The Nimrod Review - Official Documents

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PART VI: LESSONS AND RECOMMENDATIONS “The only source of knowledge is experience” (Albert Einstein, 1879-1955) Part VI – Lessons and Recommendations 1. The lessons to the learned from the loss of Nimrod XV230 are profound and wide-ranging. 2. Many of the lessons to be learned are not new. The organisational causes of the loss of Nimrod XV230 echo other major accident cases, in particular the loss of the Space Shuttles Challenger and Columbia, and cases such as the Herald of Free Enterprise, the King’s Cross Fire, the Marchioness Disaster and BP Texas City (see Chapter 17). 3. Those involved in Military Aviation Airworthiness would benefit from an understanding of Accident Theory (see Chapter 18). 4. The shortcomings in the current airworthiness system within the MOD are manifold (see Chapter 19). 5. I have found: (1) a failure to adhere to basic Principles; (2) a Military Airworthiness System that is not fit for purpose; (3) a Safety Case regime which is ineffective and wasteful; (4) an inadequate appreciation of the needs of Aged Aircraft; (5) a series of weaknesses in the area of Personnel; (6) an unsatisfactory relationship between the MOD and Industry; (7) an unacceptable Procurement process, leading to serial delays and cost over-runs with a baleful effect on In-service Support; and (8) a Safety Culture that has allowed ‘business’ to eclipse Airworthiness. 6. In my view, wide-ranging reform and a sea-change in attitudes and approach is required in order to address the deficiencies revealed by Nimrod XV230 and the subsequent investigations by the Review. 7. I make Recommendations in the following eight key areas: (1) A new set of Principles (see Chapter 20). (2) A new Military Airworthiness Regime (see Chapter 21). (3) A new approach to Safety Cases (see Chapter 22). (4) A new attitude to Aged Aircraft (see Chapter 23). (5) A new Personnel Strategy (see Chapter 24). (6) A new Industry Strategy (see Chapter 25). 445
The Nimrod Review 446 (7) A new Procurement Strategy (see Chapter 26). (8) A new Safety Culture (see Chapter 27). 8. I also make a number of further Recommendations (see Chapter 28). 9. The ultimate aim of this Report is to improve Safety and Airworthiness for the future. 10. The duty of those in authority reading this Report is to bring about, as quickly as possible, the muchneeded and fundamental improvements for the future which I have identified. This is not only for the safety of the men and women in the Services most immediately at risk, but also for the benefit of the effectiveness of Defence generally. 11. A safe and airworthy fleet is a more capable and effective fleet.
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THE NIMROD REVIEW An independent re
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© Crown Copyright 2009 The text in
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THE LOSS OF RAF NIMROD XV230 A FAIL
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XV230
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2 The Nimrod Review Section Two: Re
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Chapter 1 - Introduction and Summar
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The Nimrod Review Offices and Team
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Executive Summary Introduction Loss
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Chapter 1 - Introduction and Summar
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Coroner’s Inquest Chapter 1 - Int
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Chapter 2 - History of the Nimrod A
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2.8 2.9 Chapter 2 - History of the
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Nimrod 2000/MRA4 2.23 2.24 Chapter
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CHAPTER 3 - THE BOARD OF INQUIRY RE
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Chapter 3 - The Board of Inquiry Re
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Chapter 3 - The Board of Inquiry Re
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3.22 Chapter 3 - The Board of Inqui
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PART II: PHYSICAL CAUSES
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The Nimrod Review 36 (2) The escape
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The Nimrod Review 40 7. The Cross-F
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The Nimrod Review 56 (3) Inadequate
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The Nimrod Review 78 5.27 to have b
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The Nimrod Review 80 of one second,
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The Nimrod Review 82 Maintenance re
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The Nimrod Review 84 Ignition/Leak
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The Nimrod Review 86 Fuselage Leaks
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The Nimrod Review 88 would generate
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The Nimrod Review 92 The Manufactur
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The Nimrod Review 94 The Procuremen
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The Nimrod Review 98 5.111 Comment
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The Nimrod Review Analysis 6.19 112
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The Nimrod Review Causation general
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The Nimrod Review 6.113 132 of fuel
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The Nimrod Review 134 Causation 9.
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The Nimrod Review Introduction 8.1
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The Nimrod Review 8.44 158 It is no
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PART III: NIMROD SAFETY CASE Introd
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CHAPTER 9 - BACKGROUND TO SAFETY CA
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Guiding Principles of Lord Cullen
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Military Regulation of Safety Cases
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The Safety Committees and Hazard Ma
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Chronology - three phases 10A.8 Cha
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Chapter 11 - Nimrod Safety Case: An
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Introduction Background - Chapters
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Review’s audit of the Pro-Formas
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PART IV: ORGANISATIONAL CAUSES
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The Nimrod Review Conclusion on MOD
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Page 415 and 416: PART V: AFTERMATH Introduction to P
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The Nimrod Review 496 I. Clarificat
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MAA The Nimrod Review Head of the M
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The Nimrod Review 520 Recommendatio
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The Nimrod Review Recommendations E
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The Nimrod Review 21.110 524 The BO
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The Nimrod Review 22.12 Third, Safe
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The Nimrod Review Genesis of Safety
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The Nimrod Review 546 (2) Common se
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The Nimrod Review 554 not represent
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The Nimrod Review 23.35 556 I consu
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The Nimrod Review Lesson Learned -
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The Nimrod Review Conclusions 25.16
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The Nimrod Review Professor Reason
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The Nimrod Review Safety Managers 2
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The Nimrod Review The critical role
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The Nimrod Review 29.6 XV230 29.7 5
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The Nimrod Review FI Fatigue Index
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ACKNOWLEDGEMENTS Acknowledgements A
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