The Nimrod Review - Official Documents

The Nimrod Review
10A.77
208
The jpg photographs for hazards H367 and H498 were incorrectly labelled in the CASSANDRA log entries:
photo Dcp0221.jpg related to Zone 614 (i.e. the starboard No. 7 Tank Dry Bay) not 514; and photo Dcp0312.
jpg related to Zone 514 only (i.e. the port No. 7 Tank Dry Bay) not both Zones 514 and 614. This meant that
a person looking at the photographs later was going to have considerable difficulty in understanding which
was which, let alone appreciating that there was a significant difference between the port and starboard
No. 7 Tank Dry Bays. Furthermore, the gaps in the insulation and the deterioration in the condition of
the insulation are not apparent from the photographs. Indeed, both photographs give the impression that
the condition of the insulation of the Cross-Feed pipe and SCP pipe was good. As I explain in Chapter 4,
however, that was not the case: much of the Refrasil insulation was old and deteriorated throughout much
of the Nimrod fleet.
10A.78 Witness K [BAE Systems] was, therefore, right when he subsequently wrote on 7 June 2004: “Given a zone
and a picture, identifying the systems at risk will be a mammoth task.” The poor quality of the initial zonal
hazard reports and photos (some of which were not labelled at all and some of which it was difficult to tell
whether they were up or down) was the subject of complaint subsequently by those tasked to carry out
the analysis and mitigation exercise, such that Richard Oldfield was obliged to offer a further aircraft at RAF
Woodford for viewing and the assistance of the BAE Systems’ Field Service Representative at RAF Kinloss at a
Phase 2 progress meeting on 7 July 2004. This offer was, unfortunately, never taken up.
4 March 2003: QinetiQ TRM confirms QinetiQ will ‘review’ NSC
10A.79 At a QinetiQ TRM on 4 March 2003, it was noted that BAE Systems hoped to sign off the NSC “ by the end
of 2003”, and it was agreed that QinetiQ “would have the opportunity to review the work done by BAE
Systems”.
April 2003: BAE Systems deliver Phase 1 Nimrod Baseline Safety Case Report
10A.80
10A.81
10A.82
In April 2003, BAE Systems delivered its Report on Phase 1 of the Nimrod Baseline Safety Case comprising
the Zonal Hazard Analysis (ZHA) of the MR2 and R1 (BLSC (Phase 1) Reports). 51 The BLSC (Phase 1) Report for
the MR2 identified some 1,300 hazards. As explained later, this enormous number of ‘hazards’ is indicative
of a lack of understanding by BAE Systems at the time as to what comprised a ‘hazard’ and what comprised
an ‘event or cause’. The majority of the 1,300 initial hazards were avionic-related and repeats of each other
with small variations. Many were not ‘real’ hazards in the first place as they assumed, e.g., that a pilot would
only look at a single instrument erroneous indication and follow it blindly.
The BLSC (Phase 1) Report annexed the CASSANDRA Hazard Log entries for Hazards H367 and H498 set
out above. As explained above, these identified the general zonal risk arising from the juxtaposition of fuel
pipes and hot bleed-air ducting in Zones 514 and 614 but: (i) contained little analysis or detail; (ii) did not
distinguish between the port and starboard sides, and in particular, did not highlight the special risk on the
starboard side arising from the SCP pipe and elbow at the bottom of Zone 614; (iii) ascribed different initial
probabilities to the same zones and hazard; and (iv) cross-referred photographs that were confusing and
difficult to follow. This did not bode well for any subsequent hazard analysis.
In an accompanying Phase 1 ‘Completion’ Report, BAE Systems reported that it had completed Phase 1 and
recommended that it be tasked to carry out Phase 2. 52
1 May 2003: Nimrod IPT acceptance of completion of Phase 1
10A.83
By a letter dated 1 May 2003, Frank Walsh (who had joined the Nimrod IPT in January 2003 as Safety
Manager) confirmed acceptance of the completion by BAE Systems of Phase 1 of the NSC and acknowledged
receipt of a soft copy of the Hazard Log “populated but not mitigated”. He made arrangements for BAE
Systems to be paid for Phase 1 and requested BAE Systems to prepare costings for Phase 2 of the contract
“now the scope of the task is clear.”
51 BAE Report MBU-DEF-C-NIM-SC0538: Nimrod MR Mk2 – Baseline Safety Case (Phase 1) Zonal Hazard Analysis (April 2003) (BLSC (Phase 1)
Report).
52 BAE Report MBU-DEF-C-NIM-SC0539. Nimrod Task 26-3244 Equipment Safety Management Safety Management Nimrod MR MK2 and R Mk1.
Preliminary Hazard Identification Report – Phase 1 Completion (April 2003).