In the past two years, almost at regular intervals, we received recurrent news about the failure of a Russian rocket launch. A few weeks ago, on July 2, a three-stage Proton-M took off from Baikonour Cosmodrome. The rocket started veering off course right after leaving the pad, deviating from the vertical path in various directions and then plunging to the ground nose first less than 40 seconds after liftoff. The fragmenting and still thrusting vehicle crashed approximately 2.5 km from the launch pad. The immediate safety concern was the 600 tons of fuel: unsymmetrical dimethylhydrazine, a toxic chemical compound that can be absorbed through the skin, and dinitrogen tetroxide, an inhalation and contact hazard causing edema and skin burns. Toxic clouds began drifting over the Kazakh plains following the crash. The Cosmodrome was evacuated and the inhabitants of Baikonour were instructed not to leave their homes, to deactivate air conditioners, and tightly close all doors and windows to avoid intake of contaminated air. In the following days a total area of 13,100 m3 had to be treated with detoxifying chemical solutions. The rocket slammed into the ground under full thrust, thus creating a catastrophic risk for launch personnel. The impact created a 40 by 25 meter crater with a depth of up to five meters.
The broader cause of this and, indeed, all Russian rocket failures of recent years is the frequent inadequacy and disparity of the quality control system of the myriad companies involved in the manufacturing of space hardware. It is a problem that will require a vast cultural revolution to resolve. The Russians started paying attention to quality as early as 1961 when a decree on “measures to improve military technology” laid the basis for institution of quality control by the military to improve the reliability of space systems. The core of their approach, however, was a capillary network of technical surveillance activities performed by military inspectors. This was exactly the opposite of what was being done in the same years in the US, where military inspections were basically dismantled in favor of the institution of independent quality assurance services by manufacturers, with emphasis on prevention. In 2009 the independent military oversight of Russian launcher production was disbanded and each company had to establish its own quality assurance capability.
The Proton’s failure was caused by some critical angular velocity sensors that had been installed upside down. The paper trail led to a technician responsible for the assembly of the hardware. The improper installation apparently required some considerable physical effort in a location difficult to access. The technician’s supervisor and a quality control specialist, who were supposed to check upon completion of the installation, both signed the assembly log to indicate that they had done so. The investigation team identified deficiencies in the installation instructions and in the mechanical design of the hardware.
How is it possible that a technician fails to perform an operation that has been repeated successfully hundreds of times over several decades? Russian technicians and engineers need to abandon their traditional attitude of seeking and maintaining jealous ownership of technical knowledge, and of guarding their mastership – the “secrets of their trade” – as a safe-conduct and a personal asset. Knowledge must be managed and transferred by means of specifications and procedures which are maintained through an effective system of non-conformances, reporting, and corrective actions. Furthermore, critical process procedures need to be revalidated by means of modern techniques like Process FMEA (Failure Mode and Effects Analysis), to ensure that effective means of human error prevention are in place. Re-establishing independent military inspection of space hardware is not the right answer to the current quality problems of the Russian space industry. Inspection is not prevention, and PREVENTION is the essence of modern QUALITY CONTROL!
Find this article and more in the Summer 2013 edition of Space Safety Magazine.