Sir Charles Haddon-Cave is giving a talk at Royal Aeronautical Society 19th November where he will be talking about his Review of the terrible accident to the Nimrod in Afghanistan and the lessons to be learnt. There can be no doubt that as a result of the Review there was a significant improvement of the management of safety issues in the Royal Air Force. However the Review was based on the analysis of the accident to Nimrod XV230 and it is clear reading the Review that the source of the fire that destroyed the aircraft was not the one described in the Review. The synopsis of the Sir Charles's talk has the paragraph :- The cause was not enemy fire, but leaking fuel being ignited by an exposed hot cross-feed pipe. It was a pure technical failure. It was an accident waiting to happen. The underlying causes were organisational and managerial. In fact, the fire was caused by inadequate testing of the Flight Refuelling system which was added to the basic aircraft design and was not a fundamental weakness of the Nimrod system. The Review discovered that the source of the fuel which caused the fire came from the blow-off valve of No 1 fuel tank while refuelling and the Review also discovered a 1985 report by BAe which warned of the danger of fuel from this source running back into the cooling duct for the very hot intercooler matrix of the secondary cooling system, 4m behind the blow-off valve; this report advised more flight testing and as a precaution to switch off this cooling system while refuelling but sadly the advice was not taken. The Review having discovered these things, did not carry out any flight testing to discover where the fuel actually went though aircraft were available for carrying out the tests; instead it convinced itself that the fuel would find its way back through the skin of the aircraft to the original incorrect source of the fire suggested by the RAF Board of Inquiry, notwithstanding that the events observed by the crew were inconsistent with that source. Clearly from the synopsis Sir Charles has not yet modified his opinion and still considers that the source of the fire was as stated in the Review. I attach a description of what actually happened matched with the associated warnings which can be read pressing this link Nothing can bring back the 14 members of the crew who were killed or the aircraft itself, but it is important that the shortcomings of the Review should be understood. However, the lessons to be learnt as stated in the Review applied glaringly to the real source of the fire and therefore there was no need to spend as much time in the Review criticising the fuel system which, though it was capable of improvement, had worked splendidly for 40 years. It is also possible that, had the Review got the source of the fire correct, the Nimrod MRA4 would not have been cancelled so abruptly, but that is another issue. Tragically if only the secondary cooling system had been switched off as advised in the BAe report the accident would never have happened. |