Learning from the Nimrod Inquiry

Mr. Charles Haddon-Cave presented learning from the inquiry into the loss of the Nimrod aircraft and its crew of 13 in 2006. Mr. Haddon-Cave is the author of The Nimrod Review - an independent review into the broader issues surrounding the loss of an RAF Nimrod aircraft in Afghanistan in 2006. The full report can be accessed at: http://www.officialdocuments. gov.uk/document/hc0809/hc10/1025/1025.pdf. Mr. Haddon-Cave opened the presentation with general remarks on the responsibilities of the regulator, and the environment within which they operate. He emphasised the need for regulators to exercise personal responsibility, accountability, integrity, and to maintain a balanced approach to regulation. The following organisational and cultural issues leading to the Nimrod accident were summarised: - Organisational complexity within the Ministry of Defence. - Management by committee and consensus. - Dilution of accountability and responsibility. - Lack of challenge, which provides a barrier to wrong decision-making. - Migration of responsibility from operators to government departments. - 'Triumph' of generalists over technical specialists. - Weak signals overlooked (small voices drowned out). - Distraction due to large numbers of organisational changes and initiatives. - Longstanding acceptance of problems. 'Can do will do' became 'Make do and muddle through'. The Nimrod inquiry identified 12 parallels between the organisational causes of the Nimrod and the Columbia accident, reinforcing the message from the first plenary presentation on common underlying themes. Mr. Haddon-Cave delivered a number of key messages for regulatory managers and leaders such as the importance of: - Recognising and reinforcing the pivotal role of the operating organisation in ensuring safety. - Questioning and challenging assumptions. - Ensuring that roles and responsibilities are clearly defined. - Exercising caution when out-sourcing to avoid 'out-sourcing your thinking'. - Focusing on simplification and avoiding complexity (in terms of processes and organisational structures). - Viewing the safety case as an aid to thinking, rather than an end in itself (the danger of 'paper safety' rather than 'real safety')