He was on radio this morning expressing as much astonishment as anyone else at the incredible complacency within the MoD, BAE Systems and Qinetiq, that were laid bare in the report published yesterday.
The inquiry by Charles Hatton-Cave, a leading aviation lawyer, is the most damning indictment of institutional failure that anyone in Westminster can remember reading.
Here' s a summary I did for the Herald of its main findings:
THE 14 men who died on board Nimrod XV230 on September 2, 2006 stood no chance of surviving the fireball that consumed their aircraft over Helmand Province.
Before the first onboard fire warning lit up their fate was sealed not by any mistaken action on their own part – indeed they appear to have acted "with calmness, bravery and professionalism" in the face of certain death.
They were killed aboard an ageing aircraft, that was overdue for replacement, by three decades of design mistakes, by complacency in the private support industry responsible for
their safety and by a culture of cost cutting at the MoD that valued business models over old-fashioned airworthiness.
Charles Haddon-Cave, the leading aviation lawyer who wrote the highly critical report, identified "a failure of leadership, culture and priorities" as contributory factors.
The largest loss in a single day for the MoD since the Falklands represented a "systemic breach" of the military covenant of care for the armed forces and devastating failings on the part of the Ministry of Defence, BAe Systems and QinetiQ, he said.
He named 10 individuals five from the MoD, three from BAe Systems and two from QinetiQ who bore responsibility for the "yawning gap between the appearance and the reality of safety" in a system not fit for purpose.
CAUSE OF THE CRASH
The earlier RAF Board of Inquiry and the coroner’s inquest found that the explosion was caused by fuel leaking into a dry bay and igniting on contact with a hot air pipe. Fuel couplings should not have been in the same compartment, the inquest was told. Mr Haddon-Cave said that overspillage from mid-air refuelling may also have been a cause.
Once the fire ignited the crew had no means of tackling the initial flames. They issued a Mayday and attempted an emergency descent to Kandahar air base, but at 3000ft the aircraft exploded, broke into four pieces and hit the ground in 12 seconds. The fire, and the bad design that allowed it to happen, could have been avoided if earlier warnings had not been ignored.
The report noted that design flaws introduced at three stages, each 10 years apart, played a "crucial part" in the loss of XV230. A Nimrod Safety Case, drawn up by BAe Systems with help from Qinetiq, between 2001 and 2005 was meant to identify "potentially catastrophic hazards before they could cause an accident"
SAFETY FAILURES
Mr Haddon-Cave said "failure" or "failings" 24 times in his press briefing.
"Serious design flaws" with the aircraft had "lain dormant for years" his report stated.
"Warnings from as early as 1998 that "the conflict between ever-reducing resources and ... increasing demands, whether they be operational, financial, legislative, or merely those symptomatic of keeping the old ac (aircraft) flying" and that close attention should be paid to safety standards were ignored.
As well as a safety review that was "riddled with errors" the inquiry found there was an assumption by those involved that the Nimrod was safe because it had flown successfully for 30 years.
This contributed to the "general malaise" that fatally undermined safety.
ORGANISATONAL
NEGLIGENCE AT MoD
Mr Haddon-Cave accused the MoD of sacrificing safety to cut costs. The department sustained a "deep organisational trauma" during the strategic defence review from 1998 to 2006 that led to a distraction from airworthiness as the priority. .
Senior officers focused on the priority of achieving the "strategic goal " of a 20% reduction in costs in five years against a backdrop of increased operational demands.
"Airworthiness was a casualty of the process of cuts, change, dilution and distraction commenced by the 1998 strategic review. These failures of leadership and the failure to keep safety at the top of the agenda contributed to the loss of XV230." said Mr Haddon-Cave.
One former senior RAF officer told the inquiry: "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."
Delays in procurement for a replacement for the Nimrod aircraft also contributed.
PEOPLE RESPONSIBLE
The 585-page report singles out 10 people for criticism. Five are from the Ministry of Defence – including two very senior military officers of four-star rank – three from BAe Systems and two from QinetiQ.
At the MOD General Sir Sam Cowan, who has since retired, whose task it was to unite the separate logistics support agencies for the Royal Navy, Army and RAF into a single Defence Logistics Organisation, was criticised for the "Stalinistic efficiency" with which targeted cost cutting by 20% by 2005
He did not give enough thought to the impact of imposing his target and should have realised it
could come at the expense of safety and airworthiness, the report said.
Air Chief Marshal Sir Malcolm Pledger, who has since retired, succeeded Gen Cowan as chief of defence logistics in September 2002 despite later admitting to Mr Haddon-Cave’s review he did not believe he was fully qualified for the job. He was "handed a poisoned chalice" and was torn between delivering the 20% cost savings and supporting the conflicts in Afghanistan and Iraq. That does not save him from criticism,
The report said he should have questioned whether it was "feasible, realistic and sensible" to achieve the 20% goal at the same pace and within the same timescale. "There should, at least, have been pause for thought," the report said.
Air Commodore George Baber and Wing Commander Michael Eagles were slated for accepting the flawed BAe safety case and delegating much of the task to an MoD civil servant Frank Walsh who was "out of his depth" and since retired.
BAe Systems managers Chris Lowe, Richard Oldfield, and Eric Prince bore "primary responsibility" for the company’s failings in relation to the safety case. Mr Haddon-Cave also said defence firm QinetiQ bore a "share of responsibility" for the failure of the Nimrod safety case in not properly carrying out its role as independent adviser.
LESSONS TO
BE LEARNED
Overall, Mr Haddon-Cave said many of the organisational causes for the loss of XV230 echoed other major accidents including the loss of the Space Shuttles Challenger and Columbia, the Zeebrugge ferry disaster, the sinking of the Marchioness and the King’s Cross fire.
He said the MoD was committed to addressing the "numerous weaknesses" in the RAF’s system for ensuring the airworthiness of its aircraft. It has grounded all Nimrods whose engine-bay hot air ducts had not been replaced but the inquiry had found no reason to recommend the grounding of the Nimrod MR2 fleet which is due to come to the end of its service life within months.
The two named RAF officers, who are still in service have been stripped of their responsibilities for safety and the RAF would now consider if any "further action" would be taken against them. A team has been put in place within the MoD to implement the report’s recommendations.
Mr Haddon-Cave concluded: "In my view, XV230 was lost because of a systemic breach of the military covenant brought about by failures on the part of all those involved. This must not be allowed to happen again."
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