The Nimrod Review - Official Documents

The Nimrod Review
10B.11
242
“In regard to identification mitigation of those hazards and subsequent entry of the
mitigation into the CASSANDRA Hazard Log, it is considered that all extant mitigation for
which BAE SYSTEMS has control has been identified and recorded accordingly against the
respective hazard in such a fashion as to provide an adequate documentation audit trail
of such mitigation.
99 hazards were identified against the Nimrod MR Mk2 type, all of which impose a
potential CATASTROPHIC outcome as a worst case scenario. The contents of ANNEX B are
derived from the CASSANDRA Hazard Log status as per the date of this report, and quotes
the Hazard Risk index for each identified Hazard. For the Status of these hazards, refer to
Annex B to this report. In relation to the DA recommendations made against all identified
hazards remaining open (qty 43), refer to ANNEX C of this report.
For the above, it can thus be concluded that, subject to IPT consideration of the abovementioned
recommendations, all potential safety hazards relating to operation and
maintenance of the Nimrod MR Mk2 type (as an equipment asset) have been appropriately
addressed....” (emphasis added)
It should have been apparent to anyone reading the BLSC Reports reasonably carefully that, far from the NSC
being completed, BAE Systems had left 43 hazards out of the 105 hazards ‘open’, i.e. some 40% of the total,
all of which were classed as having “a potential CATASTROPHIC outcome as worst case scenario”.
10B.12 BAE Systems accepted in interview that the Executive Summary involved “awkward writing” but maintained
that the BLSC Reports as a whole were not misleading. This is to miss the point. It is true that a reasonably
careful reading of the BLSC Reports should have picked up the fact that 43 of the hazards remained “Open”
and a large number “Unclassified” and many had only the vaguest recommendations along the lines of
“further analytical techniques are required”. However, anyone quickly glancing at the Executive Summary
of the BLSC Reports (particularly someone who had already been told that the task had been “completed”)
would find their eye naturally alighting on the unqualified concluding words in bold italics at the end: “… the
top level goal “The aircraft type is deemed acceptably safe to operate and maintain within specified
contexts” has been demonstrated as having been achieved” (emphasis added), and could easily have been
misled. This appears to have been recognised later by Witness B [BAE Systems] in his notes of a meeting with
the Nimrod IPT on 3 January 2008, where he recorded “Summary of safety case report is too positive. Should
reflect 32 [sic] open hazards.”
10B.13
10B.14
If a query had been raised by anyone at the Nimrod IPT on reading the Executive Summary of the BSLC Phase
2 Report about the number of “Open” hazards, BAE Systems could have pointed to the ‘consensus’ reached
at the Customer Acceptance Conference and said that the completion of the task had already been agreed.
To this extent the Nimrod IPT and QinetiQ had already somewhat been been ‘sold the pass’.
It an unfortunate fact of life that, in busy offices, where numerous lengthy and apparently impenetrable
technical reports pass over people’s desks, many people tend often to do no more than glance at the Executive
Summary and then too often put the report on the shelf. Few venture to read all of such reports. If, however,
the reader had ventured to the Conclusion to the BLSC Phase 2 Report for the MR2, at page 45, he or she
would have found the following:
“– 50 Hazards have been assessed as HRI ‘C’. It is recommended that IPT accept these
hazards as closed at a probability of IMPROBABLE, by being adequately managed ALARP
without further recommendation being proffered.
– 11 Hazards have been assessed as HRI ‘B’ and are considered as still being ‘OPEN’ with a
current probability of REMOTE. Towards closure, it is recommended that IPT consider the
ANNEX C Section C2 Table 1 recommendations proffered against these respective Open
Hazards.