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The board of inquiry found that the crew were all on duty and were properly trained, qualified and authorised. They had arrived at their deployed operating base on 21 August and had flown three sorties since their arrival, the last being on 27 August. The crew were all medically fit and considered to have been adequately rested prior to the sortie. The aircraft had not exhibited any significant faults while in theatre.
The board found no evidence that the maintenance or servicing conducted on the aircraft was a cause or contributory factor in the loss of XV230. It also concluded that, while the continued commitment to long-term operations places pressure on the Nimrod force, there was no evidence of that this was a cause or factor in the loss of the aircraft.
Following the crash, and in conjunction with the board of inquiry's investigations, a number of measures have been taken to ensure the continued safe operation of the aircraft. Additional maintenance and safety checks have been carried out on all of the Nimrod
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We have continued to adapt our Nimrod force maintenance and operating procedures in response to the emerging findings of the board of inquiry and the lessons identified from ongoing operations in the Middle East and the United Kingdom, just as we would for any other aircraft.
The Chief of the Air Staff’s professional judgment is that, taking all these measures into account, the Nimrod aircraft fleet remains safe to fly. I have accepted his assurance on this and his opinion that all necessary safety measures have been implemented.
The board of inquiry made 33 recommendations in total, relating to maintenance policy, the fuel and hot air systems, air-to-air refuelling, operational issues, aircraft modifications, post-crash management, engineering and personnel. Twenty-one of these recommendations have been accepted outright by the chain of command. Eight of the recommendations are actively being considered. One recommendation (Recommendation 5, to determine a specific life for fuel seals) has not proved possible to implement but mitigating action has been taken. One recommendation (Recommendation 17, to investigate the utility of parachute escape on Nimrod aircraft) has not been taken forward as it is not considered feasible. One recommendation (Recommendation 20, to review the design of No. l fuel tank) has not been taken forward but the issue it sought to solve has been addressed by other means. One recommendation (Recommendation 28, to increase the RAF's stocks of BOI kits) has not been taken forward because BOI kits could be made available from Royal Navy and Army holdings.
The detailed recommendations of the BOI and the chain of command's response to them, are as follows:
1. The Nimrod maintenance policy is reviewed to ensure that maintenance procedures reflect the increasing age of the aircraft.
This recommendation has been accepted.
2. The Nimrod ageing aircraft audit is reviewed to include aircraft systems.
This recommendation has been accepted.
3. The Nimrod safety case is reviewed, reassessing the factual data used for interpretation and categorization of hazard and risk.
This recommendation has been accepted.
4. A safety review of the Nimrod fuel and hot air systems is completed.
This recommendation has been accepted.
5. A life for the FRS Series 1 fuel seal be determined, based on the designer's recommendation that fitted seals are replaced after 25 years.
The recommendation that fuel seals be given a specific life has not been accepted because experts advise the life of seals will vary considerably, according to the conditions of their installation in the aircraft. Further studies have yet to identify any predictable
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6. A maximum installed life for fuel seals of other material types is determined.
This recommendation is under consideration. A review is being conducted to determine whether the regulations for the lifing of seals are adequate.
7. A one-off inspection of the integrity of each Nimrod's fuel system, between Ribs 3 starboard and port, be conducted with access panels removed and the system pressurised.
This recommendation has been accepted.
8. An inspection regime for fuel seals be initiated as recommended by Eaton Aerospace.
This recommendation has been accepted. A comprehensive inspection of fuel couplings is also under way.
9. A procedure is developed to pressure test the fuel vent system at the fuselage to wing interface.
This recommendation has been accepted.
10. Detailed instructions for the correct fitting and locking of FRS couplings and seals be incorporated formally within the Nimrod AMM and publicised widely.
This recommendation has been accepted.
11. Hot Air System. Existing limitations, prohibiting the use of the supplementary conditioning pack (SCP) and of the cross-feed pipe in the air be continued.
This recommendation has been accepted.
12. Nimrod air-to-air refuelling (AAR) procedures are reviewed in the light of the board's report, to establish appropriate levels and rates of refuel, which will prevent overspill of fuel from tanks.
This recommendation has been accepted.
13. A study be initiated to determine the cause of pressure surges during air-to-air refuelling and their long-term effect on aircraft fuel systems.
The feasibility of the recommendation is being examined and a technical proposal on how this could be implemented has been requested.
14. A statement specifying that the maximum normal operating pressure of 50 psi during air-to-air refuelling be reintroduced into the Nimrod aircrew manual.
The recommendation has been accepted.
15. Air-to-air refuelling refuel rates in the dynamic simulator are changed to reflect actual refuel rates to provide more realistic training.
This recommendation is under consideration.
16. Existing limitations, prohibiting the use of the No. 7 fuel tanks, introduced following the loss of XV230, be discontinued.
This recommendation has been accepted.
17. A study be undertaken into the utility of parachute escape on the Nimrod MR2.
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This recommendation has not been taken forward. The Nimrod has no airborne escape system as it was not designed for the deployment of parachutes. It is highly likely that any attempt to abandon the aircraft from the front or rear exit would result in either being pulled into the engine or hitting the tail of the aircraft.
18. Nimrod STANEVAL (standard evaluation team) consider the lessons identified at Annex P (description of crew actions during the emergency) and their potential impact on crew emergency procedures.
This recommendation has been accepted.
19. The port rear emergency oxygen bottle is relocated to a more central position, or another oxygen bottle is provided in this position.
The feasibility of the recommendation is being examined and a technical proposal on how this could be implemented has been requested.
20. The design of No. 1 fuel tank is reviewed to reduce the effect of asymmetric filling.
It is not currently intended to review the design of the No. 1 fuel tank as this problem has been resolved by only refuelling the No. 1 tank to a level well below that which could initiate the safety valve.
21. The outlet pipes for fuselage fuel tank blow-off valves be modified to ensure that blown-off fuel cannot run down the exterior of the fuselage.
The feasibility of the recommendation is being examined and a technical proposal on how this could be implemented has been requested.
22. The connections of the No. 1 tank vent pipes be modified to reduce the risk of fuel leakage.
The feasibility of the recommendation is being examined and a technical proposal on how this could be implemented has been requested.
23. The drainage of the lower panel in the No. 7 tank dry bay be improved to prevent any accumulation of fuel.
The feasibility of the recommendation is being examined and a technical proposal on how this could be implemented has been requested. In the mean time the likelihood of a hazard arising from fuel pooling in this area has been significantly reduced by suspending the use of the supplementary conditioning pack and cross-feed pipe system and introducing the enhanced inspection regime.
24. A crash-protected means of recording aircraft position and intercom voice is introduced to the Nimrod.
This recommendation is under consideration.
25. The Defence Aviation Safety Centre (DASC) should investigate the provision of details of type-specific emergency equipment (ADR, etc) and key internal components (for example the ADR tape unit and housing) on their website to enable Post-Crash MoD Incident Officer (PCMIO) to provide guidance to search teams.
This recommendation has been accepted.
26. Instructions for PCMIO are revised to provide guidance when attending crash sites that are likely to become inaccessible.
This recommendation has been accepted.
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27. Instructions for PCMIO at crash sites which are likely to become inaccessible should include advice to make every effort to ensure the widest possible photographic coverage of the crash site, at the highest possible resolution. This should take priority over all other tasks for any photographic team.
This recommendation has been accepted.
28. DASC should increase its current stock of post-crash BOI kits.
This recommendation has not been accepted. We currently hold four post-crash BOI kits. In the unlikely circumstance that a fifth BOI post-crash kit is required the RAF could borrow a kit from one of the other services.
29. Body bag fluidproof liners should be stored within the outer ruggedised bags in crash kits to ensure that they always arrive on scene together.
This recommendation has been accepted.
30. The Nimrod MoD Form 700 Sections 2 and 3 (F703/F704) should be copied and retained before the document is carried on the aircraft.
This recommendation has been accepted.
31. The use of non-approved mission system panel blanks be discontinued.
This recommendation has been accepted.
32. Consideration be given to reinstating the SO1 (Wg Cdr) engineering post in Forward at RAF Kinloss to provide senior oversight of station engineering matters.
This recommendation has been accepted.
33. A review of engineering training is undertaken to identify those areas which, while relevant to Nimrod capability, are not encompassed within existing formal training courses.
This recommendation has been accepted.
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Regional Development: One NorthEast
The Minister of State, Foreign and Commonwealth Office & Department for Business, Enterprise and Regulatory Reform (Lord Jones of Birmingham): My right honourable friend the Minister of State for Competitiveness (Stephen Timms) has made the following Written Ministerial Statement.
I have decided to appoint the new board members listed below:
Alex Cunningham, Gill Hale, Christopher Higgins, Graham Thrower and Ian Dormer.
The new appointments will all be for a period of three years.
The appointments will begin on 14 December 2007 and will expire on 13 December 2010.
I have placed further details of the new appointments in the Library of both Houses. They were all made in accordance with the code of practice of the Commissioner for Public Appointments.
Taxation: United Kingdom and Bermuda
Lord Davies of Oldham: My right honourable friend the Financial Secretary to the Treasury (Jane Kennedy) has made the following Written Ministerial Statement.
A new tax information exchange arrangement with Bermuda was signed on 4 December 2007. After signature, the text of the arrangement was deposited in the Libraries of both Houses and made available on HM Revenue and Customs’s website. The text of the arrangement will be scheduled to a draft Order in Council and laid before the House of Commons in due course.
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