BLSC (Phase 1) Report.
47 i.e. where the wing joins the fuselage.