Fourteen service personnel were killed when their Nimrod spy plane crashed in Afghanistan in 2006 – the largest single fatality since the Falklands War – because the Ministry of Defence (MoD) sacrificed essential safety for the sake of saving money, the review said. The independent investigation, led by Charles Haddon-Cave QC, named 10 people who contributed to the "systemic breach of the military covenant" – the duty the nation owes to its armed forces. Five of those came from the Ministry of Defence – including two senior military officers of four-star rank – three from BAE Systems and two from QinetiQ.
The Defence Secretary, Bob Ainsworth, told the Commons that two RAF officers have been removed from their posts because of their roles in the crash of aircraft XV230. They have been moved to staff positions without any safety aspects. The RAF is now considering what further action needs be taken against them.
The Nimrod MR2 exploded in mid-air near Kandahar, in southern Afghanistan, shortly after air-to-air refuelling. The crew and passengers were on a mission to support Nato and Afghan forces in an operation against the Taliban in Helmand. A military board of inquiry found the crash was caused when leaking fuel came into contact with a hot-air pipe.
Yesterday Mr Haddon-Cave, a leading aviation lawyer, found there had been serious corporate shortcomings which led to the "lamentable" failures of a safety review carried out a year before the crash. Procedures were "riddled with errors" and the "best chance to prevent the accident to XV230 was, tragically, lost."
The organisational failures, said the report, were of such magnitude that this disaster echoed other major historic accidents, including the loss of the space shuttles Challenger and Columbia, the Zeebrugge ferry disaster, the sinking of the Marchioness and the King's Cross fire.
The MoD's safety system was "not fit for purpose". There was serious weakness among the personnel; an "unsatisfactory" relationship between the MoD and industry; an "unacceptable" procurement process, and a culture which "has allowed business priorities" to overcome concentrating on airworthiness.
The report stated: "BAE Systems deliberately did not disclose to its customer the scale of the hazard" and only "gave vague recommendations that 'further work' was required". The work carried out by the company was "poorly planned, poorly managed and poorly executed".
The customer, the MoD, also "bears substantial responsibility for the failure of the Nimrod Safety Case" and "failed to do its essential job of ensuring the safety of the Nimrod fleet".
Mr Haddon-Cave pointed at a time between 1998 and 2006, when financial targets appeared to take precedence over safety.
The QC quoted a former senior RAF officer who told his inquiry: "There was no doubt that the culture of the time had switched. In the days of the RAF chief engineer in the 1990s, you had to be on top of airworthiness. By 2004 you had to be on top of your budget if you wanted to get ahead."
The report cited a document from 1998 which warned of "the conflict between ever-reducing resources and... increasing demands, whether they be operational, financial, legislative, or merely those symptomatic of keeping the old aircraft flying". The document warned that close attention should be paid to safety standards. However, these concerns were ignored.
Families of some of those who died pointed out that Gordon Brown was Chancellor when this culture switch, with saving money taking precedence, was taking place. The report, however, does not apportion any blame to the Prime Minister.
The firm QinetiQ, once a part of the MoD which had been privatised under controversial circumstances, was brought in as an independent advisor. But the company, said Mr Haddon-Cave, "failed to clarify its role act at any stage as the independent 'conscience' of the MoD".
QinetiQ had "failed to read BAE Systems reports or check BAE System work properly", had " failed to advise its customers properly", and had "subsequently signed off BAE Systems work in circumstances where it was manifestly inappropriate to do so". The company's approach was "fundamentally lax and compliant."
Mr Haddon-Cave said: "My report concludes that the accident to XV230 was avoidable, and that XV230 was lost because of a systematic breach of the military covenant brought about by the significant failures on the part of the MoD, BAE Systems and QinetiQ. This must not be allowed to happen again."
Accepting the findings of the review, commissioned by Des Browne, his predecessor, Mr Ainsworth told MPs: "I am sorry for the mistakes that have been made and that lives have been lost as a result of our failures. Nothing I can say or do will bring these men back."
But relatives of the 14 servicemen killed in the crash called for immediate Government action after meeting Armed Forces Minister Bill Rammall.
Robert Dicketts, the father of Lance Corporal Oliver Dicketts , said: "I think what we found the most sad was that saving money was put before safety.
"I wonder how many people would get onto a civil flight if they are told that we have cut as much cost as possible, and airworthiness is something which comes secondary." He said that "Mr Rammall had a rough ride [in the meeting]. We wanted to ensure that the recommendations will be put into practice." He added: "Mr Haddon-Cave has done a brilliant job... I just hope that lessons have been learned."
Trish Knight, whose son Ben was killed, called for resignations "from the very top". The MoD's conduct had been "disgraceful" after failures in safety procedures had been highlighted.
"It's what we've said all along. The MoD tried to tell us everything was fine," Mrs Knight said.
Last night the Defence Secretary said: "I am grateful for the rigorous review that Mr Haddon-Cave QC and his team have undertaken. He has identified key areas where we have failed in our duty, and he has made a number of recommendations which we will consider as a matter of high priority.
"We will examine all aspects of the report closely before we issue a full response. We begin this immediately but it is vital to do this thoroughly in order to ensure our actions are appropriate and robust."
Conservative defence spokesman Liam Fox said the report was "a formidable indictment". He said: "Its most damning central conclusion is that there were previous incidents and warning signs that were ignored, and that the loss of the aircraft was avoidable."
Named and shamed: The 10 senior figures who contributed to the 'systemic breach of the military covenant'
General Sir Sam Cowan
Appointed the first Chief of Defence Logistics in April 1999. Gen Cowan set a target the following year of reducing costs by 20 per cent by 2005. He left the post in August 2002 and is now retired.
Air Chief Marshal Sir Malcolm Pledger
He succeeded Gen Cowan as Chief of Defence Logistics in September 2002 despite later admitting to Mr Haddon-Cave's review he did not believe he was fully qualified for the job.
Group Captain (now Air Commodore) George Baber
He was the leader of the Ministry of Defence integrated project team responsible for a safety review of the RAF's Nimrod that took place between 2001 and 2005. Mr Haddon-Cave accused Group Capt Baber of a "fundamental failure of leadership".
Wing Commander Michael Eagles
As head of air vehicle for the Nimrod, he was supposed to be in charge of managing production of the safety review. But the report found that he delegated the project "wholesale" to a civilian worker.
Frank Walsh
He was safety manager for the Nimrod review and primary point of contact with the BAE Systems team carrying out the work.
Chris Lowe
As chief airworthiness engineer for BAE Systems, he was heavily involved in preparing the main documents in the Nimrod safety review. The report said he bore the heaviest responsibility for the "poor planning, poor management and poor execution" of the project.
Richard Oldfield
He was the leader of the Nimrod review for BAE Systems. The report found he did not come clean about large gaps in the analysis of possible risks and failed to manage the project properly.
Eric Prince
As the company's flight systems and avionics manager, he played a key role in the Nimrod safety project.
Martyn Mahy
He was Nimrod review task manager for defence technology firm QinetiQ. Mr Haddon-Cave criticised him for failing to do his job properly in certain key areas.
Colin Blagrove
As technical assurance manager for the Nimrod safety review, it was his ultimate responsibility to ensure QinetiQ did not sign off anything unless it was appropriate to do so. The report concluded that he failed in this "critical task".
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