The Nimrod Review - Official Documents

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POSMS Project Oriented Safety Management System PSWG Project Safety Working Group PUS Permanent Under Secretary RPO Resident Project Officer RTI Routine Technical Instruction RTO Resident Technical Officer RTS Release to Service RTSA Release to Service Authority SCP Supplementary Cooling Pack SFR Serious Fault Report SMO Safety Management Organisation SMP Safety Management Plan SMS Safety Management System STI Special Technical Instruction TAA Type Airworthiness Authority TLB Top Level Budget TLM Through Life Management TRM Task Review Meeting UOR Urgent Operational Requirement Glossary 583
The Nimrod Review 584
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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 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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The Nimrod Review Introduction 18.1
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The Nimrod Review 462 The three yea
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The Nimrod Review 466 ‘Bow Tie’
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The Nimrod Review The ‘organisati
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The Nimrod Review 18.38 470 1 Accid
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The Nimrod Review Current position
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The Nimrod Review (6) There is a bi
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The Nimrod Review 476 by the IPT an
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The Nimrod Review 478 trails’ rat
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The Nimrod Review 480 Meeting / Wor
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The Nimrod Review 482 operational t
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The Nimrod Review 484 19.34.16 ”A
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The Nimrod Review Four Key Principl
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The Nimrod Review 20.12 20.13 490 1
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The Nimrod Review 20.24 20.25 492 S
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The Nimrod Review 494 (8) Mandatory
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The Nimrod Review 496 I. Clarificat
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The Nimrod Review 498 issues person
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The Nimrod Review 500 Recommendatio
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The Nimrod Review 502 Head of the M
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The Nimrod Review 504 Defence Airs
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The Nimrod Review 506 those who are
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The Nimrod Review 21.37 Paragraph 6
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MAA The Nimrod Review Head of the M
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The Nimrod Review 512 will also mai
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The Nimrod Review 21.59 21.60 Objec
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The Nimrod Review 21.80 21.81 Objec
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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 21.119 526 in a p
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The Nimrod Review 21.129 21.130 Obj
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The Nimrod Review 530 provide overs
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Page 535 and 536: The Nimrod Review Introduction 22.1
Page 537 and 538: The Nimrod Review 22.12 Third, Safe
Page 539 and 540: The Nimrod Review 538 22.16.1 First
Page 541 and 542: The Nimrod Review Genesis of Safety
Page 543 and 544: The Nimrod Review 22.27 22.28 542 T
Page 545 and 546: The Nimrod Review Six Principles fo
Page 547 and 548: The Nimrod Review 546 (2) Common se
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Page 553 and 554: The Nimrod Review Life Extension Pr
Page 555 and 556: The Nimrod Review 554 not represent
Page 557 and 558: The Nimrod Review 23.35 556 I consu
Page 559 and 560: The Nimrod Review Lesson Learned -
Page 563 and 564: The Nimrod Review 24.12 562 nor per
Page 567 and 568: The Nimrod Review Conclusions 25.16
Page 573 and 574: The Nimrod Review Professor Reason
Page 575 and 576: The Nimrod Review Safety Managers 2
Page 577 and 578: The Nimrod Review The critical role
Page 579 and 580: The Nimrod Review 578
Page 581 and 582: The Nimrod Review 29.6 XV230 29.7 5
Page 583: The Nimrod Review FI Fatigue Index
Page 587: ACKNOWLEDGEMENTS Acknowledgements A
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