From SKYbrary Wiki
The Haddon-Cave Report
The Loss of Nimrod XV230
On 2 September 2006, a Nimrod aircraft, being operated over Afghanistan by the UK Royal Air Force, caught fire shortly after air-to-air refuelling (AAR) had taken place and crashed after a loss of control caused by the effects of the fire. All 14 of occupants of the aircraft were killed. Although the loss occurred in a military operational theatre, it was not related in any way to the military task being undertaken except insofar as the immediate origin of the accident was the AAR.
RAF Board of Inquiry
In accordance with standard procedures, an RAF Board of Enquiry was convened and found that the most probable physical cause of the loss of the aircraft was “the escape of fuel during Air-to-Air Refuelling (AAR)” after which the fuel was ignited by “contact with an exposed element of the aircraft’s Cross-Feed/Supplementary Cooling Pack (SCP) duct”.
The Nimrod Review
An Independent Review of the broader issues surrounding the loss of the aircraft was subsequently ordered by UK Secretary of State for Defence and was announced on 4 December 2007 with the following Terms of Reference:
In light of the Board of Inquiry report to:
- Examine the arrangements for assuring the airworthiness and safe operation of the Nimrod MR2 in the period from its introduction in 1979 to the accident on 2 September 2006, including hazard analysis, the safety case compiled in 2005, maintenance arrangements, and responses to any earlier incidents which might have highlighted the risk and led to corrective action;
- Assess where responsibility lies for any failures and what lessons are to be learned;
- Assess more broadly the process for compiling safety cases, taking account of best practice in the civilian and military world;
- Make recommendations to the Secretary of State as soon as practicable, if necessary by way of interim report.
London barrister Charles Haddon-Cave QC, who had considerable prior experience of leading major Public Inquiries, was appointed to lead the Review.
It was not found necessary to publish an Interim Report and the Final Report was published on 28 October 2009. It was sub titled “A Failure of Leadership, Culture and Priorities”. It confirmed that the loss of the aircraft had nothing to do with either the flight crew, or any other front line personnel, but was attributable entirely to gross failures in the organisational and safety culture of the senior management who had been responsible for the aircraft type being accepted as fit for operations.
Whilst the analysis provided in the Review was made in a UK military context and a prevailing regulatory model that at the time bore little resemblance to the corresponding practices in civil aviation, it was recognised that the principle findings were readily transferable to such operations. The Review therefore became essential reading for those seeking to understand why organisational cultures must embrace operational safety in a meaningful way.
The Review focuses primarily on:
- the comprehensive inadequacies of the ‘Nimrod Safety Case’ which was carried out in the period 2001- 2005, and which resulted in the continued operation of the aircraft type.
- the organisational origins of poor operational safety oversight at the UK Ministry of Defence, including:
- No clear break in organisational responsibilities resulting in conflicts of interest between operational delivery and commercial pressures to make programme savings;
- Airworthiness becoming a part-time function; and
- Loss of technical skills within the organisations charged with assuring Airworthiness
- missed opportunities to learn from lesser incidents which had occurred prior to the accident
The Review notes that many of the organisational causal factors which it has identified are not new and “echo those of other major transport accidents” in particular:
- the loss of the Space Shuttle Columbia in 2003
- the loss of the Herald of Free Enterprise (a ferry which sank after it departed Zeebrugge in 1987)
- the Kings Cross Fire (at a large London Underground railway station in 1987)
- the Marchioness Disaster (a pleasure boat which sank on the River Thames in London in 1989 after colliding with another boat)
- BP Texas City, 2005.
The Recommendations of the Review included the need for:
- A new Safety Culture
- A new approach to Safety Cases
- A new attitude to Aged Aircraft
- A new Procurement Strategy
- A new Military Airworthiness Authority
Unlike a Civil Aircraft Accident Investigation under ICAO Annex 13 provisions, this Review attributes blame for loss to a series of named organisations and individuals “whose conduct (in the view of the author of the Review) fell well below the standards which might reasonably have been expected of them at the time, given their rank, roles and responsibilities”. The author of the Review also states that “I have only named and criticised organisations and individuals where, in my view, it is necessary, fair, proportionate and in the public interest to do so”.
- Organisational Culture
- Safety Culture
- SMS Organisational Structure
- Safety Management System
- Risk Assessment
- Safety Assurance
- Safety Accountabilities and Responsibilities
- Acceptable Level of Safety
- Hazard Identification
- NIM, vicinity Kandahar Afghanistan, 2006
- An Independent Review into Broader Issues Surrounding the Loss of the RAF Nimrod MR2 Aircraft XV230 Review by Charles Haddon-Cave QC
- Investigation into the Kings Cross Underground Fire UK Department of Transport 1988
- UK Marine Accident Investigation Board Report into the loss of the ferry ‘Herald of Free Enterprise’ in 1987