The Nimrod Review - Official Documents

CHAPTER 16 – INQUEST
Contents
Chapter 16 covers the Inquest and answers the following questions:
Summary
What, in law, is the true nature of an Inquest?
What evidence relevant to the Review emerged from the Inquest?
Chapter 16 – Inquest
Was the Coroner’s narrative verdict regarding the source of the fuel for the fire on XV230 correct?
Was the Coroner’s Rule 43 recommendation justified?
1. A Coroner’s Inquest is essentially a limited factual inquiry into the circumstances leading to the loss
of life.
2. The Inquest, in fact, produced little factual evidence of value to the Review.
3. The Coroner’s finding as to the likely source of fuel did not accord with the realistic probabilities, or
the evidence before him.
4. The Coroner’s Rule 43 recommendation (that the Nimrod fleet should be grounded pending certain
repairs) was based on his misunderstanding of the meaning of ALARP.
5. I have found nothing to justify the Coroner’s widely-publicised remark that the MOD had a “cavalier
approach to safety”. The fundamental problems are ones of structure, culture and procedure, not
indifference (see Chapter 19).
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