Charles Haddon-Cave’s Nimrod Review: An Independent Review into the Broader Issues Surrounding the Loss of the RAF Nimrod MR2 Aircraft XV230 in Afghanistan in 2006 was laid before Parliament and published by the Stationery Office on 28 October. Two days later it was out of print. The Review was not a Public Inquiry with statutory powers. It sat in Ministry of Defence premises. Some staff were seconded from the ministry. But its conclusions, and its naming of the incompetent, leave no doubts about its independence.

The accident to XV230 was avoidable.

My report identifies manifold shortcomings in the UK airworthiness and in-service support regime, and reveals matters which are as surprising as they are disturbing.

The Nimrod Safety Case took a total of nearly four years to produce (April 2001 to March 2005) and cost in excess of £400,000… [It] 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.

The Nimrod Safety Case process was fatally undermined by a general malaise: a widespread assumption by those involved that the Nimrod was ’safe anyway’ (because it had successfully flown for 30 years).

Haddon-Cave looked at the organisational causes of other major accidents, notably the loss of the Space Shuttle Columbia, and found strong similarities. Both had long incubation periods. Strong signals of problems had been identified and recorded, but analysed away. Diane Vaughan in her study of the Challenger Space Shuttle disaster coined the phrase ‘normalisation of deviance’ to categorise this phenomenon: for Challenger it was a fault in the O-rings in the solid booster rockets; for Columbia it was foam insulation coming loose. These were judged – wrongly – to be acceptable risks.

The normalisation of deviance is not peculiar to aviation or space travel. The categorisation of escalator fires on the London Underground as ’smoulderings’ before the King’s Cross fire is another example.

I chaired a public inquiry into the 2005 South Wales E.coli O157 outbreak (157 cases, mostly in schoolchildren, with one death). There was a normalisation of deviance. In 1994 the abattoir that supplied contaminated meat to the butcher responsible for the outbreak had an unannounced independent inspection. Its hygiene scored 11 out of 100, the worst ever recorded in Britain (scores less than 66 were deemed to be unacceptably low). A recommendation went up the line that it should be closed. But it was not. Months and years went past. There was no significant improvement. Deficiencies were recorded, but not rectified. The same independent inspector visited in April 2005. He concluded that the problems he found looked remarkably similar to those in 1994. The outbreak occurred in September. Like the MOD, the Meat Hygiene Service had failed.

Food hygiene is assessed using a system known as HACCP: hazard analysis and critical control points. Haddon-Cave’s description of what he found with Nimrod – a lamentable job, riddled with errors, missing the key dangers – applies to the butcher’s perfectly. His HACCP said things that were untrue (for example that the butcher had a ‘number of quality awards for excellent service and hygiene standards’), it made claims that were physically impossible to achieve (about the speed of cooling of meat), and it did not consider the processing of bought-in products (errors in their handling caused the outbreak). The environmental health officers who inspected the butcher failed to spot these deficiencies, just like the wing commander (since promoted to air commodore) who signed off the Nimrod safety case, having ‘failed to check carefully and query what he was signing’.

From ‘Slate’, 9 February 1999:

Last week I went to Claude Lévi-Strauss’s 90th birthday party at the Collège de France. It seemed an unremarkable occasion at first. Though the courtyard of the Collège de France is fittingly grand for the republic’s premiere scholarly institution, the rooms inside are meanly proportioned and shabby. The three dozen or so academics in attendance looked dreary and moth-eaten the way academics do. There was a sprinkling of journalists, but no cameras or microphones. Fortified by a couple of glasses of indifferent burgundy, I obtained an introduction to Lévi-Strauss, who rose with difficulty from his chair and shook my hand tremulously. The conversation went poorly, owing both to my shaky French and to my lack of conviction that the nonagenarian I was talking to could actually be Claude Lévi-Strauss. More »

When I was growing up in County Wexford the highest ambition you could have was to play hurling for your county. I remember being taken as a nine year old to watch my older brother play for Wexford in Croke Park in Dublin, which is the national stadium for Gaelic games. Even as I sat there watching my brother’s prowess, I knew that I would never match up to him, that I was a wimp and would always be one. Hurlers and players of Gaelic football were heroes; they were role models and figures of enormous moral authority and seriousness. They put their whole lives into sport without earning a penny. It was done for love, for duty, for patriotism; it was done for your club and county. They were towers of masculine strength. The hurlers especially were lithe and fit. To be a player of Gaelic games was to place you beyond sex; and this meant that they were straight, or were supposed to be. A gay hurler was something that happened only in your dreams. It was pure impossibility. More »

The Economist’s blog on American politics is called ‘Democracy in America’, its Asian blog ‘Banyan’ and its European blog ‘Charlemagne’ – names with such earnest symbolic authority that you might think for a second that the Economist had launched a fleet of new aircraft carriers. All Economist blogs are unsigned, which is in keeping with a publication that prides itself on corporate anonymity, but many entries are written in the first person. For example, four recent posts include the following sentences:

Yesterday my colleague posted on the partisanship of Fox News, suggesting we shouldn’t take the network seriously.

For the first time so far in my career, I briefly fell for a hoax.

I’ve long believed that Mongolia, among wild countries, is the Last Best Place, to steal the slogan for Montana.

I have real problems with the idea that because Europe is in relative decline, we have no right to promote our values.

Whoever he or she is, whatever their colleague may have posted and whether they fell (so unfortunately) for a hoax; regardless of what they make of Mongolia or of European ‘values’ – why is it such a struggle to say who they are? What do ‘our values’ and your ‘real problems’ mean if we don’t know who you are?