The Nimrod Review - Official Documents

The Nimrod Review
Failure of management and leadership
11.311 The fact that QinetiQ found itself in the position whereby it was ‘signing-off’ on the BLSC without having seen
the actual Reports was due in part to its failure to clarify its role at an early stage and its failure later on to insist
on being given sight of relevant documentation at any stage. Matters were allowed to drift. This was a failure
of management and leadership. QinetiQ’s much vaunted ‘Matrix Management System’ allowed a situation
to develop whereby QinetiQ slid into a position of being prepared to go along with an informal process and
give assent without any proper formalities being followed. The fact that QinetiQ was prepared to support the
sign-off of the NSC in these circumstances is symptomatic of the twin vices of: (a) a lax attitude to the proper
proprieties; and (b) a desire to please the client.
If QinetiQ had read the BLSC Reports
11.312 If anyone at QinetiQ had carefully read either of the BLSC Reports for the MR2 and R1 the following matters
would, or should, have been apparent to them that:
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151.1 BAE Systems had left 43 hazards “Open”, many with no recommendation beyond “Further analytical
techniques are required...”, i.e. over 40% of the total.
151.2 BAE Systems had failed to assess all the hazards and left 33 hazards “Unclassified”, with no
recommendation beyond “Further analytical techniques are required...” i.e. over 30% of the total.
151.3 There was no indication as to what “Further analytical techniques are required...” meant, beyond simply
‘further work’ being required.
151.4 The following unqualified statement on page 2 of the Executive Summaries of the BLSC Reports was not
justified:
“From the above, it is thus declared that all potential hazards have been identified,
assessed and addressed and that all appropriate standards had been met. Accepting
this the top level goal of the Nimrod MR Mk2 type Equipment Safety Case that
“The aircraft type is deemed acceptably safe to operate and maintain within
specified contexts”
has been demonstrated as having been achieved.”
151.5 The following (materially different) statement on page 46 in the Conclusion of the BLSC Reports required
explanation:
“From the above, it is thus declared that all potential hazards have been identified, assessed
and addressed to ALARP (subject to consideration of the proferred recommendations)
and that all appropriate standards had been met. Accepting this the top level goal of the
Nimrod MR Mk2 type Equipment Safety Case that
“The aircraft type is deemed acceptably safe to operate and maintain within
specified contexts”
is considered as having been demonstrated as having been achieved.”
(underlined emphasis added)
151.6 There was no mitigation evidence of any sort included in either of the BLSC Reports (contrary to the
requirement set out in Martyn Mahy’s e-mail to the Nimrod IPT dated 24 June 2004 and repeated to the
QinetiQ TRM on 16 July 2004).
151.7 There was no basis upon which QinetiQ could check and satisfy itself that BAE Systems had used
appropriate mitigation evidence to sentence the hazards.
151.8 BAE Systems had failed to complete PDS Task 06-3409 and the sign-off was not appropriate.