The Nimrod Review - Official Documents

The Nimrod Review
Why was no query raised at so few recommendations being actioned?
11.218 It is fair to say, however, that many at the meeting may have assumed that Frank Walsh had been through all
the recommendations and determined which would be actioned. Why did Frank Walsh bring no more than a
handful of ‘unresolved’ recommendations arising from the NSC to the Sixth PSWG meeting and why was no
query raised? 116 BAE Systems’ BLSC Reports had contained over 25 pages of outstanding recommendations
which could not conceivably all have been ‘resolved’ in the three weeks since receipt of the Reports. 117 The
answer lies in the fact that neither Frank Walsh nor BAE Systems had any real expectation that a large amount
of work would be done, or was required to be done, before the NSC was approved for ‘sign off’ by the PSWG.
This was, however, in my view, for different reasons (I discuss BAE Systems’ position above). Frank Walsh’s lack
of expectation was the result largely of ignorance: he had not been led to believe at the Customer Acceptance
Conference that there was a great deal of work still to be done; he had not carefully read the BLSC Report(s)
themselves by this stage; he had confined his attention to the Certification, Hazardous Materials and Fire &
Explosion Reports and the CASSANDRA Hazard Log; he did not appreciate the number of “Open”/“Unclassified”
hazards or the volume of recommendations made by BAE Systems at this stage. He tended, in any event, to be
sceptical of recommendations by BAE Systems that they carry out further work.
11.219 It is fair to say, as George Baber submitted, that “the overall impression that BAE Systems were giving was that
they had done a good job”. But, in my view, it was his and the Nimrod IPT’s responsibility properly to satisfy
themselves that BAE Systems had in fact done a good job and done what it was contracted to do.
11.220 In my judgment, George Baber (IPTL, PE and Chairman of the PSWG), Michael Eagles (Head of Air Vehicle) and
Frank Walsh (Safety Manger), fundamentally failed in their duty to take adequate steps: (a) to ensure that the
PSWG properly considered all Category ‘A’ and ‘B’ risks identified in the NSC in accordance with the Nimrod
SMP; and (b) to ensure that the NSC work had been satisfactorily carried out and completed by BAE Systems.
No ISA audit
11.221 Contrary to JSP553 and Def-Stan 00-56, no independent audit had been carried out of BAE Systems’ NSC
reports by a properly appointed ISA. For this reason alone, the work should not have been signed off.
(7) The Nimrod IPT proceeded to sentence the remaining hazards on a manifestly
inappropriate and inadequate basis.
11.222 In my judgment, the Nimrod IPT proceeded to sentence the remaining risks which had been left “Open” and
“Unclassified” by BAE Systems on a manifestly inappropriate and inadequate basis.
Missed opportunity
11.223 Ironically, as stated above, BAE Systems’ failure was the Nimrod IPT’s opportunity. BAE Systems’ failure to
complete the task gave the Nimrod IPT an opportunity to rectify the position by identifying the risk posed by
the Cross-Feed/SCP duct. As explained in Chapter 10A, Mech Systems had failed properly to analyse the risk
posed by the Cross-Feed Pipe/SCP in Zone 614 (Hazard H73), and classified the overall zonal hazard probability
as “improbable”. Hazard H73 would, therefore, have been ‘closed’ but for the Electrical Systems Appenda
which stated “Further analytical techniques are considered necessary in order to categorise the risk of the fire/
explosion hazard identified in sections 3A, 3H and 3P above”. Consequently, the effect of the Electrical Systems
Appenda, and other similar ‘holding’ statements, consequent on the fact that BAE Systems had run out of
time to finish the Task, was to leave Hazard H73 and numerous other hazards “Open” and “Unclassified”, thus
passing a substantial proportion of the NSC task back to the Nimrod IPT. This meant that the Nimrod IPT had a
fresh opportunity, theoretically at least, to capture the risks which BAE Systems had not spotted, including the
risk inherent in Zone 614. Unfortunately, as a result of the total failure on the part of George Baber and Frank
Walsh to exercise due care, skill and attention when sentencing the remaining risks, and a failure to follow the
Nimrod SMP, the Nimrod IPT failed to grasp this opportunity.
116 See Annexes A and B to the Minutes of the Sixth PSWG meeting on 10 November 2004.
117 See Annex C to the BLSC Reports.
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