The Nimrod Review - Official Documents

The Nimrod Review
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16 The Coroner’s Rule 43 recommendation , that the Nimrod fleet should be grounded, was the result of a
misunderstanding by him of the meaning of the term ALARP (As Low As Reasonably Practicable). The ‘R’ in
ALARP has a temporal element: a reasonable time is allowed to implement appropriate measures to mitigate
identified risks. If this were not the case, few commercial or military aircraft would ever fly. (See generally
Chapter 9).
I have conducted a detailed and wide-ranging investigation lasting many months, including interviewing
hundreds of witnesses and examining thousands of documents. I have found nothing to justify the Coroner’s
(widely-publicised) remark that the MOD had a “cavalier approach to safety”. 17 Nor, in my judgment, was there
anything before him to justify such a remark. 18 The problem is not indifference to safety. The problem is the
numerous systemic shortcomings in the MOD’s safety and airworthiness structure, culture and procedure which
need addressing. (See generally Chapters 19 to 28).
The difficulties arising from inquests running in parallel to inquiries was highlighted in 1987 by Mr Desmond
Fennell QC in his Report into The King’s Cross Underground Fire. 19 Reform of the ‘arcane’ Coroner’s system
was recommended by Sir Anthony Clarke in 2001 in his Report into the identification issues following The
Marchioness Disaster. 20 A Draft Coroners Bill was published by the Government in June 2006. The Government
announced its intention to bring forward the Coroners Bill in the Queen’s Speech in December 2008. This long
overdue reform is to be welcomed.
16 Rule 43 of the Coroners Rules provides: “A Coroner who believes that action should be taken to prevent the recurrence of fatalities similar to that
in respect of which the inquest is being held may announce at the inquest that he is reporting the matter in writing to the person or authority who
may have power to take such action and he may report the matter accordingly.”
17 Coroner’s narrative verdict, 23 May 2008, page 49, second paragraph.
18 See, in particular, his misunderstanding of ‘ALARP’.
19 The Investigation into the King’s Cross Underground Fire (Cm 499) by Mr Desmond Fennell QC (p. 141).
20 Report of the Public Inquiry into the Identification of Victims Following Major Transport Accidents (Cm 5012) by the Rt. Hon. Lord Justice Clarke,
dated March 2001.