The Nimrod Review - Official Documents

The Nimrod Review
15.38
15.39
424
In keeping with its previous completion estimates, BAE Systems failed to achieve this deadline.
A further meeting at RAF Kinloss in March 2009 began the process of distributing the zonal and functional
Pro-Formas to stakeholders such as front line operators and QinetiQ. This process continued over the ensuing
months, with no real evidence of progress being achieved.
The new Pro-Forma
15.40
15.41
15.42
15.43
Pursuant to the Review’s request (and, it has to be said, after displaying some considerable reluctance to do
so), BAE Systems provided draft copies of some of the restructured Zonal Hazard Pro-Formas, as they existed as
at 1 July 2009. In particular, the Review was provided with, and duly read, copies of the Pro-Formas pertaining
to Hazard H73 (No. 7 Tank Dry Bay/Zone 614). In the draft versions of the new Pro-Formas, Hazard H73 was
identified as having eight potential causes, each one having its own zonal analysis Pro-Forma. As an example,
I discuss below the Pro-Forma relating to Cause NM/Z143; this describes the potential for fuel and hot air to
interact and cause a fire or explosion.
The original Zone 514/614 Pro-Forma ran to seven pages and included all potential causes of fire and explosion
in the No. 7 Tank Dry Bay. As already noted, there were significant weaknesses in the structure and analysis of
the original Pro-Formas. Turning to the new Pro-Forma, NM/Z143 is only one of eight individual ‘causes’ and
consists of 23 pages. All of the Pro-Formas for the eight causes together total over 100 pages. Unfortunately,
the growth in size has not been matched with an improvement in clarity. On the contrary, the current size
and structure of the Pro-Formas have served to create a dense, almost impenetrable document. In an attempt
to provide a discrete audit trail, there is a great deal of unnecessary repetition and minutiae. Each Pro-Forma
records in minute detail the thoughts, analysis and recommendations of the reviewing engineer, again much to
the detriment of clarity. This sort of defensive engineering, which appears to have more to do with protecting
the back of engineer in question than with genuinely improving the safety of the aircraft, is most unhelpful. It
is also, in my view, detrimental to safety because it: (a) serves to submerge and obscure the real points under a
welter of unnecessary detail; and (b) distracts operator manpower from its vital day-to-day work because they
have to spend an inordinate amounts of time reading and checking the material in question when they could
be otherwise better occupied.
It was disturbingly evident even from the few drafts provided to the Review that some of the weaknesses
from the original NSC had migrated into the new documents. For instance, there was evidence of a ‘cut and
paste’ mentality which is perhaps an inevitable consequence of endless repetition in a long series of very similar
documents. Rather worryingly, there were also factual errors, which although seemingly minor, have resulted in
much labour for those front line operators and the IPT charged with the duty of reviewing the draft Pro-Formas.
Examples of these errors are :
a. Hazard H68 Cause Z320 describes the potential for fire to be caused by the interaction of fuel and electrical
components. One of the indications of a fuel leak is given as possible loss of engine performance. Hazard
68 Cause Z322 describes the potential for fire to be caused by interaction of hydraulic fluid and electrical
components. It goes on, however, to describe that one of the indications of a hydraulic fluid leak would be
loss of engine performance; this is not true as hydraulics do not determine or affect engine performance.
Virtually all other paragraphs in these two proformas are identical apart from the words “fuel” and
“hydraulics”. They are both (an inordinate) 13 pages long.
b. Hazard H46 Cause Z209, the potential for fire caused by interaction of hot air and electrical systems, is
related to the No. 6 tank fuel compartment. Unfortunately, it wrongly describes the location of the tail
anti-icing delivery pipe as being on both the port side and the starboard side of the compartment.
The latter error may appear small but is indicative of a lack of real familiarity with the airframe, as this would be
instantly spotted by any front-line operator. The former is of concern as it is buried within the dense, 13 page
structure, should have been easily recognisable as a ‘silly typo’, and has obviously occurred due to a cut and
paste operation being completed without proper thought or proof reading. Neither inspire confidence in the