The Nimrod Review - Official Documents

Chapter 10B – Nimrod Safety Case: The Facts (Third Phase)
[MOD]) had considerable experience of working on Nimrods, which was not the case with the A(1) and A(3)
desks. There were similar desks responsible for the Spey engines and Avionics.
BLSC Reports not read carefully by Nimrod IPT when first received
10B.23
10B.24
Frank Walsh said in interview with the Review that, following receipt from BAE Systems on 21 September
2004, he recalled circulating the Minutes of the Customer Acceptance Conference and the six deliverable
Reports within the Nimrod IPT, including to the specialist desk officers, most likely by email. He also said in
interview that, upon receipt of the six Reports, he would have printed them off and started “wading through”
them himself, with a view to putting together a list of issues for consideration by the other IPT desk officers.
There is, however, no evidence of the six Reports ever being circulated by Frank Walsh within the Nimrod IPT
or to the relevant IPT desk officers. I have concluded that he did not do so. I have also concluded that he did
not read all of the BLSC Reports carefully at this stage. Nor did Michael Eagles at any stage. Nor did George
Baber. I discuss in Chapter 11 the reasons why not and the consequences of the same.
It would appear that, in so far as Frank Walsh gave any consideration at all to the six deliverable Reports,
he focused primarily on the Certification Statement and the Fire & Explosion Report and paid little or no
attention to the (key) BLSC Reports. He had been shown the content of the Fire & Explosion Report by
Chris Lowe at the Customer Acceptance Conference and no doubt regarded it as the over-arching report
dealing with the major risk of fire and explosion. It made a limited number of recommendations (nine) and
concluded that the fire/explosion risk was ‘ALARP’. The extent to which Frank Walsh properly read, digested
and understood the Executive Summary of the BLSC Reports is unclear. Frank Walsh admitted in interview
with the Review that his primary focus was on the CASSANDRA Hazard Log which he had been sent in CD
Rom form. He said that he had probably worked from the CASSANDRA hazard log rather than the annexes.
He also said that at some stage he rang Witness C [BAE Systems] or Chris Lowe regarding the ‘unclassifieds’
and was told to focus on CASSANDRA since things had ‘moved on’. He said: “I believe I queried the fact
that there was [sic] differences between the safety case report and what was actually now in the hazard
log. And I was told that the hazard log had been updated with the latest information.” The extent to which
this may be ex post facto rationalisation for using CASSANDRA rather than Schedules B and C of the BLSC
Reports is unclear. At all events, as I explain below, it appears he did not understand the nature of the ‘initial
probabilities’ in CASSANDRA.
Preparations for the Sixth PSWG
10B.25
10B.26
Following the delivery of the six Reports, it was intended that the completion of the ‘BLSC’ by BAE Systems
would be formally acknowledged and ‘signed-off’ by the Nimrod IPTL at the next PSWG. The Sixth PSWG was
scheduled for 10 November 2004. Frank Walsh was tasked to prepare briefing documents for this meeting.
He drew up two annexes dealing with ‘outstanding recommendations’ under the NSC. Annex A identified
13 outstanding recommendations, all emanating from recommendations in the Certification Statement, Fire
& Explosion Report, the Hazardous Materials List, and the Review of Service Accidents. Annex B identified
outstanding recommendations relating to Hazards H2, H15, H23, H26 and H27; these appear to have been
taken randomly from CASSANDRA; only two overlap with Annex C of the BLSC Reports. Neither Annex
made any reference at all to the BLSC Reports. Neither touched on, or even mentioned, the large number of
recommendations in relation to the 43 “Open” hazards contained in Annex C thereto.
It appears, therefore, that despite having received copies of the BLSC Reports, Frank Walsh still remained
ignorant of the full picture. As indicated above, he had either simply failed to read the BLSC Reports at all
by this stage, or had merely glanced at the Executive Summary thereof and assumed the top-level goal had
been achieved from the words: “The aircraft type is deemed acceptably safe to operate and maintain within
specified contexts”. I reiterate: a careful reading of the Executive Summary and Annexes B and C to the BLSC
Reports, however, would and should have alerted him to the fact that 43 of the hazards remained “Open”,
some 33 hazards remained completely “Unclassified” and a large catalogue of recommendations had been
made which required further action. It is unfortunate that Frank Walsh appears not to have studied the BLSC
Reports more carefully or at all at this stage because if he had appreciated that over 40% of the hazards
245