The Nimrod Review - Official Documents

20.17
Chapter 20 – New Principles
“If reliability and safety are preached as “organizational bumper stickers”, but leaders constantly
emphasize keeping on schedule and saving money, workers will soon realize what is deemed important
and change accordingly. Such was the case with shuttle program.” (Brigadier General Duane W. Deal,
USAF, 2004) 13
“In hindsight, the Panel believes that if [the Chief Executive] had demonstrated a comparable leadership
and commitment to process safety, that leadership and commitment would likely to have resulted
in a higher level of process safety performance in BP’s U.S. refineries.” (Report of BP U.S. Refineries
Independent Safety Review Panel, January 2007).
“[T]he real fault lies, as Shakespeare noted, in ourselves, the leaders of the business. Businesses are
the product and the extension of the personal characteristics of its leaders - the lengthened shadows
of the men and women who run them.” (Donald Keough, former Chief Executive of Coca-Cola, Ten
Commandments of Business Failure, pages 8-9).
“Generally speaking, organisations behave and teams behave in the way that their management,
immediate boss, does, this dictates culture. So if you have a boss in a bank who likes to take risks, his
staff will take risks. ...And you end up with a culture of risk.” (Witness L [QinetiQ], Safety Engineer,
2009)
The present case of Nimrod XV230 is no different. The fundamental failure was a failure of Leadership. As
preceding Chapters have shown, lack of Leadership manifested itself in relation to the way in which the Nimrod
Safety Case was handled, in the way in which warning signs and trends were not spotted, and in relation to
inexorable weakening of the Airworthiness system and pervading Safety Culture generally. For these reasons,
Leadership is a key principle for the future.
✓ Independence
20.18 Principle of Independence: There must be thorough independence throughout the regulatory regime,
in particular in the setting of safety and airworthiness policy, regulation, auditing and enforcement.
20.19
20.20
20.21
A fundamental weakness of the MOD Airworthiness and regulatory system in the past decade has been the
lack of independence. This lack of regulatory independence is manifest in two major respects. First, the lack
of truly independent regulatory oversight. Second, the number of people throughout the Support and Front
Line organisations who are dual-hatted, having to combine and reconcile conflicting Airworthiness and Output
duties. This is manifestly unsatisfactory.
The notion of the independent Regulator, setting policy and regulations, carrying out audits and enforcement,
is key to ensuring that the orthogonal values of Safety and Airworthiness are preserved. This is all the more
required in the military context where the pressures and conflicts on time, attention and resources are often so
acute.
As has been pointed out:
“It is important that that regulation is truly independent of operation.” (Rupert Britton, Legal Advisor
to CAA, 14 2008)
✓ People (not just Process and Paper)
20.22 Principle of People: There must be much greater focus on People in the delivery of high standards of
Safety and Airworthiness (and not just on Process and Paper).
20.23
The MOD Airworthiness and regulatory system has become increasingly process-driven and process-reliant. The
amount of process has burgeoned exponentially. Compliance with Process and Paper has been at the expense
of People.
13 Member of Columbia Accident Investigation Board, ASPI article ‘Beyond the Widget’, 2004.
14 Civil Aviation Authority.
491