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The systemic failings behind the Chinook and Nimrod tragedies

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By James Jones Five years after the report by the Chinook Airworthiness Review Team (CHART) was published in 1992 – a report in which many of the recommendations related to the "integrity of the overall airworthiness management system" – a similar review was carried out for the Nimrod aircraft. This airworthiness review (NART) was only undertaken after the departure of Air Chief Marshal Michael Alcock as chief engineer (RAF) and Air Chief Marshal Sir Peter Squire as assistant chief of air staff. The NART report suggests that there was “neglect” during the 1990s, culminating in low manning levels, declining experience, failing morale, overstretched tasking and reduced resources – and, in many aspects, it is a carbon copy of the CHART report. The NART report calls for “highly attentive management”, which needs to be “closely attuned” – clearly these are airworthiness ingredients which had been missing for several years. This period also saw a marked decline in airworthiness spending, in particular that associated with Post Design Services (PDS) tasks – those deemed essential for maintaining the “build standard” and ultimately the safety case. How then was it possible for Sir Charles Haddon-Cave to state, in paragraph 13.124 of his 2009 report into the 2006 loss of Nimrod XV230 over Afghanistan, that this was the “golden period” for airworthiness, “due in no small measure to the high calibre and leadership to those who held the post [the chief engineer]”? Haddon-Cave conveniently uses 1998 as the starting point for his detailed airworthiness analysis, and attributes blame to those who followed – when in fact the true starting point for the airworthiness “meltdown” was some eight years earlier. Using the 1990 starting-point brings up a different batch of names and guilty parties: instead of Group Captain George Baber, General Sir Sam Cowan and Air Chief Marshal Sir Malcolm Pledger, one has to read Alcock and Squire. The question that needs to be answered is this: was Haddon-Cave encouraged to adopt the 1998 start-point, or did he simply get too engrossed in 136 pages of a safety case and ignore the bigger picture? Haddon-Cave also failed to recognise the “airworthiness” message embedded in the QinetiQ report of March 2006. He saw the report as a simple study into wing fuel leaks, when in fact it was a re-run of CHART and NART: diminished manning levels and experience, inadequate training, over-flying, failure to investigate faults, outdated publications, failure to communicate between departments, etc. Clearly, the meltdown continued after the NART report and at a time when ACM Squire had been elevated to the position of chief of air staff. Later, at the inquest, it became clear that the practice of “misusing” the Special Trials Fit (STF) procedure was still being practiced at the time of the Nimrod crash, despite all the warnings given in CHART. Recent attempts to obtain a full copy of the 1998 NART report, under freedom of information, have been thwarted by MoD claims that the document cannot be found. This seems to be an extraordinary claim, just one year after the formation of the new Military Aviation Authority, and the report should have been made available to the new organisation if we are really intent on correcting past failings in the airworthiness system. The MoD also claims that it is unable to locate information relating to a fuel coupling leak on the Nimrod XV230 during 2006, the year of the accident, even though the defect is identified in the Board of Inquiry report. However, it was never followed up. The following extract from chapter 13 of the Haddon-Cave report illustrates the importance of the NART report: "In 1997, as part of an ongoing Airworthiness Review programme, the Assistant Chief of the Air Staff (ACAS) and Air Member for Logistics (AML) tasked the Inspectorate of Flight Safety to carry out a review of the Nimrod fleet. The review was duly conducted by the Nimrod Airworthiness Review Team (NART) which was instructed “to conduct a wide ranging independent review of all in-service marks of the Nimrod aircraft to assess the integrity of the airworthiness management and maintenance practices in place or proposed; the currently planned out-of service date for the MR-Mk2 is 2006 and 2009 for the R-Mk 1.” Clearly this was a high-level tasked report, which would have been presented to the ACAS on completion. The ACAS from 1998 to 2000 was Air Vice Marshal "Jock" Stirrup, now Lord Stirrup. This prompts the question: “What action did Lord Stirrup take when presented with the NART report?” Haddon-Cave points out that the concerns and warnings in the NART report were dismissed at the time as "uninformed, crewroom level, emotive comment lacking substantive evidence and focus". He refers to notes of a meeting to discuss the report dated 24 September 1998, and also to a brief for the assistant director of information (ADI) dated October 1998 D/DAO/14/3/5 which refers to: “regret that some of the content [of the NART report] does tend to reflect crewroom gossip/whinges rather than factual data”. This raises some additional questions: Who attended the meeting in September 1998? Who prepared the brief? Who received the brief? I believe that this attitude towards NART was representative of the cavalier approach shown towards airworthiness during the 1990s – a period in which we lost a Chinook (1994) and a Nimrod R1 (1995). It is worth noting that a Board of Inquiry recommendation to replace alloy couplings in the Nimrod’s hydraulic systems was rejected on cost grounds. Some 11 years later, the crew of Nimrod XV230 lost control of the aircraft just 15 miles from Kandahar airfield, because of hydraulic failure. The most likely cause was that the alloy couplings melted. It is also important to note that the Chinook role office and Nimrod role office were both under the functional control of the same wing commander. This is how systemic problems arise. What becomes acceptable and the norm on one aircraft quickly becomes the norm on others. In my opinion, the 1994 Chinook and the 2006 Nimrod accidents happened, not because of mist on the Mull of Kintyre, or a lack of fire detection in Dry Bay 7, but because of significant systemic failings in the in the airworthiness organisation in the 1990s. This was the real breach of the military covenant. It is clear that the very personal criticism of General Cowan and ACM Pledger by Haddon-Cave can now be seen to be completely unfounded. Both officers, especially General Cowan, inherited decades of neglect, as evidenced by CHART and by extracts from the much-guarded NART report. It is unreasonable, and a practical impossibility, to resurrect the airworthiness systems during a two-to-three-year posting as Chief of Defence Logistics, especially at a time when further cuts have been ordered at a political level. – James Jones worked as a Nimrod engineering officer and was responsible for carrying out flight trials prior to the aircraft entering service in 1968. Since the 2006 Nimrod XV230 crash in Afghanistan, he has acted as a technical advisor to the families who lost loved ones and has advised their legal counsel during the subsequent inquest.

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