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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
pearl jewelry 2001 and 2005, the flaw was not discovered.
“The
Nimrod safety case was a 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
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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 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
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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 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.”