human factors

Nimrod XV230: 15 years on

Five years ago, I launched this website with a series of articles about the Nimrod XV230 disaster.

Today, on the 15th anniversary of this tragedy, I’d like to reflect on the key recommendations. From the subtitle of the independent Review – “A failure of leadership, culture and priorities” – it’s obvious that there may be lessons for us all. The question is, have we learned these lessons?

“Nimrod was a painful, catastrophic lesson for the RAF, it’s a free lesson for everybody else”

The Hon. Mr Justice Haddon-Cave, Hazards 26 conference, 24 May 2016

On 2 September 2006, all 14 crew of a UK Royal Air Force (RAF) ‘spy plane’ Nimrod XV230 were lost following a catastrophic mid-air fire. The aircraft was on a routine mission 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.

I’m frequently surprised (and a little frustrated) at how few safety professionals are familiar with this event or the key lessons. ‘The Nimrod Review’, led by The Hon. Mr Justice Haddon-Cave, is a model investigation, and should be required reading for executives and leaders in all industries. The Review takes the aircraft fire as its starting point, but casts its net far and wide through the organisation, as well as considering relevant events in other industries.

This Nimrod XV230 tragedy is so rich in lessons, I wrote seven articles on these in 2016. Rather than repeat the key messages here, I’ve provided links to the articles below.

What can you learn from the Nimrod disaster? 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.

Nimrod XV230: Parallels with healthcare. By discussing the relevance of the Nimrod XV230 event to healthcare, I aimed to illustrate that the organisational lessons from this event are applicable to almost any industry. The parallels with several major healthcare events are quite disturbing. My conclusion was that in the next major inquiry in healthcare, failures of leadership, culture and priorities will likely play a significant role. Does it have to be that way?

Success, complacency and failure. The track record of the Nimrod aircraft led to a high level of confidence in the safety of the fleet, and this impacted on the quality of safety assessments. In this article I refer to many other incidents where past successes, together with a failure to effectively act on warnings, contributed to disaster.

Normalisation of deviance. Here, I explain what this term means, why it’s important and how it can be countered. In relation to the Nimrod XV230 incident, fuel leaks were seen as inevitable. As in other organisations, small deviations from the norm, gradually become the norm. This ‘new normal’ then allows further deviance to become acceptable, a new baseline is created and the organisation shifts what it perceives to be acceptable. In the article, I list a set of questions for you to consider, to help you identify and manage inappropriate deviations before they become the new normal.

Change is the only constant. The Nimrod Review refers to organisational trauma and a tsunami of cuts and change. Organisational change may be inevitable, but it does not have to lead to disaster. Companies often fail to consider the cumulative impact of successive changes, simply focusing on individual changes in isolation.

Keep it simple. The author of The Nimrod Review, The Hon. Mr Justice Haddon-Cave, states that simplicity is your friend and complexity is your enemy. I was quoted in The Nimrod Review for my comment on the complexity of the NASA organisation in relation to the Shuttle incidents (“NASA was so complex it could not describe itself to others (Martin Anderson, HSE, 2008“, Nimrod Review, p. 492).

Ten questions on organisational failures. In my final article in this series, published on the 10th anniversary of the Nimrod XV230 tragedy, I provided ten questions to help stimulate discussion and reflection. These questions are based around the three topics of leadership, culture and priorities.

The Nimrod Review itself is almost 600 pages in length. I suggest that you at least read the brief chapter summaries, or read this transcript of a speech by The Hon. Mr Justice Haddon-Cave, given at a conference in Perth.

I also recommend watching this video, of The Hon. Mr Justice Haddon-Cave – filmed at a conference to mark the 25th anniversary of the Piper Alpha disaster.

“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” 

(Nimrod Review, 2009, p. 580)