Statement by Charles Hadddon-Cave QC
(Source: Nimrod Review; issued Oct. 28, 2009)
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An independent review has found that wholesale failure of MoD, BAE and QinetiQ to do their job, among other factors, led to the mid-air explosion of Nimrod XV230, killing all 14 people on board. (UK MoD photo)1.
I was appointed in December 2007 by the then Secretary of State for Defence, Des Browne MP, to conduct an independent inquiry into the loss of RAF Nimrod XV230, and charged, in particular, with establishing responsibility for any failures and what lessons are to be learned. I have now completed my 20-month inquiry in accordance with my Terms of Reference. I presented my final Report to the current Secretary of State for Defence, Bob Ainsworth MP, yesterday. The Secretary of State laid my Report before Parliament earlier today.
2. Nimrod XV230 was lost on 2 September 2006, whilst on a mission over Helmand Province in Southern Afghanistan, in support of NATO and Afghan ground forces. XV230 suffered a catastrophic mid-air fire, leading to the total loss of the aircraft and the death of all 14 Service personnel on board. Faced with a life-threatening emergency, every member of the crew of XV230 acted with calmness, bravery and professionalism, and in accordance with their training. They had no chance, however, of controlling the fire. Their fate was already sealed before the first fire warning.
3. The loss of the 14 men on board XV230 represented the single biggest loss of life of Service personnel in one incident in theatre since the Falklands War.
4. A sacred and unbreakable duty of care is owed to the men and women of the Armed Forces by reason of the fact that they are necessarily called upon to make substantial personal sacrifices, including the ultimate sacrifice, in the service of the Nation. This duty has found modern expression in the term Military Covenant. The duty, in my view, embraces the whole panoply of measures which it is appropriate the Nation should provide and sustain for Service personnel, including adequate training, suitable and properly maintained equipment, sufficient provisions in theatre and proper support and conditions for Service personnel and their families at home.
5. My Report concludes that the accident to XV230 was avoidable, and that XV230 was lost because of a systemic breach of the Military Covenant brought about by significant failures on the part of the MOD, BAE Systems and QinetiQ. This must not be allowed to happen again.
6. My Report identifies manifold shortcomings in the UK military airworthiness and in-service support regime, and reveals matters which are as surprising as they are disturbing. The wholesale failure of all three organisations involved in the Nimrod Safety Case to do their job, and the apparently inexorable deterioration in the safety and airworthiness regime in the MOD in the period 1998 to 2006 are particularly troubling aspects of the Nimrod XV230 story. There has been a yawning gap between the appearance and reality of safety. The system has not been not fit for purpose.
7. My Report specifically names and criticises 10 individuals for their roles: five from the MOD, three from BAE Systems and two from QinetiQ.
8. I will now summarise some of the key findings of my Report as laid before Parliament.
Physical causes
9. The Board of Inquiry found that the cause of the fire on XV230 was aviation fuel coming into contact with a high temperature ignition source. My Report agrees with the Board of Inquiry that the ignition source was the Cross-Feed/Supplementary Conditioning Pack (SCP) duct in the starboard No. 7 Tank Dry Bay. As regards the fuel source, new evidence (not available to the Board of Inquiry or other agencies) has come to light which points to an overflow during Air-to-Air Refuelling being the most likely fuel source; although a leak from a fuel coupling remains a realistic possibility.
10. Design flaws introduced at three stages played a crucial part in the loss of XV230. First, the original fitting of the Cross-Feed duct by Hawker Siddeley in about 1969. Second, the addition of the SCP by British Aerospace in about 1979. Third, the fitting of a permanent Air-to-Air Refuelling modification by British Aerospace in about 1989. These organisations now form part of BAE Systems.
11. There were a number of previous incidents and warning signs, potentially relevant to XV230, which represented missed opportunities. In particular, the rupture of the SCP duct in Nimrod XV227 in November 2004 should have been a wake up call.
Nimrod Safety Case
12. The best opportunity to capture the serious design flaws in the Nimrod was during the preparation of the Nimrod Safety Case in 2001-2005. The very purpose of a Safety Case is to identify, classify and mitigate potentially catastrophic hazards before they can cause an accident. The Nimrod Safety Case was drawn up BAE Systems (Phases 1 and 2) and the MOD Nimrod Integrated Project Team (Third Phase), with QinetiQ acting as independent advisor. It cost in excess of £400,000.
13. If the Nimrod Safety Case had been drawn up with proper skill, care and attention, the catastrophic fire risks dormant within the Nimrod MR2 fleet would have been identified and dealt with, and the loss of XV230 in September 2006 would have been avoided.
14. Unfortunately, the Nimrod Safety Case was a lamentable job from start to finish. It was riddled with errors. It missed the key dangers. Its production is a story of incompetence, complacency and cynicism. The best opportunity to prevent the accident to XV230 was, tragically, lost.
15. The Nimrod Safety Case process was fatally undermined by a general malaise: a widespread assumption by those involved that the Nimrod was safe anyway (because it had successfully flown for 30 years) and the task of drawing up the Safety Case became essentially a paperwork and tick-box exercise.
16. BAE Systems bears substantial responsibility for the failure of the Nimrod Safety Case. Phases 1 and 2, carried out by BAE Systems were poorly planned, poorly managed and poorly executed, and work was rushed and corners were cut. The end product was seriously defective. There was a big hole in its analysis: BAE Systems had left 40% of the hazards Open and 30% Unclassified. The work was anyway riddled with errors of fact, analysis and risk categorisation. The critical catastrophic fire hazard relating to the Cross-Feed/SCP duct had not been properly assessed and, in fact, was one of those left Open and Unclassified. Further, at handover meetings in 2004, BAE Systems gave the misleading impression to the MOD Nimrod Integrated Project Team (IPT) and QinetiQ that the task had been properly completed and could be signed off. BAE Systems deliberately did not disclose to its customer the scale of the hazards it had left Open and Unclassified, many with only vague recommendations that further work was required). The MOD IPT and QinetiQ representatives were lulled into a false sense of security. These matters raise question marks about the prevailing culture at BAE Systems. The regrettable conduct of some of BAE Systems managers suggests that BAE Systems has failed to implement an adequate or effective culture, committed to safety and ethical conduct. The responsibility for this must lie with the leadership of the Company. Throughout my Review, BAE Systems has been a company in denial.
17. The MOD IPT bears substantial responsibility for the failure of the Nimrod Safety Case. The MOD IPT inappropriately delegated project management of the Nimrod Safety Case task to a relatively junior person without adequate oversight or supervision; failed to ensure adequate operator involvement in BAE Systems work on Phases 1 and 2; failed to project manage properly, or to act as an intelligent customer at any stage; failed to read the BAE System Reports carefully or otherwise check BAE Systems work; failed to follow its own Safety Management Plan; failed properly to appoint an Independent Safety Advisor to audit the Nimrod Safety Case; and signed-off BAE Systems work in circumstances where it was manifestly inappropriate to do so. Subsequently, the MOD IPT sentenced the outstanding risks on a manifestly inadequate, flawed and unrealistic basis, and in doing so mis-categorised the catastrophic fire risk represented by the Cross-Feed/SCP duct as Tolerable when it plainly was not. The MOD IPT was sloppy and complacent and outsourced its thinking. The MOD IPT fundamentally failed to do its essential job of ensuring the safety of the Nimrod fleet.
18. QinetiQ also bears a share of responsibility for the failure of the Nimrod Safety Case. QinetiQ failed properly to carry out its role as independent advisor, and in particular: failed to clarify its role at any stage; failed to check that BAE Systems sentenced risks in an appropriate manner and included risk mitigation evidence in its Reports; sent someone inadequately briefed to the critical handover meeting; failed to read BAE Systems reports or otherwise check BAE Systems work properly; failed to advise its customer properly or ask any intelligent questions at the key handover meetings; and subsequently signed-off BAE Systems work in circumstances where it was manifestly inappropriate to do so: in particular, without even having read any of the BAE System reports and contrary to relevant military regulations and standards. QinetiQs approach was fundamentally lax and compliant. QinetiQ failed at any stage to act as the independent conscience of the MOD IPT.
Organisational causes
19. Organisational causes played a major part in the loss of XV230, adversely affecting the ability of the MOD IPT to do its job, the oversight to which it was subject and the culture within which it operated, during the crucial years when the Nimrod Safety Case was being prepared, in particular 2001-2004. The MOD suffered a sustained period of deep organisational trauma between 1998 and 2006, beginning with the 1998 Strategic Defence Review. Financial pressures and cuts drove a cascade of multifarious organisational changes which led to a dilution of the airworthiness regime and culture within the MOD and distraction from vital safety and airworthiness issues as the top priority. There was a shift in culture and priorities in the MOD towards business and financial targets, at the expense of functional values such as safety and airworthiness. The Defence Logistics Organisation, in particular, came under huge pressure. Its primary focus became delivering change and the change programme and achieving the (so-called) Strategic Goal of a 20% reduction in output costs in five years and other financial savings.
20. This was against a backdrop of dramatically increased operational demands as a result of the conflicts in Afghanistan and Iraq.
21. Airworthiness was a casualty of the process of cuts, change, dilution and distraction commenced by the 1998 Strategic Defence Review; organisational pressures, weaknesses and failures were a significant cause of the loss of XV230; the failures were both a failure of leadership, and collective failures to keep safety and airworthiness at the top of the agenda, despite the torrent of change during the period 1998 to 2006. As one former Senior RAF Officer said to the Review: There was no doubt that the culture at the time had switched. In the days of [the RAF Chief Engineer in 1990s] you had to be on top of airworthiness. By 2004, you had to be on top of your budget, if you wanted to get ahead.
22. Poor Procurement practices have created bow waves of deferred financial problems, the knock on effects of which have been visited on In-Service Support, with concomitant change, confusion, dilution and distraction as occurred in the post-Strategic Defence Review period . The Procurement history of the replacement for the Nimrod MR2 fleet, called the Nimrod 2000 but subsequently re-named Nimrod MRA4, has been one of continuous delays and cost over-runs. But for the delays in the Nimrod MRA4 replacement programme, XV230 would probably no longer have been flying in September 2006. The day before his resignation on 5 June 2009, the immediate past Secretary of State for Defence, John Hutton MP, stated in the House of Commons that ...we have no choice but to act with urgency on Procurement.
Aftermath
23. A large number of steps have been taken post-XV230 in relation to the Nimrod fleet to address the Board of Inquiry Recommendations and other maintenance and airworthiness issues which have since been revealed by subsequent incidents and investigations. I have been kept closely informed of all such developments and, pursuant to my Terms of Reference, would have issued an immediate interim report if, at any stage, a matter of concern had come to my attention which I felt affected the immediate airworthiness of the Nimrod fleet or safety of its crews. I have not felt it necessary to issue an interim report.
Lessons and Recommendations
24. There are, however, profound and wide-ranging lessons to be learned from the loss of Nimrod XV230. Many of the lessons are not new. The organisational causes of the loss of Nimrod XV230 echo those of other major accidents, in particular the loss of the Space Shuttle Columbia, and cases such as the Herald of Free Enterprise, the Kings Cross Fire and the Marchioness Disaster.
25. The shortcomings in the current airworthiness system in the MOD are manifold. They include:
(1) a failure to adhere to basic Principles;
(2) a Military Airworthiness System that is not fit for purpose;
(3) a Safety Case regime which is ineffective and wasteful;
(4) an inadequate appreciation of the needs of Aged Aircraft;
(5) a series of weaknesses in the area of Personnel;
(6) an unsatisfactory relationship between the MOD and Industry;
(7) an unacceptable Procurement process leading to serial delays and cost over-runs;
(8) a Safety Culture that has allowed business to eclipse Airworthiness.
26. My Report has accordingly made Recommendations in the following eight key areas:
(1) A new set of Principles: I have recommended adherence to four key principles: Leadership, Independence, People and Simplicity.
(2) A new Military Airworthiness Regime: I have made detailed and comprehensive recommendations under 10 headings comprising a blueprint to enable the MOD to build a New Military Airworthiness Regime under the control of an independent Military Airworthiness Authority. The new regime must be effective, relevant and understood, must properly address Risk to Life, and must drive new attitudes, behaviours and a new Safety Culture. The aim of my Recommendations is that:
-- The new Military Airworthiness Authority will bring coherence and governance to the currently fragmented regulatory structure.
-- Airworthiness regulation will no longer be a part time job, or lack top-level leadership.
-- There will be clarity as to who holds ultimate Airworthiness responsibility.
-- Airworthiness Duty Holders will be properly supported.
-- There will be proper training in Airworthiness regulation.
-- The concept of Airworthiness will be properly understood.
-- Regulations will be readable and usable.
-- Mandatory reporting will be properly managed and overseen.
-- Accident investigations will be independent and effective and assisted by a new Military Air Accident Investigation Branch.
-- Important Airworthiness roles and disciplines previously lost will be restored: Chief Engineer, Flight Safety Inspectorate and rigorous compliance Audits.
(3) A new approach to Safety Cases: I have made recommendations for best practice for Safety Cases for the future, which are to be brought in-house, re-named Risk Cases and made more focused, proportionate and relevant.
(4) A new attitude to Aged Aircraft: I have recommended that generic problems associated with aged and legacy aircraft are addressed.
(5) A new Personnel Strategy: I have recommended that current weaknesses in the area of personnel are addressed, in particular strengthening the ability of the MOD to act as an intelligent customer.
(6) A new Industry Strategy: I have recommended that flaws in the current bilateral and triangular relationships between the MOD, BAE Systems and QinetiQ revealed by the Nimrod Safety Case are addressed.
(7) A new Procurement Strategy: I have recommended that Bernard Grays Report on Procurement be published without delay and appropriate action taken as a matter of urgency. (It should be noted that Mr Grays Report was in fact suddenly published on 15 October 2009).
(8) A new Safety Culture: I have made recommendations for a new Safety Culture.
27. I welcome the setting up of the MOD Haddon-Cave Implementation Team to implement the Recommendations in my Report as rapidly as possible.
28. I recognise that some of the matters revealed in my Report may come as a shock, both to members of the public and to many of those in the Services and the organisations concerned. But my Report should not herald a collective, or individual, loss of confidence by the public or those within the Services or Defence Industry generally, or a reluctance to shoulder responsibility in the future. Indeed, quite the opposite. The important point is that the facts leading to the loss XV230 have now been investigated and examined carefully and have yielded numerous lessons and truths. Many of these lessons and truths may be unwelcome, uncomfortable and painful; but they are all the more important, and valuable, for being so. It is better that the hard lessons are learned now, and not following some future catastrophic accident.
29. Tragically, for the crew of XV230, the lessons have come too late, and at an infinite price. The most fitting memorial to the loss of the crew of XV230 will be that the lessons from their sacrifice are truly learned, and the Recommendations set out in my Report are fully implemented. I believe that my Recommendations will immeasurably strengthen safety for the future.
Charles Haddon-Cave QC
28 October 2009
http://www.defense-aerospace.com/articles-view/release/3/109468/%E2%80%9Cwholesale-failures%E2%80%9D-by-mod%2C-bae%2C-qinetiq-led-to-nimrod-loss.html
Full report (587 pages in PDF format) on the The Stationery Office website.
http://www.official-documents.gov.uk/document/hc0809/hc10/1025/1025.pdf
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