The Weekly Reflektion Week 08 / 2020

This week’s Reflektion considers the attitude of management to acceptance and encouragement of ‘Stop the job’ mantra, which many consider to be a barrier to major accidents. Thanks to Pam Currie for input to this Reflektion.

How do you encourage your organisation to ‘stop the job’ if they consider something to be unsafe? Is anybody listening if they have doubts? How can you strengthen this aspect of your defences?

During the Cold War between the Eastern and Western Blocs after the Second World War, one aspect of competition was the race to dominate space, commonly known as the Space Race. This period was characterised by rapid innovation and technical advancement, but also by many accidents and loss of life. Leonid Brezhnev, the leader of the Soviet Union from 1964 until his death in 1982, wanted a spectacular celebration of the 50th anniversary of the Bolshevik Revolution in 1967. The concept of two spacecrafts, Soyuz 1 and Soyuz 2, docking in space and cosmonauts exchanging places from one vehicle to another was proposed and then chosen. Vladimir Komarov was chosen as the pilot for Soyuz 1, with his friend, Yuri Gagarin as back-up pilot. Komarov commanded the Voskhod 1 space craft in 1964, which was the first space flight to carry more than one crew member.

There was limited time available from project conception to execution, and there was general concern among the crews that the risks were far too great and it was beyond the capabilities of the engineering team to mitigate the risks before May 1st, the anniversary. Nikolai Kamanin, the man responsible for cosmonaut training, criticised the Soyuz spacecraft as being shoddily constructed, with antiquated communications systems. A team of 50 engineers inspected the Soyuz spacecrafts and found 203 issues, which were detailed in a 10-page memo sent to the project management team arguing for a delay in the mission. The cosmonauts became very anxious due to the lack of response from project management. It’s not entirely clear what happened to that report, but what is clear that its message wasn’t heeded. There was no acceptance for postponement as the celebration could not be delayed.

Komarov was convinced that the project was doomed, but did not want to withdraw, both because he would be dishonoured, and because, his friend, Yuri Gagarin, would have to take his place. He decided to take the flight but requested a funeral with an open casket so that the Soviet leadership could see what they had done.

Soyuz 1 lifted off on April 23rd, but one of two solar panels failed to deploy, leaving the capsule with only half power. The solar panel that failed to deploy stayed wrapped around the service module and blocked orientation sensors. Given these problems with Soyuz 1, the Soyuz 2 flight was cancelled immediately, and the focus turned to getting Soyuz 1 safely back to Earth.

On his 19th orbit, Komarov managed to fire the retro-rockets to re-enter the Earth’s atmosphere, however, the two parachutes which would slow the descent of Soyuz 1 failed to deploy properly. Both Komarov and ground control knew that nothing could be done, and that this was the end. While falling to his death, Komarov called his wife to say goodbye, and cursed in rage at the Communist Party for being responsible for his misfortune. These transmissions were picked up by listening Western Bloc radio operators. At 0700 hrs on April 24th, Soyuz 1 crashed into the Russian Steppes near Orenberg, close to the border with Khazakstan, killing Komarov instantly.

His remains were quickly cremated, but he got his wish of a funeral with an open casket. Gagarin criticised the mission saying that Komarov’s death should teach the establishment to be more rigorous in its testing and evaluation of the spacecrafts. He also criticised the program head, Vasily Mishin, for poor knowledge of the Soyuz spacecraft and its operational details, and lack of cooperation in working with cosmonauts. An investigation team was raised, including Gagarin, with a mandate also covering a review of the design and as-built documentation for the spacecraft, subsystems, and training program.

Have you ever said stop for an activity you have had responsibility for? If members of your team have issues with safety, would they say stop? What have you done to ensure a concern will be taken seriously and the job stopped? Do the people in your organisation think it’s pointless to complain because no-one is listening?

Reflekt AS