The Nimrod Review - Official Documents

Chapter 11 – Nimrod Safety Case: Analysis and Criticisms
none of the hazards was really a problem and, in so far as ‘further work’ was said to be required, this was
essentially BAE Systems looking for excuses to do further unnecessary work. Fourth, the general malaise that the
Nimrod fleet was ‘safe anyway’ and, therefore, the NSC was merely a ‘tick-box’ paperwork exercise.
(8) The Nimrod IPT failed to follow its own Safety Management Plan.
11.234 In my judgement, the Nimrod IPT failed to follow its own Safety Management System (SMS). The IPT’s safety
system was rightly described by Frank Walsh himself in evidence to the Review as having “broke”.
SMP three-stage process
11.235 George Baber, Michael Eagles and Frank Walsh all ignored, or short-circuited, the Nimrod Safety Management
Plan (SMP) processes. The Nimrod IPT should have followed the three-stage “Hazard Management Process”
laid down in Annex A-1 of the SMP119 to sentence all hazards identified and raised by BAES but left ‘open’. 120
This was initially averred by George Baber in his written evidence, 121 and accepted by Michael Eagles and Frank
Walsh and other witnesses. But when it was pointed out that the procedure had not been followed, George
Baber, Michael Eagles and Frank Walsh sought to suggest that the SMP procedure did not in fact apply to the
initial population of CASSANDRA. There was, however, no other procedure could be said to apply or be relevant.
In these circumstances, I am satisfied that the Annex A-1 process should have been followed. Michael Eagles
accepted that Annex A-1 of the SMP was ‘the only show in town’ so far as relevant procedures for handling the
NSC were concerned.
By-passed
11.236 Regrettably, the Nimrod IPT essentially by-passed or ignored the “Hazard Management Process” in the SMP.
The SMP required an initial ‘proposed’ risk categorisation to be carried out by the appropriate LOD: however,
the ‘proposed’ risk categorisation was not carried out by the appropriate LOD holder (Michael Eagles) but was
carried out by Frank Walsh, who was not an LOD holder. The SMP required advice to be taken from the relevant
Engineering Heads of Branch (HOB): however, in relation to the vast majority of hazards (including Hazard H73),
no advice whatsoever was taken (by Frank Walsh) from relevant Engineer HOB. The SMP required all ‘A’ and ‘B’
and borderline ‘C’ risk categorisations to be reviewed by the meetings of the Aircraft Safety Reviews (ASR) and
PSWG: however, at no stage were the vast majority of the hazards left open by BAE Systems (including Hazard
H73) even considered by the ASR or the PSWG, let alone reviewed. The key role of the PSWG was recognised
early on. At the Inaugural PSWG meeting on 18 March 2002, Witness C [BAE Systems] said that if the IPT did
not want to task BAE Systems to sentence a risk “the hazard will go to the PSWG” and IPTL ultimately has the
say whether he accepts the risk. The function of the PSWG was “to examine and sentence hazards across both
marks at platform level.”
11.237 These were by no means the only respects in which the SMP was ignored. In particular, as explained above,
despite having “ownership” of the NSC, Michael Eagles played little or no role in its development, either directly
or indirectly, and had little direct contact with BAE Systems. Instead, he left the task almost entirely to Frank
Walsh, exercising minimal supervision of his actions. Frank Walsh, for his part, failed to voice any objection to
this and further failed to document the hazard identification process as required by the SMP. 122
11.238 I am confident that, if it had followed the SMP, the Nimrod IPT would have picked up the fundamental mistake
in Frank Walsh’s Annex A relating to the presence of a fire detection and suppression system in so many zones
of the aircraft, including Zone 614. It may also have been that the discovery of this egregious mistake would
have led to greater challenge to the project as a whole, and a fundamental re-examination by the Nimrod IPT
of the work that BAE Systems had done. I am bound to say, however, that I am not sanguine that this would,
ultimately, have led to a different outcome because of the general lassitude and lack of real interest in the
content of NSC by those involved.
119 Set out in Chapter 9 at paragraph 9.77.
120 Ibid, paragraph 15, page C-5, provided that hazard identification could come from any source, e.g. individual IPT members, industry or users.
121 Although George Baber somewhat equivocated in his oral evidence when it was pointed out that the process had not been followed.
122 Ibid, paragraph 14.
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