Posted by
jiezi236 on Tuesday, December 15, 2009 1:01:40 AM
There had been signs before the disaster that the Nimrod MR2, of which
aircraft XV230 was one, had design faults, notably the juxtaposition of
fuel pipes with hot-air ducts which presented a “catastrophic fire
risk”. Mr Haddon-Cave said new evidence had revealed that fuel had
overflowed into a dry tank during air-to-air refuelling. But when BAE
Systems carried out a safety review between 2001 and 2005, the flaw was
not discovered.
“The Nimrod safety case was a
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lamentable job from start to finish,” the report said. “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.” Mr Haddon-Cave said the
Nimrod safety review was “fatally undermined by a general malaise: a
widespread assumption by those involved that the Nimrod was ‘safe
anyway’ (because it had flown successfully for 30 years) and the task
of drawing up the safety case became essentially a paperwork and
‘tick-box’ exercise”.
The MoD announced in March that any
Nimrod that had not had its hot-air duct removed — the perceived design
fault identified in the RAF’s board of inquiry report in December 2007
— would not be flown until the work was done. An RAF spokesman said all
11 Nimrod MR2s at RAF Kinloss in Morayshire and three MR1s at RAF
Waddington in Lincolnshire had now had the air ducts removed. No Nimrod
is flying in Afghanistan. Mr Haddon-Cave said of those on the aircraft:
“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.”
If the Nimrod safety case by BAE Systems,
monitored by QinetiQ, had been drawn up “with proper skill, care and
attention, the catastrophic fire risks dormant within the
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Nimrod MR2 fleet would have been identified and dealt with, and the
loss of XV230 in September 2006 would have been avoided”, Mr
Haddon-Cave said.
He likened the organisational causes to
those of other disasters, in particular the loss of the Space Shuttle
Columbia in 2003, the sinking of the ferry Herald of Free Enterprise in
1987, the King’s Cross Underground station fire in 1987 and the
Marchioness riverboat’s sinking in 1989.
Poor procurement
practices had damaging effects. The Nimrod MR2 should have been
replaced by the Nimrod MRA4, but the programme had been delayed. “But
for the delays in the Nimrod MRA4 replacement programme, XV230 would
probably no longer have been flying in September 2006,” Mr Haddon-Cave
said.
A former RAF officer had told his inquiry: “There
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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 if you
wanted to get ahead.”