RAF Nimrod air crash investigation delivers devastating verdict

http://www.theguardian.com/uk/2009/oct/28/nimrod-crash-inquiry-blames-mod

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On 2 September 2006, RAF Nimrod XV230, with 14 crew members on board, was on a routine reconnaissance mission over Helmand province in Afghanistan, looking out for insurgents.

It crashed shortly after a catastrophic fire broke out on board when it had been refuelled in mid-air. Faced with a dire emergency, every member of the crew of the 37-year-old aircraft acted with calmness, bravery and professionalism, but they had no chance of controlling the fire. "Their fate was sealed before the first fire warning," today's report concludes.

The devastating 586-page report, published amid apologies from the government and dismay from families of the lost men, suggests the aircraft was doomed years earlier by lamentable and systemic failings on the part of senior individuals and leading corporations, compounded by the MoD sacrificing safety to cut costs.

The independent report names 10 individuals in the MoD, defence company BAE Systems, and QinetiQ – the privatised defence technology company – for their role in a catalogue of serious and avoidable errors which culminated in the biggest single loss of life of service personnel since the Falkands war in 1982.

Charles Haddon-Cave QC, asked by Des Browne, the then defence secretary, to investigate the Nimrod's long and troubled history, describes the way the "safety case" carried out between 2001 and 2005 – intended to identify potential problems – was "a lamentable job from start to finish". It represented the best opportunity to discover the "serious design flaws in the Nimrod which had lain dormant for years". Yet it was "riddled with errors", Haddon-Cave says. "Its production is a story of incompetence, complacency, and cynicism". It was "fatally undermined by a general malaise: a widespread assumption that the Nimrod was 'safe anyway' because it had successfully flown for 30 years".

If the safety exercise had been drawn up with proper skill and attention, says the report, then the fire risks involved in air-to-air refuelling and the placement of a pipe – a design fault introduced in 1969 – would have been avoided.

BAE Systems bore "substantial responsibility" for the failure of the safety case, the report says, and the exercise was "poorly managed and poorly executed, work was rushed and corners were cut".

In damning criticism of Britain's largest defence and arms company, Haddon-Cave says that question marks remain about BAE Systems' prevailing culture. He adds: "The regrettable conduct of some of BAE Systems' managers suggests [it] 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."

In 2004, the report notes, BAE Systems gave "the misleading impression" to MoD officials and QinetiQ about the assessment of the hot air piping system, whose potentially dangerous fixture was the immediate cause of the fire. The company "deliberately did not disclose to its customer the scale of the hazards", says the report.

Also to blame, says Haddon-Cave, were the financial pressures and "deep organisational trauma" within the MoD between 1998 and 2006, sparked by the 1998 strategic defence review, which led to a "cascade" of organisation changes and "a dilution of the airworthiness regime and culture within the MoD".

The report quotes a former senior RAF officer: "There was no doubt that the culture of the time had switched. In the days of the RAF chief engineer in the 1990s, you had to be on top of airworthiness. By 2004 you had to be on top of your budget to get ahead."

Pressures on the MoD occurred against the backdrop of greatly increased demands as a result of the conflicts in Iraq and Afghanistan. Yet the failures were those "both of leadership, and collective failures to keep safety and airworthiness at the top of the agenda despite the torrent of change …"

Among the shortcomings identified in the MoD are "a failure to adhere to basic principles", an "airworthiness system that is not fit for purpose", a "safety case regime which is ineffective and wasteful", "an inadequate appreciation of the needs of aged aircraft", "an unsatisfactory relationship between the MoD and industry", and "an unacceptable procurement process leading to delays and cost overruns".

Had the project for a new, advanced Nimrod reconnaissance aircraft not been subjected to continuous delays, XV230 "would probably no longer have been flying in September 2006", says the report.

The MoD team responsible for overseeing the Nimrod project failed to follow its own safety plan, signed off on BAE Systems' work when it was manifestly inappropriate to do so, and judged the outstanding risks on a "manifestly inadequate, flawed, and unrealistic basis". It was "sloppy and complacent" and "fundamentally failed to do its essential job of ensuring the safety of the Nimrod fleet," says the report.

QinetiQ, too, bore a share of responsibility for the failure of the safety hazard investigation into the Nimrod: it failed properly to carry out its role as an independent adviser and failed to check BAE Systems' conclusions properly, it says.

In a further passage severely damaging to the government, Haddon-Cave says: "In my view XV230 was lost because of a systemic breach of the military covenant brought about by significant failures on the part of all those involved. 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."