The Nimrod Review - Official Documents

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Figure 5.4: Nimrod Fuel Venting System Chapter 5 – Leak from Fuel Coupling The starboard No. 7 Tank Dry Bay 71
The Nimrod Review 72 Description of Fuel Couplings 5.5 5 The Nimrod fuel system contains approximately 400 fuel couplings, of which the majority are of the FRS type. The remaining 66 are Avimo couplings. Both FRS and Avimo couplings have been in existence for many years and are widely used in aerospace applications. 6 FRS coupling 5.6 An FRS coupling is shown below (see Figure 5.5). It consists of an inner and outer metal sleeve, a flexible rubber seal, two split collars, two circlips and a locking wire (not shown in the diagram). The elastomeric seal is used to create a pressure-tight seal between two pipes. The seal is chamfered at each end and has moulded grooves which fit over a bead formed near the end of each fuel pipe. The split collars are fitted at each end of the seal and retained by circlips. Assembly is completed by screwing together the inner and outer metal sleeves, after which the locking ring is applied. Each sleeve has a shoulder formed at one end, which abuts the outer face of the adjacent split collar, thus applying pressure to the split collar (and hence the elastomeric seal) to ensure an effective joint. The most recent Declaration of Design and Performance for the FRS 110 coupling notes that the maximum pipe angle deflection for the installation is 1º. 7 Figure 5.5 shows an FRS coupling prior to assembly, while Figure 5.6 portrays an FRS coupling assembled. The elastomeric seals are currently manufactured from a Nitrile Series 4 compound (Series 1 Polysulphide rubber “Thiokol” was used until 2004, 8 but this material is now obsolete). Split Collar and Circlip Fuel Seal Inner and Outer Metal Sleeves Figure 5.5: FRS Coupling Assembly (parts shown separated) 5 Used to connect pipes to other pipes, and pipes to fuel tanks. 6 FRS couplings were fitted to Spitfires, Lancasters and Vulcans; and the original patent for the Avimo Original coupling dates back to the 1930s. 7 Eaton DDP-FRS110-Series-1, dated 7 June 2007. The original Declaration of Design and Performance issued in 1968 likewise stated under the heading of ‘Special Limitations’ “Maximum pipe deflection 1° in any direction with or without axial pipe restraint.” See XV230 BOI Report Exhibit 75. 8 Change of material notified at FR-HiTemp Service Information Letter SIL/CS/1/03 9.
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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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Page 71 and 72: The Nimrod Review 66 Prevailing App
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Page 97 and 98: The Nimrod Review 92 The Manufactur
Page 99 and 100: The Nimrod Review 94 The Procuremen
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Page 103 and 104: The Nimrod Review 98 5.111 Comment
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Page 107 and 108: The Nimrod Review 5.134 102 The ave
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Page 117 and 118: The Nimrod Review Analysis 6.19 112
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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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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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10A.39 10A.40 Chapter 10A - Nimrod
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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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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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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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The Nimrod Review 21.152 532 nd I w
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The Nimrod Review 22.12 Third, Safe
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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 22.27 22.28 542 T
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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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