The Nimrod Review - Official Documents

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Chapter 21 – New Military Airworthiness Regime Recommendation 21.B.1: The MOD shall clearly identify the three Duty Holders in each Air domain as follows: Top Level: The single Service Chiefs (CNS, 34 CGS, 35 and CAS) shall be appointed the senior (corporate) Duty Holders for the respective aircraft and personnel within their domain. AOA Level: The heads of the AOAs (the three AOCs for the RAF) shall be appointed the (operational) Duty Holders for their respective personnel and platforms who are responsible for the safe employment of the equipment usage. Unit Level: Unit Commanders shall be appointed the (delivery) Duty Holders with operating Airworthiness responsibility for personnel and platforms under their command, and who will report directly to their Aircraft Operating Authority for all ‘Duty Holder’ matters. Recommendation 21.B.2: Each Service shall appoint (a) a Chief Air Engineer to head the self-regulation of Technical Airworthiness in each of the operating authorities and (b) a Senior Operator to head the self-regulation of Operational Airworthiness and Flight Safety. 21.43 For the avoidance of doubt, for Recommendation 21.B.2: As regards (a), the Duty Holder, as the senior operator, will manage operational regulation with his Command and Group Staff, but will necessarily rely on a Chief Air Engineer to govern the self-regulation activity in the Engineering domain, including standards and practices and strategic engineering and support issues that cross platforms. Further, there will be no requirement for the Chief Air Engineer appointed by the AOA to be an Airworthiness Authority as this latter function will be undertaken by the Senior Engineers or their equivalents at Unit/base level, who will be responsible to their duty holder Unit/Base Commanders, and to the Regulator heading the MAA for Airworthiness compliance. Senior Engineers would be given a LOA from the Duty Holder. As regards (b), the Flight Operations/Flight Safety Service Lead will be equivalent to the Chief Air Engineer and will be responsible to the AOA for ensuring the self-regulation of the Operational Airworthiness within the AOA in addition to being the lead for the management/delivery/inspectorate of Flight Safety. Recommendation 21.B.3: Those in Duty Holder posts (Service Chief, AOA and Unit Commanders) shall have Airworthiness responsibility and authority issued by decree by the MAA. When personnel and/ or aircraft are deployed on Operations in Theatre, Service Chief, AOA and Unit Commanders shall retain their Duty Holder responsibilities (only) for those Airworthiness issues which remain under their control. 21.44 For the avoidance of doubt, for Recommendation 21.B.3: (1) When Unit Commanders’ personnel and/or aircraft are deployed on Operations in Theatre, such Unit Commanders shall retain their particular Duty Holder responsibilities, e.g.: (a) to ensure the aircraft are Airworthy to deploy; (b) to ensure the personnel being deployed are sufficiently competent and trained; and (c) for continued airworthiness management (CAMO function); (2) When personnel or aircraft are deployed, the Commander Joint Operations (CJO) and Theatre Commanders will not become designated Duty Holders, but will acquire a Duty of Care for the personnel and aircraft under their command for the time being similar to that of any other commander. Theatre Commanders will also acquire a responsibility for the time being for regulatory compliance exercised through their nominated deployed Operations and Engineering Specialists; (3) The MAA shall provide adequate guidance/direction on the Airworthiness aspects associated with Airworthiness decisions during Operations in Theatre, including setting the broad rules/requirements, e.g. regarding demonstration of having sought specialist In-Theatre Type Airworthiness advice. Such guidance must recognise that Operational Commanders may be required to make operational decisions at short notice in a highly dynamic and intense environment; and (4) The MAA shall also provide adequate guidance/policy on specific Airworthiness responsibilities where UK assets/personnel are commanded by Non-UK Operational Commanders. 34 Chief of Naval Staff. 35 Chief of General Staff. 509
MAA The Nimrod Review Head of the MAA 3-Star 510 (incl. HQ/Policy and Strategy) Operating Airworthiness Regulator 2-Star Service Inquires and MAAIB Technical Airworthiness Regulator 2-Star DE&S AOAs Service Chief Duty Holder CDM AOA Duty Holder AW Risk Register RTS Op Centre Director Safety Case Flight Safety and Flight Operations AOA Chief Engineer Forward Unit Cdr Duty Holder Project Engineer Project Team Type Specific Policy & Regulation Depth Senior Operations CAMO/FHQ Continued Airworthiness Management ( Delivery – ‘within the bounds’) Senior Engineer CAM ‘Setting the Bounds’
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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 Gap between fairi
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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.15 10B.16 Chapter 10B - Nimrod
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10B.31 Bronze Award 10B.32 Chapter
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10B.42 Chapter 10B - Nimrod Safety
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10B.67 10B.68 Chapter 10B - Nimrod
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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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The Nimrod Review (2) ‘Torrent of
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The Nimrod Review (10) ‘Normalisa
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The Nimrod Review 454 who are gover
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The Nimrod Review 456 17.39.3 “It
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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’
Page 469 and 470: The Nimrod Review The ‘organisati
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Page 473 and 474: The Nimrod Review Current position
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Page 481 and 482: The Nimrod Review 480 Meeting / Wor
Page 483 and 484: The Nimrod Review 482 operational t
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Page 489 and 490: The Nimrod Review Four Key Principl
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Page 493 and 494: The Nimrod Review 20.24 20.25 492 S
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 and 502: The Nimrod Review 500 Recommendatio
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Page 525 and 526: The Nimrod Review 21.110 524 The BO
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Page 541 and 542: The Nimrod Review Genesis of Safety
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Page 545 and 546: The Nimrod Review Six Principles fo
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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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