The Nimrod Review - Official Documents

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CHAPTER 20 – NEW PRINCIPLES Contents “Rules are not necessarily sacred, principles are.” (Franklin D. Roosevelt, 1882-1945) Chapter 20 identifies the key principles for an effective airworthiness system. Summary 1. It is important to identify the right principles and always to be guided by them. Chapter 20 – New Principles 2. In my view, the key principles for helping assure and ensure an effective safety and airworthiness regime in the future are four-fold: ✓ ✓ ✓ ✓ Leadership Independence People (not just Process and Paper). Simplicity 487
The Nimrod Review Four Key Principles Introduction 20.1 20.2 20.3 488 “Perfect wisdom has four parts, viz. wisdom, the principle of doing things aright; justice, the principle of doing things equally in public and private; fortitude, the principle of not flying danger, but meeting it; and temperance, the principle of subduing desires and living moderately.” (Plato, 428 BC-348 BC). It is important, in any sphere of life, to identify the right principles and then to be guided by them. In the complex world of high-risk technologies, there are a myriad of forces competing for time, attention and resources. This is nowhere more true than in the world of modern Military Aviation. Designing, maintaining and operating heavier-than-air machines remains one of man’s most complex technological achievements. The boundaries of aviation technology continue to be pushed. In the Military Aviation context, the overriding imperatives of achieving the military mission, the need to be able to operate towards the edges of the safety ‘envelope’, and the vicissitudes of modern warfare, add layers of complexity to an already difficult equation. Most aviation organisations worth their salt espouse safety and airworthiness as their ‘highest priority’ and enunciate ‘principles’ to which they profess adherence. Translating these laudable aspirations into a practical reality, however, is easier said than done. Current policy, principles and definitions 20.4 The Safety Management Policy of the Secretary of State for Defence is expressed as follows: “I expect the Ministry of Defence and the Armed Forces, in their organisation and processes, to ensure that in the acquisition of material and equipments of all kinds, safely and environmental management begins at the requirement definition stage and is carried forward through service to disposal. This includes all aspects of maintenance and operation.” 1 20.5 The Secretary of State requires: “that the airworthiness arrangements for military aircraft should be at least as effective as those for civil aircraft contained in the [Air Navigation Orders], and should comply with the [Health & Safety at Work Act 1974] where relevant. This is particularly important in roles that are paralleled in civil operations, such as where passengers are carried.” 2 20.6 The current Military definition of Airworthiness is: “The ability of an aircraft or other airborne equipment or system to operate without significant hazard to aircrew, ground crew, passengers (where relevant) or to the general public over which such airborne systems are flown.” 3 20.7 In the MOD, those in receipt of Type Airworthiness Authority delegated authority are required to: “Ensure that airworthiness-related processes, functions and activities are: completed to accepted standards, performed by competent individuals, accomplished by approved organisations [and] undertaken using accepted procedures”. 4 20.8 1 JSP815. 5 6 The ‘Four Pillars’ of Airworthiness in the MOD are expressed as: Use of Competent People (by means of the Design Approved Organisation Scheme (DAOS), the Maintenance Approved Organisation Scheme (MAOS) and assessment of MOD staff to whom Letters 2 JSP553, paragraph 1.15. 3 Military definition of ‘airworthiness’, JSP553, Change 5, Notes to Users, paragraph 2. 4 AD(Air Systems), D&MSD. Presentation to the Nimrod Review, April 2008. 5 DE&S. 6 AD(Air Systems), D&MSD. Presentation to the Nimrod Review, April 2008.
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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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2.37 Chapter 2 - History of the Nim
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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 38 because Nimrod
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The Nimrod Review 40 7. The Cross-F
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The Nimrod Review 42 Addition of SC
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The Nimrod Review 44 No. 7 Tank Dry
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The Nimrod Review 46 4.17 4.18 Tria
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The Nimrod Review 48 4.24 Figure 4.
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The Nimrod Review 50 Shrouds 4.32 b
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The Nimrod Review 52 4.36 This conf
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The Nimrod Review 54 4.42 Gaps 4.43
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The Nimrod Review 56 (3) Inadequate
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The Nimrod Review 58 (1) Breach of
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The Nimrod Review 60 4.64 4.65 4.66
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The Nimrod Review 62 4.72 4.73 haza
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The Nimrod Review 66 Prevailing App
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The Nimrod Review 68 18. Targeted f
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The Nimrod Review 70 Figure 5.3: Ni
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The Nimrod Review 72 Description of
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The Nimrod Review 74 Figure 5.8: Fu
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The Nimrod Review 76 5.17 determine
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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 90 5.75 5.76 5.77
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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 96 Contractual ch
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The Nimrod Review 98 5.111 Comment
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The Nimrod Review 108 6. I have con
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The Nimrod Review Analysis 6.19 112
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The Nimrod Review 6.44 6.45 118 The
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The Nimrod Review 6.72 Cognisant of
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The Nimrod Review 6.96 128 I have c
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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 7.47 Causation 14
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The Nimrod Review 7.53 Dealing with
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The Nimrod Review 7.67 Conclusion 1
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The Nimrod Review Introduction 8.1
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The Nimrod Review 156 or destructio
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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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9.44 Chapter 9 - Background to Safe
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White Booklet 9.67 Chapter 9 - Back
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Philosophy of the SMP 9.72 9.73 Cha
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The Safety Committees and Hazard Ma
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Chapter 9 - Background to Safety Ca
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CHAPTER 10A - NIMROD SAFETY CASE: T
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Chapter 10A - Nimrod Safety Case: T
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Chronology - three phases 10A.8 Cha
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10A.19 Chapter 10A - Nimrod Safety
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Worksheets 10A.60 10A.61 10A.62 Cha
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DCP 0221.jpg DCP 0312.jpg Chapter 1
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8 May 2003: Third PSWG Meeting 10A.
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1 March 2004: BAE Systems strategy
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Initial ‘pro-forma’ template to
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June 2004: slow progress on zonals
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Fire & Explosion Report completed C
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Chapter 10B - Nimrod Safety Case: T
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Chapter 11 - Nimrod Safety Case: An
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Criticism of individuals Chapter 11
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Introduction Background - Chapters
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(2) BAE Systems failed to carry out
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Sketchy details and inadequate phot
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Delays resulted 11.51 Chapter 11 -
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11.61 Chapter 11 - Nimrod Safety Ca
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Primary sentencing source was MRA4
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Purpose of meeting 11.77 Dilemma 11
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Ethics 11.95 Causation 11.96 Chapte
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Review’s audit of the Pro-Formas
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‘Zone 7.23’ Chapter 11 - Nimrod
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(3) Leaving the NSC task incomplete
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Detailed analysis and criticisms of
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George Baber’s lack of care and a
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(8) QinetiQ was too compliant and e
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PART IV: ORGANISATIONAL CAUSES
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The Nimrod Review 342 6.2 1994-1999
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The Nimrod Review 344 Figure 12.2:
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The Nimrod Review 12.9 IPTs 346
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The Nimrod Review ‘Partnering’
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The Nimrod Review 358 (2) Demise of
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The Nimrod Review 13.14 362 In my v
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The Nimrod Review 13.23 De-layering
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The Nimrod Review 13.44 ‘CUTS’
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The Nimrod Review 372 or organisati
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The Nimrod Review ‘Reduction in o
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The Nimrod Review Realpolitik 13.10
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The Nimrod Review DLO Business Plan
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The Nimrod Review 13.126 AD(Eng)Pol
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The Nimrod Review 388 D Tech AD(Eng
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The Nimrod Review Conclusion on MOD
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The Nimrod Review Evidence of Nimro
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The Nimrod Review 402 5. The immedi
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The Nimrod Review 2003: ISD ‘slip
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The Nimrod Review 14.16 14.17 406 F
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The Nimrod Review 14.25 408 forces
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The Nimrod Review Conclusion 14.30
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PART V: AFTERMATH Introduction to P
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Chapter 15 - BOI Recommendations an
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15.8 Chapter 15 - BOI Recommendatio
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Fuel Seal Replacement Programme 15.
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The Process 15.32 15.33 Chapter 15
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The Cost 15.44 15.45 Chapter 15 - B
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Appendix A to Chapter 15 AIRCRAFT:
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Serial Recommendations Status Numbe
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Serial Recommendations Status Numbe
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Page 461 and 462: The Nimrod Review Introduction 18.1
Page 463 and 464: The Nimrod Review 462 The three yea
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Page 467 and 468: The Nimrod Review 466 ‘Bow Tie’
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The Nimrod Review 538 22.16.1 First
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The Nimrod Review Genesis of Safety
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The Nimrod Review Six Principles fo
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The Nimrod Review 546 (2) Common se
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The Nimrod Review Life Extension Pr
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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 24.12 562 nor per
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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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