"We are working hard to ensure we capture lessons from incidents and inquiries to improve our safety. As an organisation the MOD is changing its culture and approach to put safety first."
So says the lamentable Bob Ainsworth.
How many times have we heard that? How many times have we heard some government minister telling us that lessons have been learned and changes made? And how many times have we been let down?
And before we go any further, just take a moment to imagine it was your partner, your son, your brother, or your father who went down with the plane.
I haven't read the whole of the 587 page Haddon-Cave Review of the 2006 Nimrod crash, but what I have read tells a familiar story of bungling, complacency, and denial:
"If the Nimrod Safety Case had been drawn up with proper skill, care and attention, the catastrophic fire risks to the Nimrod fleet... would have been identified and dealt with, and the loss of XV230 in September 2006 would have been avoided...
Unfortunately, the Nimrod Safety Case was a lamentable job from start to finish. It was riddled with errors. It missed the key dangers. Its production is a story of incompetence, complacency, and cynicism."
It is a shameful tale, and nobody emerges with credit. Unusually for such an enquiry, the Review names names, in the MOD, the RAF, and the private contractors involved - BAE and Qinetiq. They should all hang their heads - as well as getting sacked.
But the real lessons go much deeper. The real lessons relate to those fundamental flaws in government we blog so often.
To start with, the only reason fourteen of our servicemen were flying in that ancient clapped out plane at all, was because our politicians decided to overrule the advice of their frontline professionals.
As BOM readers will recall, back in 1996 the RAF and MOD procurement team wanted to replace the ancient Nimrod MR2 fleet with the Lockheed Orion, the world's most successful maritime reconnaisance aircraft. But the politicians effectively overruled them, opting instead for an updated version of the Nimrod.
Why? Well, we'll never know exactly, but we may presume it was to shore up BAE which depends critically on MOD orders. In other words, it was a decision made on industrial policy grounds rather than military needs (the Defence Secretary at the time was BBC TV pundit Michael Portillo, who subsequently became - yes, you guessed it - a non-executive director of BAE).
Second, the reason the Nimrod MR2 is still flying, rather than its replacement MR4, is that BAE has still not finished the new version. The MR4 was originally supposed to go into service in 2003, but the latest official estimate is 2011 - eight years late. Eight years in which our servicemen have been expected to go on flying in dangerous planes that are older than they are themselves (indeed, when you consider the Nimrod is basically a converted Comet airliner, these planes are actually even older than Tyler).
And of course, the delay is on top of a truly wild cost escalation. The project was originally supposed to cost £2bn for 21 planes- £95m each. But we're now paying £3.6bn for 12 aircraft- £300m each. That's a price increase of 216%.
Should we blame BAE for the overruns? Well, yes, of course. But it fits into a much broader pattern of government being incapable of managing its contractors effectively. We've blogged this issue many times, and it includes the inability to spec the job properly, the inability to draw up workable contracts, the inability to price jobs realistically, and a chronic inability to stick to the original spec. The all too predicatable result is delay and cost overruns, just as we see with Nimrod.
Third, the reason the MR2's known safety issues were not tackled - or better still, the plane grounded - was that the 2001-2005 safety review (the "Safety Case") was little more than a gigantic box-ticking exercise. Haddon-Cave says:
"... the task of drawing up the Safety Case became essentially a paperwork and ‘tickbox’ exercise...
... The Nimrod IPT [the MOD's own project team] inappropriately delegated project management... to a relatively junior person without adequate oversight or supervision; failed to ensure adequate operator involvement in BAE's work; failed to project manage properly, or to act as an ‘intelligent customer’ at any stage; failed to read the BAE System Reports carefully or otherwise check BAE Systems’ work; failed to follow its own Safety Management Plan; failed properly to appoint an Independent Safety Advisor to audit the Nimrod Safety Case; and signed-off BAE Systems’ work in circumstances where it was manifestly inappropriate to do so. Subsequently, the Nimrod IPT sentenced the outstanding risks on a manifestly inadequate, flawed and unrealistic basis, and in doing so mis-categorised the catastrophic fire risk... as ‘Tolerable’ when it plainly was not. The Nimrod IPT was sloppy and complacent and outsourced its thinking."
We encounter this kind of sloppiness in government all the time. Senior managers who delegate critical functions to juniors without proper supervision. Non-existent project management. Failure to act as "an intelligent customer". Failure to check contractors' work. Failure to follow their own procedures. Failure to audit results.
Government is very good at compiling massive codes of practice and rules both for itself and other people. But when it comes to practical execution in the real world, it is terminally hopeless. It simply isn't up to the job.
Fourth, the Nimrod disaster reflects the unintended consequences of this government's much-hyped "efficiency" programmes. Haddon-Cave describes how the cuts demanded by the 1998 Defence Review sent the MOD into "organisational trauma":
"Financial pressures and cuts drove a cascade of multifarious organisational changes, which led to a dilution of the airworthiness regime and culture within the MOD, and distraction from safety and airworthiness issues as the top priority. There was a shift in culture and priorities in the MOD towards ‘business’ and financial targets, at the expense of functional values such as safety and airworthiness."
As we've blogged many times, these so-called efficiency programmes may sound good on paper, but they almost always degenerate into farce (Gershon) or tragedy, as here. Government just doesn't do efficiency. To get better value we have to dismantle it.
But defence is a rather special case. Government has to do defence. And that being so, our first and overriding priority must be to support our servicemen and women, especially in the line of fire. It is completely unacceptable to put their lives at risk in an attempt to shave 20% off the logistics budget, as apparently happened here.
Yes, we should switch to buying off-the-shelf kit (like the Orion). But beyond that we should recognise that we will always end up paying over the odds - that's just the way government is (eg see this blog).
So to summarise, the real lessons of the Nimrod killings are:
- Politicians should not override the operational judgements of frontline staff
- Government is hopeless at managing outside suppliers - and the end-customers become the victims
- Government is hopeless at project management - and indeed, at management more generally
- Government is hopeless at efficiency programmes - cuts are never the same as efficiency savings
But of course, we knew all that long ago. It really should not have taken 14 more service deaths to remind us.
PS BAE comes out of this even worse than the MOD. The Review says: "BAE Systems bears substantial responsibility for the failure of the Nimrod Safety Case. Phases 1and 2 were poorly planned, poorly managed and poorly executed, work was rushed and corners were cut. The end product was seriously defective... The work was riddled with errors of fact, analysis and risk categorisation... These matters raised question marks about the prevailing ethical culture at BAE Systems." BAE may claim that the cause of the crash “will never finally be determined”, but if I were a relative I'd be suing.