The teacher asked us to ask more why (why this happened) and asked us to use the lecture notes

| October 22, 2018

aim of this assignment is to seek and improve the knowledge of Organisational
Behaviour, and various reasons to organizational behavioral issues thatbelieved were evident in the organisations and
how they might have developed. We will be discussing how and why like these
organizations were wrong or has not been guided seriously and also what other
actions could be done in order not to an incident occur. Although the troubles
which have been made by the organisations, leaders and managers that did not
act and decide responsibly or ignored the problems which presented itself.

Hawker Siddeley nimrod was a military Aircraft which has been made in the
United Kingdom. It was designed as Royal Air Force maritime patrol aircraft.
Nimrod has been originally created by “De Havilland” successor, which is an
aircraft company and it is a group of British manufacturing companies engaged
to Aircraft production, now part of BAE System. It served from early 1969 to
march 2011 to play an important role in Defence. On 2ndof September
2006, in Afghanistan, the RAF Nimrod XV230 was lost when it suffered a
disastrous mid-air fire, leading to the total loss of the aircraft and the
death of all 14 crews on board. There were several matters that caused the
incident. The main issue was from fuel and ignition which considered two of the
physical causes. These all troubles were
because of incapability of an organisation in neglecting or wrong decision
making, Mistakes that mainly caused by different organisations culture,
behaviour, structure, leadership and management lack of knowledge and
communication which in this case was mostly because of regulations and
legislations that has been ignored. All three organisations (BAE, IPT and
QINETIQ) failed somehow in Nimrod Safety Case and they needed trilateral
relationship in order to avoid the incident. Aircraft age, Defence
Establishment and Industry was inevitably complex sophisticated, incestuous,
and elliptical. It is also a very necessary and valuable relationship, not
least because of the need to design, develop, build, test and maintain
increasingly high-technology and high-cost weaponry. The story of the loss of
Nimrod XV230 and the NSC should be a catalyst to a careful re-examination of
the various relationships at all levels, in order quickly to rebuild trust in
the short term and in the longer term to develop joint values and new ways of
working together to achieve common outcomes. To be far more discriminating in
the future as to what is, and is not, outsourced in Industry. Also cost and
budget cut in order to change out-of-service old equipment was another issue
that might take into consideration.


and their tasks.
British aerospace systems:
Nimrod XV230 which crashed badly on September
2006 was made by BAE systems. Before that sad incident the BAE systems with
Ministry of Defense Nimrod IPT made the nimrod safety case to identify the
’serious design flaws’ that was present on Nimrod between 2001 and 2005.
The table below represents the main characters
involved in BAE systems.

Richard Oldfield:

Nimrod review’s

Did not fully
show up the hidden risks present on the Nimrod

As a leader, did
not support position with full responsibility

Chris Lowe

airworthiness engineer.

The one behind
“poor planning, poor management and poor execution” of the project.

Eric Prince

The manager of
the flight systems and avionics.

Played main role
in the safety review.

Table 1

Nimrod integrated position team(IPT)
Nimrod IPT was in charge of the planning of the
Nimrod safety case (Third Phase). The table below shows the main characters
involved in Nimrod IPT(Haddon-Cave2009).

Frank Walsh

The safety review

Worked as primary
point of contact to the team at BAE Systems tasked with planning of the
safety review.

George Baber

MOD integrated
project team leader.

In the Nimrod
review, Mr Haddon-Cave allege George Baber of “fundamentals failure of

Wing Commander
Michael Eagles

Chief of air

Responsible for
the production of the safety review and it was found that Wing Commander
Michael Eagles passed on the project to a civilian worker.

Table 2

Qinetiq was the independent adviser to the
Nirmod Safety Case with also the responsible of signing off or approving the
Nimrod Safety Case.
The table below
shows the main characters involved in Qinteq (Haddon-Cave2009)

Colin Blagrove

assurance manager to the Nimrod Safety Review.

Carried the
responsibility of signing or approval, unless it has been appropriate to do
so and failed in his specific task in accordance with the Nimrod report.

Martyn Mahy

Nimrod review
task manager for Qinetiq.

Mr Haddon-Cave
Criticized for having to do his work in certain areas such as consent to
sign-off on the Nimrod safety case “without seeing or reading documents”.

Table 3

Key Organisational Issues
The nimrod’s incurable crash has been
reviewed for several times.
The organisation and maintenance of the
aircraft were the key aspects of its failure. The military was attempting to
conceal its mistakes for numerous years. They tried to hide their malaise and
disrespect for military producers. Several warning signs were not addressed,
and this results in the huge failure of the aircraft.(Opinion)

was a difficulty to analyse the nimrod’s failure due to that most of the
wreckage was hunted by locals in the area, there was not much left to analyse. The
flight logs and black box were claimed by a ground force that made it to the
crash location. However the revolutionaries were attacking them continuously
and finally forced to retreat. By the time they were able to come back in force
to recover and analyse the wreckage, most of it was gone. Therefore the
military was left with very little to analyse.
independent investigator Charles Haddon-Cave QC mentioned in his report, it was
clear that “had been a “systemic breach” of the Military Covenant –
the nation’s duty of care to the Armed Forces.” (Charles Gall, 29th October
2009, Daily record). Charles Haddon then carried on to explain that there had
been safety report before the incurable crash, though “lamentable
job” which was “riddled with errors” (Charles Haddon-Cave QC, Nimrod
report). Lastly he added, “In my view, XV230 was lost because of a
systemic breach of the Military Covenant brought about by significant failures
on the part of all those involved. “This must not be allowed to happen
again.” (Charles Haddon-Cave QC, Nimrod report). (why)
From this report, it is
obvious that there was significant malaise to proper service of the aircrafts.
The ageing fleet had many issues that directed at it. The RAF officers and managers of
the fleet has received from the confidential airworthiness report team that
there were, “almost 60 “airworthiness concerns” and
“airworthiness hazards” (Brian Brady, 11 SEPTEMBER 2011, The
Afterward none of these
issues were addressed. In
a safety assessment of the 25 Nimrods in service the review declared that
“low manning levels, declining experience, failing morale and perceived
overstretch” had directly caused the downfall of the Nimrod fleet. (Brian
Brady, 11 SEPTEMBER 2011, the Independent). This shows how despite several clear notices to the MOD,
there was no action taken to correctly service these ageing, out of date and
failing aircraft.
Nothing was done despite of
all these warning reports that the aircraft was not suitable for flight. It is now emerging that “RAF
chiefs at the time dismissed the report’s warnings”. (Brian Brady, 11 SEPTEMBER
2011, The Independent)

of the fathers of the sufferers is still trying to seek legal action. He mentions
that “I was aware of the failings of the Nimrods, but I did not know that they
had been put so clearly in a report eight years before the XV230 went down”.
(Graham Knight, father of lost serviceman). Charles Haddon-Cave QC confirms
that, “Nart concerns and warnings were not sufficiently heeded in the… years
leading up to the XV230 accident.” Charles Haddon-Cave QC, claims that this was
most likely the reason for the failure of the Nimrod.

▪ Discussion:

Possible Outcomes and Consequences
Three main organisastions were deeply criticized by the
report , (BEA systems, Nimrod IPT and Qinetiq) ,All
three organizations failed somehow in Nimrod Safety Case and they needed
trilateral relationship in order to avoid the incident.the review also included Ministry
of Defence and the Royal Air Force to the list to take responsibility for
incident, Besides the individual mistakes by the key role personnel , the lack
of organisation played a major role in the tragedy.
The report show
many of the important lessons to learn from them, but unfortunately these
lessons are not new, espically in terms of organzational causes, and share with
a lot of famous incidents previously for example ( The explosion of the
challenger and the colobmbia space shuttles)
main similarities which have included organizational issues comprehend (Haddon
C and Cave QC 2009):

*Implementing of ‘business’ principles.

* Organisational disorder and rapid
* Perfect place culture
* Normalisation of deviance
* Cuts in resources and manpower.
It is obvious that most of the
points Haddon-Cave represented regarding the rapid changes are mostly caused by
a financial crisis. These issues result in controversial decisions which
compromise the future of the organization in order to minimize the expenses, by
cutting down the quality of the service. For this reason it is difficult to
think that in this context lessons has been learnt. This is not because of the
organisational behaviour, but generally because of the individual behaviour of
key rule personnel.
The report outcome has urged countries
like Britain and Australia to take a step in the field of safety of engineering
systems .For instance the Royal Academy of
Engineering (RAE) in the UK was among participants by releasing researches and
documents that support the new safety approach recommended by the Nimrod
of Haddon-Cave recommendation that was embraced the RAE in the UK , is that a
single professional body should be formed for Safety Experts to set
professional and ethical standards, RAE turned the recommendation into practice
by finding a way for the different institutions to work in cooperation and
share vital information. (Altinisik H, 2010)
Moreover, the Royal New Zealand Navy did not hesitate on
making similar approach towards avoiding future incidents. Implementing the
safety rules recommended by Nimrod report and growing emphases on guidelines
such as (Holmes.b) :
-“Training needs to deliver fully competent people”
– “Safety Cases are not a tick box paper exercise”
– “There are safety implications to address if changing
– “approach e.g. from ‘function’ to ‘project”
An extra positive result of
the report is the significant change in the Australian defence material
organization (DMO) which took place over the last two decades. As a result of the heavy
bureaucracy system major changes were implemented by The DMO in terms of
structure and culture. It was very essential to replace the management of main
military services by a trained civilian force in order to catch up with most
western militaries and build an efficient in addition to a professional force.(
Air Cdre E. J. Bushell, 2011)
Unfortunately, as a result of rapid of changes, organisational
disorder and the misconception of running the DMO organisation like a ‘simple’
business, it went through heavy downsizing and de-skilling.( Air Cdre E. J.
Bushell, 2011)
The Nimrod review findings and the internal deterioration of the
organisational structure shared similar ideas, which led the Australian Senate
and the Department of Defence to realize the potential of disaster and
recommended to implement the Haddon-Cave review as a model for the future. (Air
Cdre E. J. Bushell, 2011)
It is impossible to go back
on time and avoid this disaster. Respectively, the accident left a better
experience for us to learn from and established a solid foundation to assist
large organisations around the world by improving their organisational

In conclusion, there were many causes for the loss of XV230, There were
physical causes like ignition source, probable fuel sources, responsibility for
design flaws and previous incidents. Also there were organisational causes
which are our main concern in this assignment. The organisational causes played
a major in the loss of XV230. It adversely affected the ability of the Nimrod
IPT to do its job. the oversight to which it was subject, also the culture
within which it operated.
The key aspects of the failure lie beyond the organisation and the
maintenance of the aircraft. There were numerous warning signs that were not
addressed as the military tried to cover up its mistakes and hide their malaise
and disregard for military procedures.
There were three main organisations (BEA Systems, Nimrod IPT and
QinetiQ) that had a failure of leadership, culture and priorities. These three
organisations were directly involved in the accident as well as criticism
towards the Ministry of Defence and the Royal Air Force. Most of the lessons
which were learnt regarding the organisational causes are not new and share
major similarities with iconic accident cases.
The Nimrod report had many positive outcomes in many countries like
UK, New-Zealand and Australia. One of positive outcome was from the Royal
Academy of Engineering (RAE) which released an official document supporting the
new professional approach of safety of engineering systems. The Nimrod Review
provides clear tools and recommendations which helped large originations to
improve their organisational behaviour, safety culture and many other
recommendations which have been list below.

The lessons to the learned from the loss of Nimrod XV230 are profound
and wide-ranging, many of the lessons to be learned are not new. The
organisational causes of the loss of the aircraft echo other major accident
The Nimrod Report made some recommendations in eight key areas:
1 – A new set of Principles: It’s very important to identify the right
principles and make sure that always to be guided by them.
2 – A new military Airworthiness Regime: To build a new military
airworthiness regime which is effective, relevant, and understood which
addresses risk to life and drives new attitudes, behaviours and new safety
3 – A new approach to safety Cases: Make the best practice for safety
cases for the future, which are to be brought in-house and re-name it to
“Risk Cases”.
4 – A new attitude to aged Aircraft: Address the generic problems that
associated with aged and legacy aircraft.
5 – A new personnel Strategy: Address the current weaknesses in the
area of personnel.
6 – A new Industry Strategy: Address the flaws in the current
bilateral and triangular relationships between the MOD, BAE Systems, and
7 – A new Procurement Strategy: Bernard Gray’s report on procurement
is published without delay and appropriate action taken as matter of urgency.
8 – A new
Safety Culture: Making a new safety culture that comprising a reporting
culture, a just culture, a flexible culture, a learning culture and questioning

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