Author: Charles Haddon-Cave

Publisher: Stationery Office

Published: 2009-10-28

Total Pages: 591

ISBN-13: 9780102962659

On 2 September 2006, RAF Nimrod XV230 was on a routine mission in southern Afghanistan when she suffered a catastrophic mid-air fire, leading to the total loss of the aircraft and the death of the 12 crew and two mission specialists on board. An RAF Board of Inquiry (2007) concluded that the loss was caused by a fuel escape and its ignition by contact with an exposed element of the Cross-Feed/Supplementary Cooling Pack (SCP) duct. The Nimrod Review was set up to examine the arrangements for ensuring airworthiness and safe operation of the Nimrod MR2, to assess where responsibility lies for any failure and what lessons are to be learned. The Review concludes the most likely source of fuel was an overflow during air-to-air refuelling and agrees with the ignition source. It highlights design flaws introduced at three stages in the life of XV230, and failure to heed previous potentially relevant incidents. The Nimrod safety case drawn up between 2001 and 2005 is found to be error-strewn and incompetent and characterised by a general malaise, an assumption that the Nimrod was safe because it had flown for 30 years. The Review criticises BAE Systems, the MoD Nimrod Integrated Project Team, QinetiQ and individual personnel from those organisations involved in the safety case. Organisational causes are also identified: in-service support for equipment; major organisational changes between 1998 and 2008; and delays in procurement of the Nimrod MRA4 replacement. Lessons to be learned are profound and wide-ranging. Recommendations are made for a new approach in eight key areas: principles (leadership, independence, people, simplicity); the airworthiness regime; safety cases; aged aircraft; personnel strategy; industry strategy; procurement; safety culture. The loss of XV230 was avoidable and a systemic breach of the Military Covenant.