The Nimrod Review - Official Documents

The Nimrod Review
228
10A.174.3 Section 6 of the Pro-Forma incorrectly stated that the Cross-Feed duct “is only pressurised when
the cross-feed pipe is open, i.e. during engine start”, and failed to take into account the lengthy
periods the cross-feed duct can be pressurised (at a working temperature of up to 420°C) when
feeding the SCP.
10A.174.4 Section 6 of the Pro-Forma stated that “From in-service data the potential for fuel pipe leakage
is given as Improbable”, i.e. 10 -6 . Any line engineer would have known this was unrealistic.
10A.174.5 The Pro-Forma failed to pick up on the zonal risk presented by the location and proximity of the
No. 1 fuel tank blow-off valve immediately forward of the starboard No. 7 Tank Dry Bay, such that
fuel expelled from the blow-off valve could track back onto the SCP pipe elbow and ignite.
10A.175 I deal with these errors in more detail in Chapter 11. I conclude that the Pro-Forma for Hazard H73 was a sloppy
and muddled piece of work, carried out under time pressure without sufficient guidance or management
oversight. It should be emphasised that some of the mistakes in the Pro-Forma were very basic indeed.
For instance, the mistake in relation to the Cross-Feed duct being pressurised “only…during engine start”
displayed a startling lack of knowledge by BAE Systems about its own aircraft. Anybody who knew anything
about Nimrods would know the cross-feed duct was bound to be used in flight (a) to re-start engines which
had been routinely shut down and (b) to run the SCP.
Last minute rush: task not completed by 31 August
10A.176 The process of completing Pro-Formas continued right up to the Customer Acceptance Conference on 31
August 2004. On 28 August 2004, Witness K [BAE Systems] reported to Eric Prince that Mech Systems had
completed 49 out of 58 Pro-Formas, Electrical Systems had completed 18 out of 35 Pro-Formas and Avionics
had completed 10 out of 12. On the afternoon of 30 August 2004, the day before the Customer Acceptance
Conference, Witness K [BAE Systems] reported to Eric Prince that Mech Systems had completed 52 of the
Pro-Formas with 6 “on-going”, and Electrical Systems had completed 27 of the Pro-Formas with several
for signature and 4 “on-going”. In fact, several Pro-Formas were not completed by Electrics until after the
Customer Acceptance Conference: Hazards H67, H78, and H79 were completed by Witness T [BAE Systems]
on or after 2 September 2004; and Hazard H63 was not completed until 24 September, i.e. somewhat
curiously after the final hard copy of the report had already been circulated to Frank Walsh.
FSD and Serous Fault Signals: word search
10A.177 A further troubling feature is that, as late as 24 August 2004, the results of a word search on the VC10 &
Nimrod Flight Safety Database in relation to ‘fire’, ‘smoke’, ‘fumes’, ‘burning’ and ‘smell’ was circulated. It is
not clear, however, as to what use, if any, this research was put.
16 August: BAE Systems’ internal “Independent Review”
10A.178 At the 16 August 2004 meeting, it had been decided that Chris Lowe should request Witness V [BAE Systems]
or Witness A [BAE Systems] to carry out an ‘independent’ review of the NSC work prior to the Customer
Acceptance Conference. Witness A [BAE Systems] was ultimately contacted on 24 August 2004 by Chris
Lowe, who e-mailed him with copies of what were referred to as “the major reports in support of the
safety case you may wish to peruse”. But only copies of three out of the six ‘deliverable’ reports were in fact
attached, namely, the Fire & Explosion Report, Review of Accident History, and Certification Statement, the
latter two of which comprised essentially factual summaries as opposed to analytical analysis. Witness A
[BAE Systems] was not shown the BLSC Reports for the MR2 and R1. Nor was he asked to conduct a proper
“independent review” of the Nimrod BLSC. Rather, he explained in evidence that he was only asked to “cast
an eye” over the three reports. It appears that an internal BAE Systems meeting may have taken place on
Wednesday 26 August 2004, attended by Witness A [BAE Systems] and Chris Lowe, at which only these three
reports were reviewed.