The Nimrod Review - Official Documents

The Nimrod Review
Summary of criticisms of the Nimrod IPT in relation to the NSC
Major failures of the Nimrod IPT
11.178 In my judgement a number of significant criticisms of the Nimrod IPT in relation to the NSC in the period 2002
to 2005 are borne out. There were two fundamental failures by the Nimrod IPT in particular:
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(1) First, a fundamental failure of project management: the Nimrod IPT failed properly to project manage
the production of the NSC by BAE Systems and, in particular, to act as an ‘intelligent customer’ when
the NSC task was handed over by BAE Systems, ostensibly properly completed.
(2) Second, a fundamental failure to mitigate catastrophic risks carefully: the Nimrod IPT failed carefully to
sentence the large number of hazards which had been left “Open” and “Unclassified” by BAE Systems
and failed to ensure that catastrophic risks were properly assessed and managed in accordance with
appropriate procedures.
11.179 The criticisms of the Nimrod IPT can conveniently be summarised by, and considered under, the following
headings:
(1) The Nimrod IPT’s attitude to the NSC was flawed from the outset: it assumed that the Nimrod
was ‘safe anyway’ because of its long record.
(2) The Nimrod IPT inappropriately delegated the management of the NSC task to a relatively
junior person without adequate oversight or supervision.
(3) The Nimrod IPT failed to ensure adequate operator involvement in BAE Systems’ work on
Phases 1 and 2 of the NSC.
(4) The Nimrod IPT failed properly to project manage the NSC, or to act as an ‘intelligent customer’
at any stage.
(5) The Nimrod IPT failed to read the NSC Reports carefully or otherwise check BAE Systems’
work.
(6) The Nimrod IPT subsequently signed off BAE Systems’ NSC in circumstances where it was
manifestly inappropriate to do so.
(7) The Nimrod IPT proceeded to sentence the remaining hazards on a manifestly inappropriate
and inadequate basis.
(8) The Nimrod IPT failed to follow its own Safety Management Plan.
(9) The Nimrod IPT failed properly to appoint an Independent Safety Auditor to audit the NSC.
(10) The Nimrod IPT failed properly to manage the NSC post its production and failed to treat it as
a “living” document.
(11) The Nimrod IPT failed to ensure that resources within the Nimrod IPT were properly utilised to
ensure the airworthiness of the Nimrod fleet and to ensure that safety and airworthiness was
the first priority.
11.180 The wider organisational causes of the failure of the Nimrod IPT in relation to the NSC are dealt with later in
Part IV of this Report.