The Nimrod Review - Official Documents

Chapter 11 – Nimrod Safety Case: Analysis and Criticisms
substitute for hands-on experience of the legacy aircraft in question. BAE Systems sought to argue that “past
hands-on Nimrod experience (whilst potentially an advantage) was not an essential requirement for the task”
of hazard assessment and mitigation. 24 I profoundly disagree. In my view, those flying and maintaining legacy
aircraft are equal, if not greater, repositories of vital knowledge regarding the aircraft than the designers for a
hazard analysis exercise. If BAE Systems had ensured proper operator input in Phase 1 and Phase 2 (or had the
Nimrod IPT insisted thereon) the outcome might well have been different. BAE Systems’ continued denial, in its
submissions to the Review, of the absence of any ‘necessary’ operator or maintenance personnel in Phase 1 or
Phase 2, was disappointing.
(5) BAE Systems failed to ensure continuity of personnel.
Importance of continuity of personnel obvious
11.32
In my judgment, BAE Systems is at fault for failing to ensure continuity of the personnel involved in Phase 1 and
Phase 2 of the NSC. The need to ensure continuity was obvious: those involved in carrying out the initial Phase
1 inspections also needed to be involved in the later Phase 2 analysis.
Little continuity
11.33
With the exception, however, of Witness G [BAE Systems[ and Witness H [BAE Systems], none of the BAE
Systems personnel who carried out the Phase 1 physical inspection hazard ‘identification’ exercise were involved
in the Phase 2 hazard ‘assessment’ and ‘mitigation’ exercises. Richard Oldfield and Witness C [BAE Systems] did
not draw up the Phase 2 Pro-Formas. Thus, the drawing up of the Pro-Formas and the sentencing of hazards
was largely done by personnel who had not been involved in the original inspections. They were, therefore, at
a considerable disadvantage even though the Phase 1 personnel may have been available in the office. I have
highlighted in Chapter 10A the difficulties that the BAE Systems personnel involved in the Phase 2 (office)
exercise faced in interpreting the sketchy quality of the initial zonal hazard reports and photographs produced
by those involved in Phase 1. 25 BAE Systems accepted this criticism but said that it was difficult to ‘ring fence’
Phase 1 participants from other commitments until such time as the IPT authorised Phase 2 to commence. In
my view, having committed itself at the beginning to carrying out the NSC, and having expressed a “high level
of confidence” in its ability to do so in a “in an effective, competent, expedient and cost-effective manner”, it
was incumbent on BAE Systems to ensure the availability of the right personnel throughout. This is why good
planning is so important.
(6) BAE Systems’ project planning was poor.
11.34
Skills
11.35
Scoping
11.36
In my judgment, BAE Systems’ project planning for the NSC was poor from the outset. There are four particular
criticisms that can be made.
First, BAE Systems gave inadequate attention at the outset to the skills required to carry out the ZHA and produce
a Safety Case. BAE Systems failed to think about whether its staff were adequately trained and experienced in
ZHA and Safety Cases. The courses they were sent on were a start, but insufficient (see above). Most were being
expected to do something which they had not done before and of which they had little background knowledge
of how to go about.
Second, BAE Systems failed properly to scope the task or give sufficient consideration to the nature and extent
of the work that the NSC would entail. Insufficient thought was given at the outset as to what, in fact, the task
required and how, in practice, it was to be carried out. BAE Systems explained in its written evidence to the
24 BAE Systems’ written submissions to the Review.
25 Chapter 10A, paragraphs 10A.78 and 10A.81.
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