'Nimrod' - Kandahar's Safety Lesson
It's 15 years since the Nimrod accident in Afghanistan - a plane crash that still reminds us of the need to maintain focus on good safety engineering. Indeed, it demands that we do so.
The Nimrod accident
As news of Afghanistan’s plight continues to dominate the airwaves, my mind inevitably turns to one of the many sacrifices made by British military forces to liberate that country from the Taliban. Today is the 15th anniversary of the fatal crash of RAF Nimrod XV230. On 2 September 2006, its fourteen member crew were on a routine reconnaissance mission over Helmand province, looking out for insurgents. Shortly after re-fueling in mid-air, a catastrophic fire broke out. The pilot attempted a rapid descent but the plane exploded before he could land. The accident was the biggest single loss of life of British military personnel since the Falklands War.
The investigation
The report of the subsequent investigation by Charles Haddon-Cave QC concluded that the plane’s fate was sealed before the first fire warning. The underlying hazard was integral to the design of the plane:
XV230 was lost because of a fire which broke out in an inaccessible part of the aircraft which had no fire protection…The crew had no chance of controlling this fire. It quickly spread and led to the mid-air break-up of the airframe, tragically only minutes before the crew could make an emergency landing at Kandahar airfield…The cause of the fire was aviation fuel coming into contact with a high temperature ignition source.
The accident was a failure of asset management. A succession of ineffectively controlled design changes were made to the aircraft over its long life, which created an unidentified failure mode:
fuel leaking from adjacent fuel couplings, or other parts of the fuel system onto exposed or vulnerable parts of the Cross-Feed duct could ignite.
It was also a failure of safety culture. The report notes that in 2004, the defence contractor gave a "misleading impression" to MoD officials about its assessment of the safety of the hot air piping system. The company "deliberately did not disclose to its customer the scale of the hazards," says the report.
Haddon-Cave’s inquiry concluded that the UK Ministry of Defence sacrificed safety to cut costs and its defence contractors failed to carry out work properly. There had been serious design flaws in the Nimrod which had lain dormant for years. The updated safety case carried out between 2001 and 2005 was:
a lamentable job from start to finish. [It was] poorly managed and poorly executed, work was rushed and corners were cut… [the leadership] has failed to implement an adequate or effective culture, committed to safety and ethical conduct [and] fatally undermined by a general malaise: a widespread assumption that the Nimrod was 'safe anyway' because it had successfully flown for 30 years.
Haddon-Cave also cited "deep organisational trauma" as a result of a strategic defence review, quoting a former senior RAF officer who told the 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.
Pressure was created by increased demands as a result of the conflicts in Iraq and Afghanistan, but the failures were:
both of leadership, and collective failures to keep safety and airworthiness at the top of the agenda despite the torrent of change…"
Lessons for today
It is depressing that the lessons from the accident related to failure to meet fundamental and known principles of good safety management. These principles seem to need constant refreshing to combat delivery pressures, ignorance and any temptation to view robust safety management as costly, or a luxury. Temporary good luck and the principle of ‘out of sight, out of mind’ almost inevitably seem to lead to an ebbing away of focus on safety engineering. All too often it takes an accident like the Nimrod tragedy to serve as a desperate reminder that focus has waned.
Our critical technological assets are increasingly complex and interconnected. Automation of operations makes ‘safety by design’ crucially important. As I have previously set out, cyber security threats are also challenging our assumptions around the safety integrity of engineered systems. COVID has created cost challenges which will encourage even more automation and digitalisation to occur in this resource-constrained world.
The post-Brexit environment in the UK creates particular challenges too. Rather than ‘taking back control,’ recent events highlight that the UK is particularly at the mercy of its supply chains and the international availability of expertise. This creates an assurance challenge for technological safety: as detailed understanding of critical assets is increasingly held outside the UK, its leverage and competence to maintain effective oversight is under tension.
Tackling the challenge
In light of these challenges, how do safety critical sectors, like transport, navigate their way through the cluttered airspace ahead? In my view, government and industry leaders need to recognise the importance of:
Setting a realistic pace of technological change that factors in all of the work that needs to be done to bring critical systems into use with appropriate oversight, recognising the depth of local expertise that is practically available.
Avoiding automation and digitalisation in areas where safety assurance cannot be complete and robust.
Ensuring that the fundamental principles of good safety engineering are not compromised on those projects that are progressed and that there is effective independent scrutiny of safety work.
Charles Haddon-Cave dedicated his report to the men who lost their lives in the accident in the “hope and expectation that lessons will be learned from their sacrifice.”
They were:
Gary Wayne Andrews
Stephen Beattie
Gerard Martin Bell
Adrian Davies
Oliver Simon Dicketts
Steven Johnson
Benjamin James Knight
Leigh Anthony Mitchelmore
Gareth Rodney Nicholas
John Joseph Langton
Gary Paul Quilliam
Allan James Squires
Steven Swarbrick and
Joseph David Windall.
The next issue
I hope you found this edition of Tech Safe Transport engaging. In the next issue I’ll be taking you through yet another topic on the safety of modern transportation. Please subscribe now so you don’t miss it.
Thanks for reading
All views are my own and I reserve the right to change my opinion when the facts change. If you have any thoughts or comments please feel free to send me a message on Twitter. Many thanks to my editor Nicola Gray. The cover image is credited to Oren Rozen, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons.