Most safety-critical or complex industries have experienced at least one pivotal incident. You will most likely be aware of Piper Alpha, NASA Columbia and the Deepwater Horizon (Macondo) well blowout in the Gulf of Mexico.
For the defence sector, one of these significant events was Nimrod XV230. You may not have heard of this event, but the lessons apply more widely than military aviation.
This is an appropriate time to consider and reflect on the Nimrod XV230 incident, as we’re approaching the ten-year anniversary. On 2 September 2006 the UK Royal Air Force (RAF) ‘spy plane’ Nimrod XV230, and all her crew of 14, were lost following a catastrophic mid-air fire. The aircraft was on a routine mission over Afghanistan, when a leak of aviation fuel, shortly after air-to-air refuelling, came into contact with a source of ignition. The fire was not accessible, not able to be remotely suppressed, and the incident was not survivable.
The investigation of this tragedy, in the form of an inquiry led by Charles Haddon-Cave QC (now The Hon. Mr Justice Haddon-Cave), reveals a sad story of an incident that simply shouldn’t have happened. Reading the independent inquiry (‘The Nimrod Review’) in 2009, I felt a strong sense of frustration.
Back in July 2008, in preparing for a meeting with the Nimrod Review team, I created a slide pack containing my thoughts on the Nimrod XV230 event. I had read that there were a number of warning signs from previous Nimrod events and these reminded me of the many warnings before the NASA Columbia disaster in 2003. So, in my presentation I compared what I knew then about Nimrod with the wealth of materials available on NASA Columbia; and the similarities were striking.
Looking back I now see the irony of presenting The Hon. Mr Justice Haddon-Cave with a set of PowerPoint slides to make a case – in The Nimrod Review he is rather negative about ‘PowerPoint Engineering’! If you watch one of the various recordings of his keynote speeches available online, you’ll notice that he successfully engages the audience for an hour with very few slides.
So, back to my reading of The Nimrod Review in October 2009. I read the 587 pages as soon as it was first published – partly because I had a personal connection to the Review, partly because my CEO wanted a summary of the document and the implications, but mainly because it is such a good discussion of organisational failures. This report sets out to be a review into the ‘broader issues’ surrounding the loss of this Nimrod aircraft.
And that’s why I was so frustrated.
Yes, at a superficial level, the specifics of this event were unique; but by delving deeper into the ‘why?’, the Review team revealed that history does in fact repeat itself. The organisational causes explored in the Review, the underlying or ‘latent’ failures to use the language of James Reason, were certainly not unique to the UK Ministry of Defence (MOD).
The Nimrod Review is subtitled ‘A Failure of Leadership, Culture and Priorities’. The same could be said for NASA Columbia, Herald of Free Enterprise, Buncefield and many other high-profile incidents. In an article in Professional Engineering (8 July 2009) I stated that: “People in different industries don’t normally learn from incidents in other industries. The technical detail will always be different and sector-specific but the organisational factors will be the same. The things that affect NASA also affect oil refineries”.
Had the MOD learnt the wider organisational lessons from previous disasters? Would you expect the defence industry to learn from high-profile events in space exploration, commercial aviation, oil and gas exploration or rail travel? If you would expect such cross-industry learning, then what has your industry learnt from these events?
In a recent keynote presentation at the Hazards 26 conference, The Hon. Mr Justice Haddon-Cave says that:
“Nimrod was a painful, catastrophic lesson for the RAF, it’s a free lesson for everybody else” (24 May 2016).
We owe it to the families and loved ones of the crew of Nimrod XV230 to learn what we can.
Over the next few weeks leading up to the 10th anniversary, I’ll be writing a series of short posts related to some of the organisational failures highlighted in The Nimrod Review. For a summary of the Nimrod incident, please see my article at humanfactors101.com.
Categories: human factors