The Nimrod Review - Official Documents

The Nimrod Review
Why did George Baber sign?
11.229 On 22 February 2005, George Baber signed the letter prepared by Frank Walsh which formally requested BAE
Systems to set the status of the CASSANDRA hazards in accordance with Annex A to Frank Walsh’s letter of 1
February 2005 as “Managed”. Why did George Baber sign the letter with such a manifestly erroneous Annex?
The answer is almost certainly because he did not read or properly consider Annex A before signing the letter,
which was put in front of him by a junior officer whom he assumed did know what he was doing and he did
not check that it was correct. George Baber’s evidence in interview on this issue was that, whilst he was unable
specifically to recall whether he had seen Annex A at the time of Frank Walsh’s letter of 1 February 2005 (but did
not think that he had), he was adamant that he would not have signed the letter of 22 February 2005 without
reviewing Annex A and stated that he clearly remembered a meeting with Frank Walsh at which he sat down
and went through the letter. He explained that “I would not just sign off a bit of paper without sitting down
with somebody. It is just not the way I operate”. He went on to state that he trusted Frank Walsh, “took what
he said at face value” and that he had never “been so hoodwinked in [his] life”.
11.230 In my view, however, given how busy George Baber was at the time, it was most likely that he had just signed
the letter without checking the contents of Annex A at all. If he had given proper consideration to what he was
signing, he would, and should, have realised two things. First, the inappropriateness of the letter stating that
the “Catastrophic”/“Remote” risks should be classed as “Managed”. 23 of the hazards had been given a Post
Control Status of “Remote” and, therefore, were to be classified as category ‘B’ or “Undesirable” risks in the
HRI, i.e. they required management action to introduce control measures and “shall only be acceptable once
reduced to ALARP”. There was, however, no evidence of any approved management ‘actions’ being in progress
to allow these 23 hazards to be referred to as “managed”. They could not be left with a ‘managed’ status of
“Remote” although this is what the letter itself indicated. Second, the manifest oddity on the face of Annex A,
in particular having 21 out of 33 absolutely identical “Interacting Systems” entries, all of which had “Aircraft
fire detection and suppression” systems in their zones, which would entail an impossible number of fire bottles.
If he had paused for thought for a moment he would, and should, have appreciated something was not quite
right. It is regrettable that he did not.
11.231 I reject George Baber’s suggestion that there was nothing “implausible” about what he was being asked to sign.
I also reject his suggestion that he was entitled to take the information “on trust” from Frank Walsh and to take
what he was told “at face value”. This was not good enough. It was his personal, non-delegable, duty as IPTL,
PE and LOD holder to satisfy himself as to the correctness of what he was signing and to ensure that these risks
were properly sentenced. This was particularly the case given that Frank Walsh lacked any real experience of the
Nimrod aircraft and was not even an airworthiness LOD holder.
Frank Walsh’s further (quiet) mistake
11.232 On 16 March 2005, Frank Walsh e-mailed BAE Systems with a revised Annex A. This comprised a “Further
Review” of the 23 hazards listed in Annex A classified as “Remote”, together with the 17 hazards in Annex B
of the BLSC Report classified as “Remote” but “Closed”, all of which he purported to sentence as “Improbable”
primarily on the basis that “A review of past incidences indicates no major occurrences of these hazards.” I
have concluded that, by this stage, Frank Walsh had realised that these 40 hazards could not simply be left as
“Remote” but had to be ‘managed’ down to “Improbable” in order to justify the assertion of ALARP. I find that
he did this entirely on his own and without the knowledge of either Michael Eagles or George Baber. Again, in
my judgment, Frank Walsh should have alerted his superiors to this matter which he had overlooked. The fact
that he did not see fit to do so is, again, regrettable and unfortunate.
Why did Frank Walsh act in this manner?
11.233 Why did Frank Walsh act as he did? The answer in my view lies in four factors. First, his inexperience and lack of
understanding as to the importance of what he was dealing with and being asked to do. Second, a reluctance
to ‘own up’ to having overlooked matters and not wanting to be found out. Third, a belief (as he effectively
admitted to the Review) that because BAE Systems had already gone through the hazards and done the work,
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