The Nimrod Review - Official Documents

The Nimrod Review
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question, Zone 124, in the MR2. 75 BAE Systems nevertheless responded to this straightforward (and indubitably
correct) factual criticism in the following (somewhat Alice-in-Wonderland) fashion:
“The Equipment Safety Case did not take into account any mitigation from these fire
bottles in the final analysis, but merely referenced them as a clarification point for the
reader to confirm that in actual fact there is no fire protection in Zone 124.” 76
11.138 In summary, factual accuracy is key to the validity of any Safety Case. It is not acceptable to produce Pro-Formas
with a plethora of factual errors.
(19) BAE Systems’ Fire/ Explosion Report was superficial and slapdash and failed
properly to address the risk of a catastrophic fire in the No. 7 Tank Dry Bays (i.e.
Hazard H73).
11.139 In my judgment, the Fire & Explosion Report prepared by Chris Lowe was a superficial and slapdash piece of
work. It contained numerous errors and omissions. It failed to identify and highlight the catastrophic risk of an
‘uncontrollable’ fire risk in the starboard No. 7 Tank Dry Bay. It was done without reference to the BLSC Reports
or the Pro-Formas and might have been better if it had been prepared by or jointly with someone in Mech
Systems as originally envisaged.
Comprehensive stand-alone report dealing with Fire and Explosion risks
11.140 The very purpose of the Fire & Explosion Report was to identify and categorise all catastrophic fire and explosion
risks in the Nimrod fleet. It was clearly intended to be a stand-alone report, which covered all functional and
zonal fire and explosion risks to the Nimrod fleet. Accordingly, a reader could be forgiven for thinking that its
findings, recommendations and conclusions would: (a) deal carefully and comprehensively with any zonal fire and
explosion risk to the aircraft types; and (b) be consistent with other NSC reports, in particular the BLSC Reports
and Pro-Formas. Unfortunately, neither was the case. The Fire & Explosion Report: (a) singularly failed to identify
serious fire and explosion risk that the No. 7 Tank Dry Bay starboard represented; and (b) was irreconcilable with
the BLSC Reports and Pro-Formas with which it, confusingly, overlapped but bore little relation.
Eight shortcomings
11.141 In my view, the Fire & Explosion Report prepared by Chris Lowe suffered from the following significant
shortcomings: (1) it failed to consider or bear any relation to any of the zonal hazard Pro-Formas (including
Hazard H73) or even follow the same zonal pattern; (2) it failed to identify aviation fuel as one of the flammable
material sources; 77 (3) it failed to highlight the catastrophic nature of an ‘uncontrollable’ fuel fire risk in the wing
bays; 78 (4) it failed to provide for adequate mitigation for many risks beyond the vague recommendation of
having regard to the “Swissair Flight 111 recommendations”; 79 (5) it failed to have regard specifically to the risk
of fuel tracking back from No. 1 blow off valve; 80 (6) in the key table (Table 2) ‘Worst case Fire Hazard by Zone’,
it left out the risk of an uncontrolled fire in the wing bays and simply addressed the scenario of a “Wheelbrake
fire or tyre explosion” and classed it as “Marginal”, “Remote”, “Closed”; 81 (7) it came to an ‘ALARP’ conclusion,
subject to a review of nine recommendations, 82 that was unjustified and irreconcilable with the Pro-Formas and
the BLSC Phase 2 Reports: “It is thus recommended overall fire/ explosion risk imposed by both types is considered
tolerably low to the extent of being considered to be … ALARP” and therefore both types “acceptably safe to
75 There are fire bottles in Zone 124 in the R1 however. BAE System may have mistaken the Nitrogen purge bottles in Zone 124 in the MR2 for fire
bottles; if so, they were also wrong to assume they discharged into the bomb bay rather than the Doppler compartment.
76 MBU-DES-LT-NIM-SC-0169-Annex 1- Issue 1, dated 30 March 2009.
77 Page 103.
78 Page 107 and page 124.
79 Page 107.
80 Page 113.
81 Page 124.
82 Page 126 under the heading “SUMMARY OF RECOMMENDATIONS DERIVED FROM ZONAL FIRE/EXPLOSION ASSESSMENT”.