Coroner Delivers Scathing Indictment of UK Nimrod Fleet, ProceduresOct 29, 2009 15:26 UTC by Defense Industry Daily staff
On Sept 3/06, an RAF Nimrod MR2 sea control aircraft was flying near Kandahar, Afghanistan, using its advanced sensors and long endurance in support of NATO ISAF forces on land. The aircraft moved to take on additional fuel from an aerial tanker, in order to remain on station longer. That’s when the trouble began. Alerts soon began to sound, and the crew remained professional and businesslike as they steered their ailing plane toward Kandahar for an emergency landing. They never arrived. RAF Nimrod #XV230 exploded in mid-air over Afghanistan, killing all 14 crew members.
Britain’s Nimrod sea control aircraft fleet first entered service in 1969. In the aftermath of the inquests and inquiries that have followed the September 2006 explosion, however, serious questions have been raised concerning the Nimrod’s fleet’s ongoing fitness, and the measures taken to maintain these aging aircraft.
The problems have continued to pile up for the RAF. Beyond a scathing coroner’s report, a set of High Court filings by the UK MoD admit to failures in the RAF’s duty of care. Those are weighty legal words, and now an official independent review has delivered its verdict…
- Nimrod #XV230: What the Coroner Said
- Updates and New Developments
Nimrod #XV230: What the Coroner Said
An RAF Board of Inquiry had already delivered a December 2007 report which declared that ageing components and lack of fire suppressants on board were among the “contributory factors” to the accident. In response to a perceived dearth of answers from official channels, however, some of the parents began to undertake investigations of their own. Graham Knight’s son was Sgt. Benjamin “Tapper” Knight, XV230′s Weapons Systems Operator on that fateful day. Knight was one of the leading figures, and spent over a year carrying out his own investigations into the matter, filing freedom of information requests, and acting as an advocate for all of the bereaved families.
According to Graham Knight, BAE Systems had recommended installing fire detection systems in the serving fleet 2 years before the accident. He also claims to have emails from high-ranking officers detailing problems with fuel leaks from December 2005 to February 2006. He is quoted as saying that:
“Since launching my investigations I have had a lot of people contact me from the RAF and MoD. There are so many people within the organizations who are not happy with what has been going on.”
Some of that emerged at the inquest. Nimrod engineer Sgt. Andrew Whitmore testified that he had discovered a “quite shocking” level of corrosion in the couplings which were used to join the fuel pipe to the point where they had to be sawn off rather than unscrewed. Sgt. Whitmore told the inquest that he had reported that matter, but a complete check of the Nimrod fleet only took place after the September 2006 crash.
Even so, Wing Commander John Bromehead told the inquest that he was not told in the months before the tragedy about increased levels of fuel leaks on Nimrod aircraft. Sgt. Mark Wallington, who supervised maintenance for the Nimrods operating in southern Afghanistan, said the same.
Assistant deputy coroner for Oxfordshire Andrew Walker, who led the inquest, is calling for the entire Nimrod fleet to be grounded. His report is not official, and cannot compel official action. Nevertheless, its May 2008 verdict is scathing:
“The crew and passengers were not to know that this aircraft, like every other aircraft within the Nimrod fleet, was not airworthy. What is more, the aircraft was, in my judgment, never airworthy from the first release to service in 1969 to the point where the Nimrod XV 230 was lost.”
“…I have given the matter considerable thought and I see no alternative but to report to the secretary of state that the Nimrod fleet should not fly until the Alarp [as low as reasonably practicable] standards are met.”
He also called for cockpit voice recorders to be fitted to all aircraft, and for the RAF’s board of inquiry to be replaced by Civil Aviation Authority investigations.
The UK MoD does not have to comply with these recommendations. In an MoD release, the RAF’s Chief of Materiel (Air) Sir Barry Thornton says they will continue to fly the planes, with some changes:
“With respect to the airworthiness of the aircraft today, we have stopped air-to-air refuelling and no longer use the very hot air systems in flight. This eradicates any dangers from the serious design failures noted by the Coroner that have been present in this aircraft since the 1980s. These measures have been supplemented with enhanced aircraft maintenance and inspection procedures to ensure the aircraft, as it is today, is safe to fly. In addition, to ensure we can operate the aircraft safely until its planned retirement from service, we have in place an effective package of more permanent measures which are being progressed as quickly as practicable.”
See also: UK MoD statement | UK MoD Board of Inquiry RE: Nimrod MR2 XV230 | The Scotsman | The Times | The Guardian | Isle of Man newspapers (IOMToday) | In The News UK | The Telegraph lists and describes the crew killed.
Updates and New Developments
Oct 30/09: It certainly looks like legal action is in the works. Defence Management reports that:
“The families are considering making corporate manslaughter charges against BAE Systems and QinetiQ, the companies responsible for delivering and maintaining the Nimrod… Another relative said his lawyers had described one MoD compensation offer as “ludicrous” and an insult, especially for the families where children were involved. The MoD is said to have offered around [GBP] 1m to some of the families on condition that they don’t make any further claims.”
Oct 29/09: QinetiQ announces that its CEO will be stepping down, effective Nov 30/09. Current CEO Graham Love will remain a consultant to the Group on the huge British Defence Training Rationalisation (DTR) project, but will be replaced by Leo Quinn as CEO. The Haddon-Cave report is mentioned nowhere in QinetiQ’s news release.
Oct 28/09: The Haddon-Cave independent review is published. It places special emphasis on the failure of the GBP 400,000 safety case work undertaken by BAE ad QinetiQ in 2001-2005, but does not exempt the UK MoD from criticism by any means. Key conclusion?
“My Report concludes that the accident to XV230 was avoidable, and that XV230 was lost because of a systemic breach of the Military Covenant brought about by significant failures on the part of the MOD, BAE Systems and QinetiQ. This must not be allowed to happen again… My Report identifies manifold shortcomings in the UK military airworthiness and in-service support regime, and reveals matters which are as surprising as they are disturbing. The wholesale failure of all three organisations involved in the Nimrod Safety Case to do their job, and the apparently inexorable deterioration in the safety and airworthiness regime in the MOD in the period 1998 to 2006 are particularly troubling aspects of the Nimrod XV230 story. There has been a yawning gap between the appearance and reality of safety… My Report specifically names and criticises 10 individuals for their roles: five from the MOD, three from BAE Systems and two from QinetiQ.”
He identifies 8 basic shortcomings of the present system, and makes a number of proposals for reform. Those shortcomings include:
“(1) a failure to adhere to basic Principles;
(2) a Military Airworthiness System that is not fit for purpose;
(3) a Safety Case regime which is ineffective and wasteful;
(4) an inadequate appreciation of the needs of Aged Aircraft;
(5) a series of weaknesses in the area of Personnel;
(6) an unsatisfactory relationship between the MOD and Industry;
(7) an unacceptable Procurement process leading to serial delays and cost over-runs;
(8) a Safety Culture that has allowed ‘business’ to eclipse Airworthiness.”
In response, Britain’s Defence Secretary Bob Ainsworth offers that rarest of modern phenomena, a straightforward and full apology:
“I am grateful to Mr Haddon-Cave who has provided a rigorous and powerful report… On behalf of the MOD and the Royal Air Force, I would like to again say sorry to all the families who lost loved ones. I am sorry for the mistakes that have been made and that lives have been lost as a result of our failure… Mr Haddon-Cave also states that in our pursuit of financial savings the MOD and the RAF allowed their focus on safety to suffer. We accept this with regard to the Nimrod XV230. As a department we have a duty to continue to seek efficiencies in how we deliver defence. However I am absolutely clear that this must not be done with any detriment to safety.”
A similar apology was forthcoming from BAE Systems. Ainsworth adds that despite weaknesses in the Nimrod’s airworthiness systems and procedures, in light if acton taken since, neither the report nor the MoD’s findings raise any concern over the airworthiness of individual fleets, and the RAF’s the Chief of the Air Staff and Defence Chief Airworthiness Engineer (a new post) have both assured him that the Nimrods remain safe to fly under the new processes. According to the MoD, aerial refueling is still stopped, Nimrods are not flying until their engine bay hot air ducts have been replaced, aircraft maintenance and inspection have been stepped up, and an Ageing Aircraft Systems Audit has been put in place, including a forensic-level inspection of a Nimrod model.
The report is poorer news for 2 serving RAF officers who were strongly criticized in its contents. They had been moved to staff posts with no responsibility for safety and airworthiness, but the RAF is now considering further action. BAE and QinetiQ have a different issue, and may have busy legal teams in the near future, even under Britain’s reasonable “English Rule” for tort law. “The Nimrod Review: an independent review into the broader issues surrounding the loss of the RAF Nimrod MR2 aircraft XV230 in Afghanistan in 2006 report” [full text, PDF] | UK MoD | BAE Systems | Defence Management.
May 31/09: The Telegraph reports that after XV230 crashed, Squadron Leader Guy Bazalgette retrieved a file that was set to be impounded because he needed it to run his detachment. He has now admitted to a follow-on inquest then decided that some of the documents within the file, known as the “stopped press folder,” should be destroyed and had them shredded. The squadron leader insists that none of the documents were relevant to the investigations, but admitted:
“They should not have been shredded and it was my fault that they were.”
The independent inquiry led by senior lawyer Charles Haddon-Cave, QC is set to issue its report slightly late, in late October 2009.
March 30/09: In response to a lawsuit filed in Britain’s High Court by the families of the families of Sgt. Benjamin Knight and Flight Lt. Steven Swarbrick, UK MoD papers concede that “The aircraft was not airworthy… The defendant owed to the deceased a duty of care and the accident was caused by this breach of that duty of care.”
The ministry has reportedly paid undisclosed compensation to some of the families of those killed, but this case claims that the RAF breached the men’s right to life under the Article 2 of the European Convention on human Rights, cites health and safety legislation, and makes a general claim for negligence. The UK MoD is continuing to contesting the human rights claim, fearing that it could set a precedent. Lawyers for relatives of some of the 10 servicemen killed when their C-130 Hercules transport plane was shot down in Iraq in 2005 are reportedly preparing a similar claim. The Telegraph.
Sept 14/08: The Sunday Times reports that the RAF sat on 2 internal reports and refused their release to the inquest. One was an internal investigation into a very similar crash, which came to conclusions that were very similar to the coroner’s XV230 crash report.
“By the time the inquest took place, it had been signed off by three separate officers, including the station commander at the aircraft’s base at RAF Kinloss in Scotland.”