The Nimrod Review - Official Documents

The Nimrod Review
Identification of 1,300 ‘hazards’ suggests incompetence
11.27
270
The initial identification of 1,300 ‘hazards’ by the BAE Systems Phase 1 team demonstrated a lack competence
and basic understanding as to what they were doing. They confused ‘hazards’ with ‘events’ and ‘conditions‘
leading to hazards. This was described by Witness L [QinetiQ] (see below) as a rudimentary “schoolboy error”,
which showed a lack of competence in safety engineering.
(4) BAE Systems failed to ensure vital operator (i.e. RAF) involvement.
Operator involvement axiomatic
11.28
In my judgment, BAE Systems is at fault for failing to ensure any real involvement of the ‘operators’ of the
Nimrod aircraft (i.e. RAF maintenance and flight crew) at any stage during Phases 1 and 2 in the production of
the NSC. 20 Lord Cullen in the Piper Alpha report had emphasised the need for operator involvement in a Safety
Case. This was reiterated by the MOD in the White Booklet. 21 It is clear that operator involvement in the process
of developing a safety case for a ‘legacy’ platform such as the Nimrod was axiomatic to its success, not least
because those charged with maintaining and flying the aircraft over the years had detailed, practical knowledge
of the aircraft and the working of its systems, which the designers would not have.
‘Joint’ working group initially envisaged
11.29
BAE Systems’ failure to involve the operators at any stage is surprising and unfortunate. BAE Systems itself
appears to have appreciated the importance of operator involvement and to have embraced the notion, at least
initially. BAE Systems recommended that a joint Safety Case BAE Systems/Nimrod IPT working group be set
up “to partake in the identification determine causes and effects and mitigation of all hazards, and contribute
toward the consequent population of the hazard log”. 22 At the Inaugural Project Safety Working Group (PSWG)
meeting on 18 March 2002, Chris Lowe stated that the identification and addressing of all safety hazards should
be carried out by a joint safety working group, small in size, with input from ADA and MOD and “be made up
of players with genuine expert knowledge”. 23
BAE Systems never set up joint working group or consulted operators
11.30
BAE Systems failed to ensure that a joint working group was set up and met regularly. BAE Systems did not
consult personnel at RAF Kinloss or RAF Waddington responsible for flying or maintaining the aircraft during
Phase 1 or 2. It is fair to point out that the Nimrod IPT is equally open to criticism for not insisting on a joint
working group, and for not officiously seeking to be involved in Phase 1 or 2 of the process at any stage. The
Nimrod IPT was very much hands-off, and eyes-off (see above). There was no satisfactory explanation for BAE
Systems’ failure to set up a joint working group. It just did not happen. It may have been regarded as giving rise
to unnecessary customer interference. This was unfortunate. None of the BAE Systems personnel had suitable
practical operating experience of the Nimrod aircraft or its systems. BAE Systems used personnel it called Nimrod
‘specialists’ but who had never, or rarely, seen or inspected a Nimrod aircraft, and who had little practical
knowledge or experience thereof, albeit some had considerable ‘design’ experience.
Practical experience vital
11.31
In seeking to justify its choice of personnel to the Review, BAE Systems sought to emphasise the number of years
that members of the Phase 1 ZHA team had spent working with Nimrods on design issues. In my view, however,
such theoretical, design, office-based experience is a far cry from the invaluable practical, hands-on experience
that those flying or maintaining the aircraft on a daily basis would have had. Both types of knowledge are
required for a proper hazard analysis. Further, whilst broad experience of other aircraft is valuable, it is no
20 Save for the Fault Tree Analysis.
21 Chapter 9, paragraph 9.66 and 9.67.
22 See paragraph 10.2 of the Feasibility Study.
23 Chapter 10A, paragraph 10A.35.