The Nimrod Review - Official Documents

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Chapter 21 – New Military Airworthiness Regime Recommendation 21.A.12: The MAA shall be the higher authority for all mandatory reporting, with the Operating Centre Directors and AOAs’ action addressees responsible for coordinating all mandatory reporting. The MAA shall have the authority to provide specific direction in the form of an Airworthiness Directive (AD) requiring immediate or particular Airworthiness management action. Recommendation 21.A.13: The MAA shall put in place appropriate arrangements which permit Duty Holders in the AOAs to go beyond the bounds of the RTS to meet specific operational requirements where time constraints preclude the issue of a change to the RTS. Such arrangements will need to encompass the need for engineering officers in the Forward domain and IPTs to make appropriate Airworthiness decisions without recourse to the MAA (in effect, such decisions will need to be deemed to be ‘approved data’ and be subsequently recognised by the approved maintenance organisations in Depth). This will be achieved by issuing Letters of Authority (LOA) to the engineering officers required to make such decisions. Recommendation 21.A.14: The MAA shall have a team of skilled surveyors who shall undertake regular compliance audits similar to those undertaken by the CAA on civil operators, such MAA audits being over and above any self-regulation undertaken by the Equipment and AOAs operating authorities themselves. Recommendation 21.A.15: The MAA shall undertake a specific ‘flight safety inspectorate’ role in furtherance of its Flight Operations regulatory (i.e. assurance) function, with the actual delivery and deployment of Flight Safety being the responsibility of the respective AOAs (i.e. ensurance). Recommendation 21.A.16: The MAA shall be the Authority and sponsor for all Airworthiness regulatory training, tailored for the specific Airworthiness responsibilities and posts. Recommendation 21.A.17: There shall be a direct two-way line of communication (by-passing the usual chain of command) between the responsible engineers employed in Airworthiness posts and the Regulator for all Airworthiness matters. 13 Recommendation 21.A.18: The definition of “Airworthiness” in JSP553 should be clarified and the Australian model of the three tenets of “Airworthiness” should be adopted, i.e.: (a) Operational Airworthiness (“ensures that aircraft are operated in their approved roles, with the right equipment, by competent operators”); (b) Technical Airworthiness (“ensures that the design, manufacture and maintenance processes provide platforms which can perform safely in their intended roles and environment”); and (c) Flight Safety (“is concerned with the human performance and operation within acceptable levels of risk”). 14 Recommendation 21.A.19: “Letters of Delegation” shall be redrafted and renamed “Letters of Airworthiness Authority” (LOAA) in a simple form to make it clear that: (a) Airworthiness is a separate and discrete area of responsibility; and (b) the grant of Airworthiness authority is not an abrogation of responsibility for Airworthiness by the delegator. Recommendation 21.A.20: Non-executives from the CAA and HSE shall be appointed to the MAA Board and shall have express responsibility to watch for and report, annually, on the MAA’s independence from financial, political and operational pressures. Recommendation 21.A.21: Suitable forums and mechanisms shall be established whereby the MAA can regularly discuss common issues with the CAA and the HSE, and use the good offices of the CAA and HSE to help develop and monitor the MAA’s Regulatory and Airworthiness policy, implementation, skills and knowledge. 13 A similar arrangement is used in the management of Defence Nuclear safety. 14 ‘Operational Airworthiness in the ADF’, September 2007 Air Vice Marshal J.N Blackburn, AO, ADF Operational Airworthiness Regulator. 501
The Nimrod Review 502 Head of the MAA 3-Star (incl. HQ/Policy and Strategy) Operating Airworthiness Regulator 2-Star Service Inquires and MAAIB Technical Airworthiness Regulator 2-Star Regulation Operating AW OF5 Assurance Operating AW OF5 Authority RTS 1-Star DAATM 1-Star Regulation Technical AW 1-Star Assurance Technical AW OF5 Authority Technical AW 1-Star Approvals & Flt test OF5 Mandatory Reporting Fig. 21.1 MAA Organogram
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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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2.45 2.46 Chapter 2 - History of th
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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 64
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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 5.123 5.124 5.125
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The Nimrod Review 5.134 102 The ave
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The Nimrod Review 5.145 5.146 104 T
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The Nimrod Review 5.155 5.156 106 T
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The Nimrod Review 108 6. I have con
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The Nimrod Review 6.6 110 this inta
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The Nimrod Review Analysis 6.19 112
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The Nimrod Review 6.28 114 limitati
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The Nimrod Review 6.40 116 Impingem
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The Nimrod Review 6.44 6.45 118 The
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The Nimrod Review 6.60 6.61 6.62 6.
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The Nimrod Review 6.72 Cognisant of
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The Nimrod Review 6.83 126 on its o
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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 7.10 136 Followin
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The Nimrod Review 7.20 138 When XV2
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The Nimrod Review 7.39 142 combinat
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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 8.23 154 Again, e
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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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9.7 9.8 Chapter 9 - Background to S
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Guiding Principles of Lord Cullen
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9.22 9.23 Chapter 9 - Background to
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Military Regulation of Safety Cases
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9.44 Chapter 9 - Background to Safe
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9.52 9.53 9.54 Chapter 9 - Backgrou
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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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10A.39 10A.40 Chapter 10A - Nimrod
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Worksheets 10A.60 10A.61 10A.62 Cha
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10A.66 10A.67 10A.68 10A.69 Chapter
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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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10A.172 10A.173 10A.174 Chapter 10A
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Switch in strategy for meeting Chap
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Chapter 10B - Nimrod Safety Case: T
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10B.31 Bronze Award 10B.32 Chapter
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10B.75 10B.76 “Change 17 Mar 2005
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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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11.85 11.86 Chapter 11 - Nimrod Saf
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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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(3) Erroneous or poor mitigation an
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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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Joint working group never set up Ch
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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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Failure to ask intelligent question
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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 2007: formation o
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The Nimrod Review 12.33 12.34 12.35
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The Nimrod Review 356 ‘change’
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The Nimrod Review 358 (2) Demise of
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The Nimrod Review 13.4 13.5 13.6 13
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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 McKinsey recommen
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The Nimrod Review 13.44 ‘CUTS’
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The Nimrod Review 13.54 370 13.53.1
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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 13.83 376 lines (
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The Nimrod Review (2) Increased ope
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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 Chief Engineer RA
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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 13.148 392 apex,
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The Nimrod Review 13.158 394 (4) Fe
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The Nimrod Review 13.169 396 with A
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The Nimrod Review Evidence of Nimro
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The Nimrod Review 13.188 13.189 Con
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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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CHAPTER 16 - INQUEST Contents Chapt
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Chapter 16 - Inquest 16.4.2 Second,
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PART VI: LESSONS AND RECOMMENDATION
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The Nimrod Review 446 (7) A new Pro
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The Nimrod Review NASA Space Shuttl
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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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Page 489 and 490: The Nimrod Review Four Key Principl
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Page 495 and 496: The Nimrod Review 494 (8) Mandatory
Page 497 and 498: The Nimrod Review 496 I. Clarificat
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Page 501: The Nimrod Review 500 Recommendatio
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Page 521 and 522: The Nimrod Review 520 Recommendatio
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Page 525 and 526: The Nimrod Review 21.110 524 The BO
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Page 545 and 546: The Nimrod Review Six Principles fo
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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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