Key Themes

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

Target Audience

Senior leaders, Safety professionals, those responsible for complex processes and legacy systems.


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.