The Nimrod Review - Official Documents

PART IV: ORGANISATIONAL CAUSES
Part IV: Organisational Causes
“The organizational causes of this accident are rooted in … history and culture, …years
of resource constraints, fluc tuating priorities, schedule pressures, …. Cultural traits
and organizational practices detrimental to safety were allowed to develop, including:
reliance on past success as a substitute for sound engineering practices …; organizational
barriers that prevented effective communication of critical safety information and stifled
professional differences of opinion; lack of integrated management across program
elements; and the evolution of ... informal ... decision-making pro cesses that operated
outside the organization’s rules.…” (Columbia Accident Investigation Board Report,
Volume 1, Chapter 1, page 9)
Introduction to Part IV
1. The organisational causes of the loss of XV230 are rooted in the history and culture of the
organisations in the MOD responsible for the in-service support and airworthiness of RAF aircraft.
2. Huge organisational changes took place in the In-Service support and airworthiness arrangements
for Defence equipment and RAF aircraft in the years prior to the loss of XV230. There were three
major themes at work: (a) a shift from organisation along purely ‘functional’ to project-oriented
lines; (b) the ‘rolling up’ of organisations to create larger and larger ‘purple’ 1 and ‘through-life’
management structures; and (c) ‘outsourcing’ to industry (see Chapter 12).
3. A Nimrod Airworthiness Review Team Report in 1998 warned of “the conflict between everreducing
resources and ... increasing demands; whether they be operational, financial, legislative,
or merely those symptomatic of keeping an old ac flying”, and called for Nimrod management that
was “highly attentive” and “closely attuned to the incipient threat to safe standards”, in order to
safeguard the airworthiness of the fleet in the future. 2 These warnings were not sufficiently heeded
in the following years (see Chapter 13).
4. In fact, the MOD suffered a sustained period of deep organisational trauma between 1998 and
2006 due to the imposition of unending cuts and change, which led to a dilution of its safety
and airworthiness regime and culture and distraction from airworthiness as the top priority (see
Chapter 13).
5. These organisational causes adversely affected the ability of the Nimrod IPT to do its job and the
oversight and culture in which it operated during the crucial years when the Nimrod Safety Case
was being prepared, in particular 2001-2004.
6. The serial delays in the In-Service Date of the replacement Nimrod 2000/MRA4 programme have
had a malignant effect on In-Service Support for the MR2 (Chapter 14).
7. The history of Procurement generally in the MOD has been one of years of major delays and cost
over-runs. This has had a malignant effect on In-Service Support and safety and airworthiness
generally. Poor Procurement practices have helped create ‘bow waves’ of deferred financial
problems, the knock on effects of which have been visited on In-Service Support, with concomitant
change, confusion, dilution and distraction, as occurred in the post-Strategic Defence Review period
1998 to 2006 (Chapter 14).
1 Also called ‘Jointery’ i.e. in the merging of single service organisations into tri-service ‘purple’ organisations. See further Chapters 12 and 13.
2 Nimrod Airworthiness Review Team Report, dated 24 July 1998, paragraphs 13 and 30.
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