The Nimrod Review - Official Documents

George Baber’s lack of care and attention when sentencing risks
Chapter 11 – Nimrod Safety Case: Analysis and Criticisms
11.224 Responsibility for the sentencing of risks ultimately resided with George Baber. As IPTL, PE and an LOD holder,
George Baber was personally responsible for sentencing all Category ‘A’ and ‘B’ risks to ALARP in accordance
with BP1201. It was his duty to do so carefully. Consequently, he should have ensured that, before sentencing
any such risks in relation to the NSC: (a) he had adequate advice and evidence before him to make a proper,
informed decision; (b) he was satisfied that the relevant Specialist Desks and Heads of Branch in the Nimrod IPT
had had appropriate input; (c) he had read and given close personal attention to the material before him; and
(d) it was appropriate in all the circumstances to categorise the risk as “Managed”.
11.225 I have concluded, however, that George Baber did none of these things. Instead, he effectively allowed Frank
Walsh to decide whether Category ‘A’ and ‘B’ risks should be sentenced even though Frank Walsh had no
responsibility, authority or capability to do so. The picture is clear from Frank Walsh’s email to George Baber
dated 20 January 2005, in which Frank Walsh asserted that “All the hazards in Cassandra” except one (Hazard
H2) had controls and references in place “to show that they were ALARP” and he that believed they should be
set to ‘Managed’. The e-mail concluded: “If you agree I will instruct BAES to amend Cassandra.” There is then
no further paper trail of the sentencing of risks until Frank Walsh’s letter to BAE Systems of 1 February 2005,
in which he authorised BAE Systems to set the post control status of the hazards in Cassandra in accordance
with the attached Annex A (see Chapter 10B). The evidence of the Nimrod IPT desk officers (which the Review
accepts as truthful and accurate) was that they were never consulted in relation to the sentencing of hazards in
the NSC in general, or the drawing up of Annex A in particular.
11.226 I have, therefore, concluded that George Baber approved Frank Walsh’s request in his letter of 20 January 2005
notwithstanding: (a) the absence of any detail or supporting material with the e-mail to have enabled him to
make a proper, informed decision; and (b) the absence of any input from the Nimrod IPT Specialist Desks or
Heads of Branch or Michael Eagles. Consequently, on 1 February 2005, Frank Walsh wrote to BAE Systems
authorising them to set the post control status of the hazards in CASSANDRA in accordance with Annex A.
Frank Walsh’s belated appreciation of the ‘hole’
11.227 As set out in Chapter 10B, I have also concluded that it was only by the time Frank Walsh came to prepare
Annex A that he finally looked carefully at Annex B to the BLSC Report and realised that there were, in fact,
no less than 32 hazards which had been left “Unclassified” and “Open” by BAE Systems and therefore needed
sentencing. Upon making this discovery, however, he did not do the proper thing, as in my view he ought to
have done, namely alert his superiors to this matter which he had overlooked and obtain the assistance of the
desk officers in carefully sentencing the outstanding risks. Instead, I have been driven to the conclusion that he
acted as if nothing was wrong and quietly sought to find a basis himself upon which the remaining risks could
be sentenced and obtain the blessing of a busy IPTL. This was highly regrettable.
Frank Walsh’s ‘idiotic error’
11.228 Unfortunately, Frank Walsh’s basis for sentencing the remaining 40% of the risks, including H73, was woefully
inadequate and erroneous. The errors contained in his Annex A were multiple, serious and in my view, obvious
even to the moderately informed reader. As suggested by Michael Bell118 in his cross-examination at the Inquest,
it was an “absolutely idiotic error” to suggest that so many zones in the wings would have fire detection and
suppression systems. Why did Frank Walsh draft the letter in this way and attach Annex A? The most likely
explanation is that he did not know what he was doing. He was simply out of his depth. He had never done
this sort of exercise before, having never come across a Safety Case or Hazard Log of this type before. He had
had little or no training or guidance as to how to go about it or the level of rigour that was required. He simply
wanted to get the matter sorted quietly and without fuss.
118 Brother of XV230 crew member, Gerard M. Bell, Deceased.
315