Raf Nimrod Xv230 Accident Case Study Construction Essay

On September 2006 an RAF Nimrod XV230 on a mission over Afghanistan suffered an unmanageable and ruinous mid-air fire in an unaccessible portion of the aircraft, which lacked fire protection. The crew had no opportunity of battling the fire, taking to a break-up of the airframe merely proceedingss before they could do and exigency landing at Kandahar Airbase. All 14 service forces on board were tragically killed. A squadron of Royal Canadian Dragoons in the locality secured the country to continue the clang scene. They were subsequently relieved by 34 Squadron RAF Regiment, who managed to retrieve organic structures, informations recording equipment and images ( subsequently turn outing to be important ) of the clang site. They were withdrawn by air after several hundred local subjects including members of the Taliban had converged on the country.

A board of question was formed to carry on a 7 month reappraisal to find the most likely causes to the accident. The country most likely to be the beginning of ignition was thought to be the high temperature Cross-Feed/Supplementary Conditioning Pack ( SCP ) canal located in the starboard No. 7 Tank dry bay. The beginning of fuel was thought to hold originated from a leak in an air-to-air refueling ( AAR ) dealing which occurred merely proceedingss before the fire.

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Top Degree Requirements

The Nimrod MR2 suffered from three cardinal design defects, which played a major portion in the loss of the aircraft. The first defect was introduced by Hawker Siddeley with the original adjustment of the Cross-Feed canal to the Nimrod MR1s and R1s in 1969. The purposes of these were to administer Auxiliary Power Unit air and engine bleed-air to the engines for land get downing. They could run at up to 470A°C during flight. The 2nd defect came when BAE Systems added an SCP to supply increased chilling for the extra equipment introduced when the MR1s where upgraded to MR2s. The concluding critical defect was introduced as an exigency demand in the Falklands War, when AAR was needed to lengthen the scope of the MR2. As the refuel galley was now pressurised there was an increased opportunity in leaks from blow-off valves which automatically let go of fuel into the ambiance to forestall over-pressurisation. This alteration produced the unwanted possibility of this extra fuel lighting on the hot Cross-Feed canals ( as such was the instance with XV230 ) .

There was a perfect chance to forestall the accident happening in 2002. ‘Safety Cases ‘ were being introduced as a authorization for military aircraft to place and measure possible ruinous jeopardies. BAE Systems along with the Ministry of Defence ( MOD ) Nimrod Integrated Project Team ( IPT ) were tasked to pull up the safety instance for the MR2. QinetiQ were employed to move as an independent safety adviser to the undertaking. The Nimrod had successfully flown for 30 old ages so at that place was a widespread premise that it was ‘safe anyhow ‘ and therefore was simply a paperwork exercising. As a consequence the parties involved became self-satisfied with work being ill planned, managed and rushed. At the handover meeting BAE Systems gave a deceptive study that all work had been completed decently when in fact 40 % of jeopardies had n’t been mitigated and 30 % were left ‘unclassified ‘ . The Nimrod IPT unsuitably delegated their proportion of the work to junior employees and failed to affect themselves adequately in BAE Systems work. QinetiQ failed to transport out its function by non look intoing BAE Systems ‘ hazard appraisal and extenuation grounds. They besides sent an employee to the concluding handover who was non merely inadequately cognizant of the instance, but had non read any of BAE Systems ‘ studies.

The MOD suffered from many organisational alterations, get downing with the 1998 Strategic Defence reappraisal. Larger direction constructions were created and many undertakings were ‘outsourced ‘ to industry. There were many cuts and alterations which served as a distraction from what should hold been the top precedence ; airworthiness and safety. These changes badly affected the Nimrod IPT in its function in the Nimrod Safety Case. The alterations imposed besides filtered down into the undertakings the MOD were heading. For case, plans for a replacing Nimrod, the MRA4 ( originally scheduled to come into service in 2000 ) were invariably pushed back due to altering demands. If this new aircraft had been completed on clip, XV230 would hold most likely, no longer been winging at the clip of the incident in 2006. In fact the figure of clip over-run MOD undertakings was at 80 % and the mean cost over-run was at 40 % . Due to the perceptual experience of the MR2 being ‘just about to travel out ‘ of service, it did non profit from longer – term investings and spares had n’t been provided for an drawn-out terminal of life period.

Methods selected to turn to demands

The board of question came to the decision that the design defects were contrary to technology pattern and design ordinances of the clip. The impermanent design can be excused due to the exigency state of affairs with the Falklands War, nevertheless when the refueling capableness became lasting the alteration should hold been addressed. The chief job with go oning to back up old aircraft in a modern environment is the tremendous alteration in criterions. Designs acceptable so, would non hold been acceptable today. There is a decreasing supply of original applied scientists and mechanics who genuinely know the aircraft. Troubles with entree and care, along with the incorporation of modern alterations and systems, lead to hapless care patterns which, if left unchecked by direction squads can turn out to be fatal. As stated above modern aircraft are built excessively much higher criterions, nevertheless when keeping old aircraft, the reappraisal made recommendations that proper preparation in Airworthiness Management is required. There is besides a demand for a proper system of coverage and analysis of mistakes and jeopardies identified. A individual Risk Management System is besides mentioned as a manner to maintain hazard analysis and records unvarying across aircraft.

The most of import opportunity anyone had of rectifying the jobs with the Nimrod was in the Safety Case. Unfortunately the reappraisal concluded that the bulk of safety instances in the armed forces were seen as paperwork exercisings. They were designed to be an assistance to believing about the hazards, but had become an terminal in themselves. As mentioned above, proper preparation in hazard analysis techniques and a unvarying hazard direction system are recommended. Additionally safety instances should be re-named ‘Risk Cases ‘ to refocus attending on the hazard component. Safety instances should be brought ‘in-house ‘ , where they can be monitored efficaciously, alternatively of being outsourced. Besides there is a recommendation for an wholly new ‘Safety Culture ‘ . Safety should be paramount in employees ‘ heads and so employees should be encouraged to readily study jobs and mistakes they encounter. There should be an accent on pulling the right decisions from safety information in order to implement any major safety reforms, as opposed to looking for ways to work around the issue. Many premises were made in the Nimrod Safety Review. As a counter to this, the new safety civilization should back up those who ask the “ What if? ” and “ Why? ” inquiries.

The MODs ‘ organisational alterations made in an attempt to make a more managerial construction have brought approximately many jobs. These have had a important impact on the administrations ability to interact with other companies sing the airworthiness of its aircraft. A major factor is the diminution in its ability to move as an ‘intelligent client ‘ . In the instance of the Nimrod Safety Review, the MOD took BAE Systems and QinetiQ ‘s word as Gospel, as they had few skilled and knowing employees to size up their work efficaciously. These deficits in skill lead to the outsourcing of many proficient occupations, which finally meant these companies had a grade of control over them, giving them the capacity to be manipulative. The reappraisal suggests a new forces scheme is devised, in order to recapture the needed degree of accomplishment and work force to convey them ‘out of the dark ‘ in future airworthiness instances. Finally we turn to procurement. Major holds in new equipment have caused old equipment to be in service manner beyond its original terminal of life day of the month. With respect to the Nimrod ; if holds in the MRA4 programme had n’t occurred, XV230 would n’t hold been winging in 2006. The reappraisal states that this MUST non go on once more. Screening out procurance should be of extreme importance in order to forestall an event like the clang of XV230 once more. It is besides recommended that Bernard Gray ‘s study on procurance should be published instantly and adhered to. This study makes recommendations to clear up functions and answerabilities in equipment distribution and acquisition. It besides suggests a Strategic Defence Review should be carried out in the first session of every new parliament to sketch its demands and aims. A 10 twelvemonth turn overing budget should besides be enforced to maintain disbursement at a steady rate.

How the methods address the scenario

With the new steps mentioned above put into topographic point, the procedures of coverage and analysing mistakes and jeopardies will go less equivocal. An addition in qualified airworthiness directors will intend critical elements are less likely to be overlooked. With uniformity set across multiple types of aircraft for hazard analysis, preparation costs across the respective companies will fall. Employees wo n’t hold to relearn ( or make in the Nimrod ‘s instance ) a new method to put on the line analysis and extenuation. When looking at new aircraft, design defects are less likely to be found as standards and ordinances have been greatly improved. For old aircraft still in service nevertheless, these alterations could intend a greatly improved rate of these types of issues being spotted before they cause ruinous effects.

The chief focal point on the recommendations made involve rigorous ordinances and a incorporate method of finishing undertakings. With the Nimrod Safety Case these recommendations are much the same. Proper preparation in hazard analysis will forestall employees transporting out such undertakings from overlooking of import and possibly fatal factors in the hereafter. The recommendation of a new safety civilization is besides a cardinal point. Employees are much more likely to do certain their work and their undertakings are 100 % H2O tight, if the possibility may originate for holes to be openly pointed out.

One of the chief recommendations from the reappraisal was to make a new forces scheme. The purpose behind this being, by holding skilled forces in-house, outsourcing of safety and proficient undertakings will no longer be needed. This means the MOD will non merely be able to maintain a closer ticker on its undertakings, but will profit financially by taking net income borders from the companies work had been outsourced to. The excess financess created by non paying these big companies such as BAE Systems, could be reinvested in procurance to forestall farther undertakings from going over-due and over-budget. The recommendations made by Bernard Gray, if put into topographic point, would assist maintain the MOD on a steady path and forestall the administration from snowballing into a province of upset, as per the aftermath of the 1998 Strategic Defence Review.

hypertext transfer protocol: //www.official-documents.gov.uk/document/hc0809/hc10/1025/1025.pdf

hypertext transfer protocol: //news.bbc.co.uk/1/hi/8329117.stm

hypertext transfer protocol: //www.mod.uk/defenceinternet/aboutdefence/corporatepublications/boardsofinquiry/boinimrodmr2xv230.htm

Description of Scenario 2 – Piper Alpha

Piper Alpha was an oil platform in the North Sea, which began production in 1976. It was subsequently transformed from oil to gas production. On 6th July 1988 a battalion of failures in communicating, processs and direction lead to a black detonation, ensuing in the decease of 167 work forces. There were merely 59 subsisters. In the hebdomads that built up to the accident, a new gas pipe line was being installed. This caused some break, but was nil of major concern. On the forenoon of the 6th July one of the platforms two pumps was undergoing care. A force per unit area safety valve ( PSV ) was removed and temporarily sealed with a level metal phonograph record. Because this care could non be completed by 6pm ( the terminal of the twenty-four hours displacement ) , the on-duty applied scientist filled out a license saying the pump must non, under any fortunes, be switched on. As the dark displacement took over, the license disappeared and the new on-duty applied scientist was ne’er informed of the state of affairs. Subsequently in the flushing the 2nd pump all of a sudden failed and could n’t be restarted. A running pump was critical to maintain the power supply of the rig active and so, without any indicant that this would be an mistake ; the determination to get down the first pump was made. Due to the losing PSV, at 10pm, gas fluxing into the pump caused an overpressure, doing gas to leak at high force per unit area from the antecedently temporarily sealed hole. Almost instantly this triggered an engulfing detonation. The rig had an automatic fire protection system ; nevertheless this had been transferred to manual control earlier in the twenty-four hours to forestall under-water frogmans from being sucked into the system. Without any assistance to battle the fire, the control room was abandoned before any effort to command an emptying from the speaker units was made. As the fire ignited other gas supply pipelines the badness of the state of affairs dramatically increased. Attempts to manually get down the fire protection system failed and so forces tried to do their manner to the lifeboat Stationss. They found their path blocked by fire and so decided to shelter in fireproof adjustment blocks to expect farther instructions. These ne’er came. Finally the platform gave manner and all those left on board tragically died. 59 subsisters were pulled from the sea by deliverance boats after holding urgently jumped from the rig.

Top Degree Requirements

In 1980 Piper Alpha was converted from an oil production rig to gas production. When the platform was originally built, it followed a criterion that meant puting the most unsafe operations off from forces countries. The transition nevertheless, broke this regulation as gas compaction had been located following to the control room, go forthing two sensitive countries situated together. From the beginning the platform had fire walls built to defy intense fire. With the alteration to gas and the scenario of an detonation, these walls did n’t hold a opportunity at making their occupation.

There were many mistakes within the license system. When returning the license saying the pump must non be started, the on-duty applied scientist failed to inform anyone who would be in a place of authorization on the dark displacement. The system of coverage and handing over at the terminal of a displacement was flawed and so of import issues were being missed.

There were two other rigs in the locality of Piper Alpha who pumped their gas to it. When Piper Alpha exploded, these rigs continued to provide gas despite being able to physically see the fires. This farther fuelled the fire, but because of the tremendous cost of closing down a rig, they chose non to because they did n’t hold the authorization.

The platform was equipped with Diesel powered fire protection pumps. In the event of a fire they withdrew H2O from the sea through big blowholes and operated with the purpose to squelch the spread of the fire. Piper Alpha was following excessively an out-of-date process which involved turning these pumps to a manual scene whenever frogmans had entered the H2O. In fact in 1983, an audit of the system changed the process, intending it should merely be set to manual when frogmans were in the immediate environing country of the blowholes to forestall them from being drawn in. In the event of Piper Alpha, this was non the instance.

A major defect with the layout of the rig was the location of the lifeboats. There was merely one path to them, which was blocked by fume and fire. The forces onboard the rig had non been sufficiently trained to move in an exigency and so sought shelter. They did n’t cognize what class of action to take following.

Methods selected to turn to demands

In the aftermath of the accident a study was carried out by Lord Cullen. It was highly critical of the patterns and processs in force on Piper Alpha and provided a list of recommendations with a hope of forestalling a similar event happening in the hereafter. 106 recommendations were made in entire to be implemented across the industry and its regulators. Many of these have now been put into force and are industry broad criterion.

In 1996 The Offshore Installations and Wells Regulations were introduced. They were aimed at guaranting the unity of installings such as Piper Alpha ‘s fire walls and keep a safe on the job environment offshore. They require each offshore installing to subject a instance to the Health and Safety Executive ( HSE ) three times a twelvemonth detailing systems put in topographic point to battle major incidents. This exercising can be seen as a certain manner to forestall subsequent accidents ; it can besides be dearly-won and insistent for companies. This may once more take to a lax in attempt given to the undertaking. An option would be to merely necessitate a new safety instance when a major lending factor has been modified or installed.

The permit-to-work system was raised as a major issue in Lord Cullen ‘s study. His remarks finally lead to the Offshore Installation and Pipeline Works ( Management and Administration ) Regulations produced in 1995. They set out demands for the safe direction of offshore installings by the debut of Offshore Installation Managers ( OIMs ) , whom act as the highest member of authorization on the rig. They should be cognizant of all the care and mistakes at all times in order to do determinations with a holistic position. The ordinances besides required proper enforcement of the permit-to-work system to guarantee duties and jeopardies are successfully allocated. It besides acts as a written log of who is in control at a specific clip. This system is an effectual tool of communicating every bit long as it is enforced purely and respected.

In 1995 The Offshore Installations ( Prevention of Fire and Explosion, and Emergency Response ) Regulations ( PFEER ) were devised. They provided demands and recommendations to protect forces and equipment from fire and detonations, along with an effectual and equal exigency response. A demand of these ordinances province that the OIM will take ultimate control in the event of an exigency scenario. They can reach next rigs to forestall them from doing wrong determinations based on their deficiency of cognition of the state of affairs. This still leaves an component of human mistake in the procedure ; nevertheless these OIMs should be directors as a exclusive business and so will hold been trained to a such a high criterion that they can do the right determinations.

The failure to hold the automatic fire control system runing is non an mistake in statute law, but one of malpractice. The Offshore Installations and Wells Regulations introduced will cover against this go oning once more. With the platforms holding to supply studies to the HSE, the appropriate processs will about surely be followed. The audit that really changed the ordinances in 1983 have non covered all possibilities, but have greatly increased the chance that the automatic fire control system will be enabled, as frogmans will infrequently necessitate to be in the immediate locality of the blowholes.

In order to battle the limited exigency developing criterion of the rig workers, Lord Cullen ‘s study made several recommendations. The OIM was introduced to take ultimate duty and to supply orders in the event of an exigency. It was besides stated that all other employees must be trained aptly in exigency scenarios. If it arose that the OIM could n’t supply counsel, they must cognize how to respond and how to run critical lifesaving equipment such as lifeboats and take a breathing setup.

How the methods address the scenario

With these recommendations now seen as an industry criterion minimal degree of criterions, the chance of another similar calamity on the graduated table has been greatly reduced. Frequent entries of safety instances should convey to light any potentially debatable or fatal elements in operation on the platforms. With the debut of an OIM, there should be less confusion non merely in the province of machinery and care positions, but besides there should be a greater trade of lucidity in an exigency scenario. If these recommendations had been made before the twenty-four hours of the accident, it is really likely that the on-duty applied scientist would hold known the province of both pumps. An detonation would hold been contained efficaciously and successfully subdued by the fire protection system. Any necessary emptying would hold been efficient and everyone onboard the rig would hold survived.

hypertext transfer protocol: //www.oilandgasuk.co.uk/cmsfiles/modules/publications/pdfs/HS048.pdf

hypertext transfer protocol: //www.ecademy.com/node.php? id=80465

hypertext transfer protocol: //www.stb07.com/process-industry-incidents/piper-alpha-fire-explosion.html

hypertext transfer protocol: //www.fabig.com/NR/rdonlyres/286997DB-836D-480F-874E-A47E38151D1D/2605/PiperAlpha.pdf

The Public Inquiry into the Piper Alpha Disaster, Cullen, The Honourable Lord, HM Stationery Office, 1990

Description of Scenario 3 – Eyjafjallajokull

Approaching the terminal of 2009 seismal activity started to be detected around Eyjafjallajokull, a vent located in the South of Iceland. They bit by bit increased until on the 20th March 2010 it erupted. Although the eruption was non of great magnitude, an ash cloud was created throwing volcanic ash several stat mis into the ambiance.


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