The Nimrod Review - Official Documents

Fire & Explosion Report completed
Chapter 10A – Nimrod Safety Case: The Facts (Phases 1 and 2)
10A.163 The Fire/Explosion Hazard Assessment (Fire & Explosion Report) was completed by Chris Lowe in August
2004. 72 It had originally been envisaged that Mech Systems would produce the Fire & Explosion Report and
that this would be based on a ZHA. There was a logic to this because Mech Systems were best placed to
carry out such a task. As at 7 April 2004, it was envisaged that Chris Lowe would provide Eric Prince with
a skeleton for the Fire & Explosion Report and Eric Prince would allocate resources from Mech Systems. The
value of a Fire & Explosion Report had been questioned but defended by Chris Lowe. By 10 May 2004, it was
decided that the Fire & Explosion Report should be done by Witness U [BAE Systems] of Mech Systems using
Chris Lowe’s framework and MSC thesis. 73 However, the task was eventually passed to the Airworthiness
Department because Witness U [BAE Systems] did not have sufficient time and Chris Lowe ultimately drew it
up himself. He said that he completed it over a period of six weeks by working on it at home. It is unfortunate
that he had not been present at either visit to RAF Kinloss or RAF Waddington and therefore had not
examined the aircraft.
10A.164
The Fire & Explosion Report purported to highlight the catastrophic risk of a serious on-board fire. In particular,
it stated pertinently:
“In the case of a deep-seated on-board fire remaining undetected and unsuppressed
during flight, irrespective of the location of the fire on the aircraft, it can very quickly
contribute to any combination of major structural failure, loss of fundamental control or
total loss of thrust; thus resulting in catastrophic loss of aircraft and occupants.
In the case of an on-board fire-related explosion (such as a fuel tank explosion), such an
event invariably leads to all three consequences simultaneously. …” 74
10A.165 Unfortunately, the Fire & Explosion Report was of very poor quality. It contained numerous errors and omissions
and failed to identify and highlight the catastrophic risk of an ‘uncontrollable’ fire risk in the starboard No. 7
Tank Dry Bay. There was also little, or no, attempt to reconcile the apparently contradictory conclusions of the
Fire & Explosion Report and the BLSC Reports. These matters are particularised and analysed in more detail
in Chapter 11.
16 August 2004: task only 68% complete
10A.166 By 16 August 2004, the position had clearly become critical. Only 50 out of 104 hazard Pro-Formas had been
done. There remained 33 to be completed by Mech Systems, 29 by Electrical Systems, seven by Avionics and
one by Structures. There were, however, only two weeks to go until the Customer Acceptance Conference
(see below). At a review meeting that morning, Chris Lowe said there was to be a “final push” and the aim
was for “end of the week completion”. A further week was going to be required to carry out the necessary
input into CASSANDRA and finalise the reports (on the basis of inputting at a rate of half an hour per hazard).
Mech Systems was told “to come up with a plan” to complete the remaining hazards “by the end of the
week”. This was not realistic. It was also likely to put undue pressure on the engineering staff involved to
cut corners simply to finish the job. Witness K [BAE Systems]’s note of the meeting states that Eric Prince
“played along with this deadline”. He did not come up with a plan. Eric Prince suggested in interview with
the Review that Chris Lowe had not meant that all the hazards should be completed by the end of the week,
but merely that he (Eric Prince) was required to come up with a plan by the end of the week; and further, that
this was “the usual sort of pressure” which was encountered with projects. In my view, neither explanation
was convincing.
72 BAE Systems Report MBU-DEF-C-NIM-SC0710: “PDS Task 06-3409 Nimrod MR Mk2 & R Mk 1 Safety Case Baseline Report Phase 2 Fire/Explosion
Hazard Assessment”, dated August 2004.
73 Lancaster University Engineering Department, September 2003.
74 BAE Systems Report MBU-DEF-C-NIM-SC0710: “PDS Task 06-3409 Nimrod MR Mk2 & R Mk 1 Safety Case Baseline Report Phase 2 Fire/Explosion
Hazard Assessment”, dated August 2004, Page 12.
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