The Nimrod Review - Official Documents

The Nimrod Review
10A.64
10A.65
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show more actual analysis being carried out at the zonal hazard inspection stage. 48 Furthermore, it is far from
clear that anyone involved in the inspections appreciated that Zones 514 and 614 (i.e. the No. 7 Tank Dry
Bays port and starboard) were different: namely the MR2’s starboard side had the additional SCP pipe at the
bottom of the dry bay. It does not appear, however, that the BAE Systems personnel conducting the zonal
inspections were instructed or expected to do more than record the bare details. The flowchart summarising
the process followed during the ZHA simply states: “For each zone – utilising checklist identify presence of
potential hazardous interactions between systems/components. Input on worksheet”.
Upon returning to Chadderton, Witness I [BAE Systems] and Witness J [BAE Systems] typed up their own
worksheets and passed these to Witness C [BAE Systems] for entering into CASSANDRA. The CASSANDRA
database entry for Hazard H498 read:
“Hazard Number: H498
Hazard Title: Multiple systems in very close proximity
...
Source Data References:
134 Photo Dep 312.jpg – Zone 514/614 – Fuel pipes in close
proximity to [?F/C flying control] cables, hydraulics and electrics and
ECS ducts
...
Description: In an area closely packed with flight control cables and pulleys,
hydraulic services, unprotected electrical cables and hot air ducting
there exists a potential for hot air, fuel and hydraulic leaks and
possible fire.
Initial probability: Remote
Origin: Maintenance Zone 514/614
Hazard type: Zonal”
There is no surviving worksheet for Hazard H367 prepared by Witness C [BAE Systems] and Richard Oldfield.
But the resulting entry for Hazard H367 in the CASSANDRA database read as follows:
“Hazard Number: H367
Hazard Title: Fire/ Explosion – Fuel or hydraulic leak onto Hot Engine Bleed Pipe
...
Source Data References:
78(?) Photo Doc 0221.jpg. Flap pulley bay – Zone 514. Fire explosion
risk due to leaking fuel impinging on hot pipe.
...
Description: Potential fuel or hydraulic leaks from fuel pipe joint, Flap hydraulic
pipelines or No. 7 Tank main feed fuel pipe immediately above the
HP, High Temp engine bleed take-off port or associated ducting
potentially causing an uncontrollable fire or explosion.
Initial probability: Improbable
Origin: Maintenance Zone 514/614
Hazard type: Zonal”
48 See Jaguar Report BAE-WPM-RP-JAG-LEX-1720 DRAFT, dated 28 February 2002.