The Nimrod Review - Official Documents

Chapter 11 – Nimrod Safety Case: Analysis and Criticisms
CRITICISMS OF THE NIMROD IPT in relation to the Nimrod Safety Case
Introduction
11.171 In my judgment, the Nimrod IPT bears considerable responsibility for the lamentable quality of the NSC and the
singular failure of the NSC to capture the catastrophic fire risk presented by the Cross-Feed/SCP duct risk. If the
Nimrod IPT had performed its duties in relation to the NSC appropriately and carefully, it is likely that the NSC
would have properly identified, assessed and addressed this fire risk and the loss of XV230 would have been
avoided.
11.172 The Nimrod IPT was responsible for ensuring the safe through-life management of the Nimrod fleet. Safety
Cases were mandated by BP1201. The Nimrod IPT outsourced the task of preparing the NSC to BAE Systems
(see further below). It was, therefore, the Nimrod IPT’s responsibility to project manage the task and ensure that
a proper Safety Case was produced for the Nimrod fleet. QinetiQ acted as ‘independent advisor’ in relation to
the NSC and supported the sign-off of the NSC. The Nimrod IPT finally completed the NSC in February 2005.
11.173 As explained above and in Chapter 10A, there were significant flaws in the NSC which was produced in the
period 2001 to 2005. The NSC failed to identify the serious fire risk in No. 7 Tank Dry Bay starboard which the
Cross-Feed/SCP duct posed to the Nimrod fleet (Hazard H73) and which subsequently caused the loss of XV230
in September 2006.
11.174 As explained above, the Review identified a number of errors in the NSC in relation to Hazard H73 alone and
decided to conduct a detailed investigation into the entire NSC and found: First, the errors identified by the BOI
and the Review in relation to Hazard H73 were not one-off, but appear to have been symptomatic of a generally
poor standard of accuracy and analysis in the NSC. Second, the NSC Baseline Safety Case Reports (BLSC Reports)
produced by BAE Systems left over 30% of the hazards “Unclassified” and 40% of the hazards remained
“Open”, many with no recommendation beyond simply that “Further analytical techniques are required” before
they could be categorised, sentenced and closed. Third, the Fire & Explosion Report did not accord with the BLSC
Reports produced by BAE Systems. Fourth, the NSC had not reduced the risks to the Nimrod fleet to ALARP. 102
11.175 Unfortunately, the Nimrod IPT failed to grasp the opportunity which then presented itself properly to categorise
and mitigate catastrophic Hazard H73.
Key Personnel
11.176 The key personnel in the Nimrod IPT with responsibilities for the NSC were: (1) the Nimrod IPT Leader (IPTL),
Group Captain (now Air Commodore) George Baber, who was also the Nimrod Project Engineer (PE); (2) the
Head of Air Vehicle, Wing Commander Michael Eagles, and (3) the Safety Manager, Frank Walsh (see further
below). References hereafter to the Nimrod IPT are generally to these key personnel.
Lack of guidance
11.177 As set out in Chapter 9, JSP318B prescribed a Safety Management System (SMS) for military aircraft and set
out the aims and objectives of such a system. Whilst JSP318B mandated a clear policy, it is fair to say that the
majority of the MOD personnel required to implement that policy had received little (if any) relevant guidance
and training, and nor was it clear to them where they were meant to look for support. The IPTs felt they
lacked advice and guidance generally regarding safety matters. A Safety Process Review in 2002 initiated by the
Defence Procurement Agency reported: “The universal plea was for early, authoritative advice on what had to
be done, by whom, when and in what format with regard to safety on their project”. 103 The lack of practical
guidance does not, however, excuse the basic failures of the Nimrod IPT to follow its own procedures or ensure
the safety of the Nimrod fleet.
102 i.e. Risks were not reduced to As Low As Reasonably Practicable (see Chapter 9).
103 Safety Process Review, dated 23 December 2002, Advantage Technical Consulting: Section 3 Interview Phase, paragraph 3.2 on IPTs, especially
paragraph 3.2.2.
305