The Nimrod Review - Official Documents

Chapter 10B – Nimrod Safety Case: The Facts (Third Phase)
(4) NIMROD MR MK2 and RMK 1 EQUIPMENT BASELINE SAFETY CASE REPORT FIRE/ EXPLOSION HAZARD
ASSESSMENT: Reference: MBU-DEF-C-NIM-SC-710 dated August 2004.
(5) NIMROD MR MK2 and RMK 1 HAZARDOUS MATERIALS LIST: Reference: MBU-DEF-C-NIM-SC-0667
dated August 2004.
(6) REVIEW OF NIMROD IN SERVICE ACCIDENT HISTORY: Reference: MBU-DEF-C-NIM-SC-0713 dated
August 2004.
10B.7 As explained in Chapter 10A, however, in fact, only four of the six ‘deliverable’ reports had been completed
by the time of the Customer Acceptance Conference, namely, the Type Certification Statement Report, the
Fire & Explosion Report, the Hazardous Materials Report, and the Nimrod In-Service Accident History Report.
The two key Baseline Safety Case (BLSC) Reports were not completed until afterwards. They both bear the
date “September 2004”. An examination of BAE Systems’ computer records revealed that Annexes B and C
to the BLSC Report for the MR2 were last amended on 9 September 2004, with the last amendment to the
Report itself being made on 13 September 2004. 2
‘Thud’ factor
10B.8
10B.9
10B.10
The delivery of the six reports together to the Nimrod IPT must have had a considerable ‘thud’ factor. The sheer
weight of paper, which ran to several inches, would have given the recipient IPT a sense of comfort that a
substantial, and indeed thorough, job had been done by BAE Systems. The BLSC Phase 2 Reports for the MR2
and R1 were, in particular, substantial and impressive-looking documents. This all would have re-enforced the
assurance and consensus, given and reached, at the Customer Acceptance Conference, that all elements of
the task had been “completed” by BAE Systems. The Nimrod IPT would, therefore, understandably have been
desensitised and expecting to receive reports which comprised the complete NSC.
The impression of ‘completeness’ would have been reinforced by an initial glance at the Executive Summary of
the BLSC Phase 2 Reports for the MR2 and R1, the second page of which contained the following declaration
by BAE Systems:
“From the above, it is thus declared all potential safety hazards have been identified,
assessed and addressed, and that all appropriate standards have been met. Accepting this,
the top level goal of the Nimrod MR Mk2 Type Equipment Safety Case that
“The aircraft type is deemed acceptably safe to operate and maintain within
specified contexts”
has been demonstrated as having been achieved.
In relation to underpinning the claims of the Safety Case with the in-service history of
the Nimrod types, it has been determined from Section 12.0 of this report that the actual
occurrence of a CATASTROPHIC Accident in service is 5.0 E-6, which when error margins
relating to small population of flying hours of this claim are taken into account, compares
favourably with the MOD requirement to achieve 1.0E-6 probability of occurrence in
service.” (emphasis added)
A careful reading of the first page of the Executive Summary, however, should have raised alarm bells. The
Executive Summary of the BLSC Phase 2 Report for the MR2 said in red in its heading: “This abstract should
be read in conjunction with ANNEX B and ANNEX C to this report.” The text of the Executive Summary
included the following:
2 Curiously, this is some 11 days before the final Pro-Forma (Hazard H63) was completed by Witness T [BAE Systems] in the Electrics Department.
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