Rocket Crashes Because of Human Failures

I am sure that everyone, at some point in their lives, has been told to check their work, be it at school or in the office.  As a kid, I know I used to skip this step more often then not.  I mean, what were the consequences?  I would get the homework problem wrong.  Oh well, no big deal.

Error Prevention is Everyone's Concern

In the real world, there are times when this step is vitally important.  At the nuclear power plant where I work, human performance and error prevention are two of the most discussed topics on site.  There is an obsessive focus on training, communication, following procedure, and stopping in the face of uncertainty.  It is far better to proceed slowly and safely, rather than quickly and in the face of uncertainty.  The consequences of an error here can result in a worker injury or fatality, an unplanned radiation exposure, damage to plant safety equipment, an inadvertent trip of the Reactor Protection System causing an immediate shutdown,  a reactivity excursion, loss of power to a vital system, or worst case, damage to the core or release of radiation to the environment.

Another industry where this mindset is just as important is aerospace.  NASA employs very similar techniques to minimize the possibility of an error occurring.  Just like in a nuclear power plant, the consequences of an error can result in the loss of a launch vehicle, payload, or human life.  While they normally do an outstanding job, obviously this process is imperfect, as NASA has had its fair share of accidents.  The Mars Climate Orbiter crashed into Mars in 1999 while controllers attempted to put it into orbit around the planet due to a mix-up between metric and imperial units.  The space shuttle Challenger was destroyed during launch in 1986, taking with it all seven crew members, because NASA managers proceeded in the face of uncertainty and ordered the launch of the shuttle in weather conditions it could not cope with.  

An Entire Organization Fails

The Russian Federal Space Agency (Roscosmos) obviously does not operate under the same standards as the nuclear industry or NASA.  There have been more than a few Russian spacecraft that have been either destroyed during takeoff, failed to reach Earth orbit, or crashed on the planetary body they were destined for.  Most recently, a Russian Proton-M rocket crashed right after takeoff, destroying its $200 million payload of three GLONASS navigational satellites.  After an investigation into the crash, the cause appears to be several angular velocity sensors being installed upside down.



This is a failure of the entire organization.  Reports suggest a young (inexperienced) technician is to blame, but an error of this magnitude is never the fault of just one person.  The technician was undoubtedly following some sort of installation procedure, which either was not written well enough to ensure success, or was not employed properly to make sure the technician had it in front of him during the installation.  The design of the sensors is such that it can be installed incorrectly.  There is no bolt pattern that ensures proper orientation, no notch that allows the sensor to fit in only one direction.  These are techniques that are employed in many industries, as well as in Ikea furniture.  There apparently was so independent verification by another technician to verify the work was done correctly.  The Quality Assurance program was insufficient to make sure errors as obvious as this did not get through.  This is a failure of everybody involved.

You may or may not have a job where an error has as severe an impact as this, but we all should be cognizant of the effect our job performance has on others.  Very few people have a job where no one else relies on them to succeed.  It is up to us to fight human nature and not get complacent and lazy, otherwise mistakes will happen, and people will get hurt.