Ten questions on organisational failures

On 2 September 2006, RAF Nimrod XV230 suffered a catastrophic mid-air fire, shortly after air-to-air refuelling. This led to the loss of the aircraft and all 14 service personnel.

The loss of Nimrod XV230 was not an aviation incident. Neither were the causes specific to the Ministry of Defence. It was due to a catalogue of organisational failures, and therefore, the lessons are relevant to any high-hazard or complex organisation.

I’ve written a detailed review of the key issues and several articles about this disaster but I recognise that many readers will appreciate a brief list of questions to help stimulate discussion and reflection.

You may find it useful to discuss some of these questions in your team meetings, reflect on them at workshops or away-days, or use them as safety moments.

The Nimrod Review was subtitled A failure of leadership, culture and priorities and so I have based the following ten questions on organisational factors around these three topics.


  1. Do you have the capability to understand and challenge technical work undertaken by contractors, consultants or independent advisers?
  2. Do you ‘join the dots’ between previous incidents, even though they may appear to be unrelated at first?
  3. Do you treat near-misses or reported errors as warnings, and act on them appropriately?
  4. Are organisational changes (including the cumulative impacts of a succession of changes) creating unintended effects?


  1. What assumptions are you making in key decisions, and are these still valid?
  2. How do you know that what you think is happening, IS actually happening (i.e. is there a gap between ‘work as imagined/planned’ and ‘work as done’)?
  3. How do you actively encourage the reporting of bad news, errors or near-misses?


  1. How might budget cuts, challenges, efficiencies, strategic targets, productivity initiatives etc. have unintended consequences?
  2. Do you accept conditions or behaviours that you wouldn’t have accepted a few years ago?
  3. What are the most prominent messages that you communicate to your teams and to the business (e.g. are they always about budgets and financial targets)?
The Hon. Mr Justice Haddon-Cave - The Nimrod Review

In the words of The Hon. Mr Justice Haddon-Cave:

“Many of these lessons and truths may be unwelcome, uncomfortable and painful; but they are all the more important, and valuable, for being so. It is better that the hard lessons are learned now, and not following some future catastrophic accident” (The Nimrod Review, 2009, p.580).

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