At 9.30am on 2nd September 2006, Nimrod XV230 took off for a mission over Afghanistan. At 11.00am it rendezvoused with a Tristar tanker for air-to air refuelling, which took about 10 minutes. One minute later a bomb bay fire warning sounded. Four minutes later the crew made their last transmission. At 11.17 am, a Harrier pilot saw the aircraft explode. All fourteen crew were lost. This workshop follows the learning from the Haddon Cave report, which found organisational, cultural and leadership failings, alongside a ‘lamentable’ safety case.


Investigator 1: As air-to-air refuelling drew to a close, fuel escaped. The fuel tracked backwards and entered the fuselage. It made contact with one of the areas of exposed ducting or it soaked into the pipe insulation.

Sarah: How did these ducts come to be exposed?

Investigator 1: Checking other Nimrod aircraft we have seen evidence that these allow gaps between the insulation and the hot pipe – gaps which allowed fuel to gather. We believe the fire started here.

Investigator 2: Fire spread to the wing. Heating of the aileron bay caused hydraulic fluid to ignite and a fire started there.

Investigator 1: The fire, now on both sides of the aileron bay wall penetrated the wall, and the aircraft at that point depressurised.

Investigator 2: The fire weakened the aircraft’s spar – which provides its structural strength. The aircraft’s hydraulic systems failed as hydraulic fluid boiled and pipe unions melted.

Investigator 1: In the last sixty seconds it is unlikely that the pilots had any control over the aircraft.

Investigator 2: And of course there were no ejection devices on-board.

Investigator 1: At a height of about 700 feet the weakened starboard wing failed, broke off and struck the tail structure.

Investigator 2: As the aircraft rolled to the right, the port wing also failed.

Investigator 1: The accident was not survivable.

Greg: In your expert opinion, at what point were the seeds of disaster sown for this aircraft?

Investigator 2: Oh there have been so many opportunities to avert it, but in answer to your question the seeds were sown when the Nimrod was first converted from the Comet. In 1968.



Defence and Allied Services
Legacy Systems
Major Hazard Organisations
Process Safety

Target Audience

Senior leaders
Safety professionals
Those responsible for complex processes and legacy systems

Key Themes
  • Safety leadership
  • ‘The Safety Case’
  • Safety culture
  • ‘Paper safety’