The Nimrod Review - Official Documents

The Nimrod Review
11.56
11.57
276
‘generic’ MRA4 data to sentence MR2 and R1 hazards (see further below). By 16 August 2004, the situation
had become critical with some 50 out of 104 hazards completed. By this stage, there was a serious backlog in
the Mech Systems and Electrical Systems departments. Nevertheless, BAE Systems management continued to
press for completion of the Task by the end of August 2004, because the project was perceived as prestigious
and important for those involved and for future BAE Systems business. Chris Lowe demanded a “final push”
for completion by the end of the week. It is no coincidence that Hazard H73 was part of this final push. In a
matter of hours on 26 August 2004, Witness T [BAE Systems] sent no fewer than four completed Pro-Formas
(Hazards H69, H76, H77 and H93) back to the Mechanical Systems Department. On 30 August 2004, the day
before the Acceptance Conference, second issues of six hazards (Hazards H70, H72, H73, H74, H75 and H77)
were formally signed-off and subsequently approved by Eric Prince.
The dangers of putting undue time pressures on engineers was put by Counsel to the Review to Richard
Oldfield:
“MR PARSONS QC: The danger with ‘final pushes’ is that there are often casualties, aren’t there?
MR OLDFIELD: I don’t think that would ever be the case, in terms of the professionalism of completing
the task from the engineers.
MR PARSONS QC: If you put engineers under pressure to complete a task in a short period of time,
there is a risk that corners will be cut and mistakes will be made?
MR OLDFIELD: I think we were just emphasising the fact that we wanted one last effort to actually
complete it, as best we could. There’s – I wouldn’t say there was any undue pressure that had been
put on top of the engineers on that. There was no additional, you know, excessive man hours that was
worked for that last final push. It was just a case of emphasising the need to put extra effort in, in the
last – last couple of weeks before the acceptance conference.”
As I explain in further detail below, the quality of ‘assessment’ and ‘mitigation’ analysis done by BAE Systems in
relation to the remaining hazards suffered as a result of these time, resource and management pressures.
(12) BAE Systems used inappropriate data to sentence risks (including Hazard H73).
11.58
In my judgment, BAE Systems resorted to using inappropriate data to sentence hazards. This was due to time
pressures, and a general lassitude about how hazards were closed off.
Inappropriate use of MRA generic data
11.59
11.60
The months of July and August 2004 were undoubtedly a time of growing pressure for those involved in the
NSC within BAE Systems, as explained above. By 7 July 2004, Mech Systems’ task was only 20% done and only
41 out of 104 hazards had been returned and 63 still remained to be done. Completion was subsequently put
back to the end of August 2004. On 8 July 2004, following discussion within BAE Systems initiated by Witness
R [BAE Systems] as to whether there were any “standard values” which could be used to sentence hazards,
Witness S [BAE Systems] circulated an e-mail to the specialist engineers attaching MRA4 generic probability
data which he said had been extracted from the Nimrod MRA4 System Safety Working Practices (Annex G). 32
The generic failure types and probabilities were derived from the in-service data obtained from a number of
other aircraft, such as the Tornado and the Hawk, and (apparently) gave a standard failure probability rating for
a number of common failure types, including that for a failure of a “fuel pipe and associated coupling”, which
was ascribed a failure probability of 1E-6. 33 Witness S [BAE Systems]’s email was copied to Chris Lowe, Richard
Oldfield and Eric Prince.
Chris Lowe’s evidence in interview on the use of MRA4 data was unsatisfactory. He said that he had been aware
that the data existed and had been sent to Witness S [BAE Systems] and Witness K [BAE Systems], but professed
not to have been aware at the time of the NSC as to “exactly” how they used that data, although he would
32 AWN/NIM/897 Issue 7 (Revision 7, Version 2).
33 This generic probability data had previously been agreed with the Nimrod MRA4 IPT for use for the Nimrod MRA4.