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December 2015 VOL. 2 NO. 2 - DECEMBER 2015 Editors: Michael T. Kezirian, Ph.D. Joseph Pelton, Ph.D. Tommaso Sgobba Journal of Space Safety Engineering – Vol. 2 No. 2 - December 2015 JOURNAL of SPACE SAFETY ENGINEERING Volume 2 No. 2 – December 2015 EDITORS Michael T. Kezirian, Ph.D. Tommaso Sgobba Joseph Pelton, Ph.D. The Boeing Company European Space Agency (ret.) George Washington University (ret.) University of Southern California Managing Editor Assistant Editor-in-Chief Editor-in-Chief EDITORIAL BOARD George W. S. Abbey Joe H. Engle Isabelle Rongier National Aeronautics and Space Administration (ret.) Maj Gen. USAF (ret.) Airbus Safran Launchers Sayavur Bakhtiyarov, Ph.D. National Aeronautics and Space Administration Kai-Uwe Schrogl, Ph.D. University of New Mexico Herve Gilibert European Space Agency Kenneth Cameron Airbus Space & Defense Zhumabek Zhantayev Science Applications International Corporation Jeffrey A. Hoffman, Ph.D. National Center of Space Researches and Luigi De Luca, Ph.D. Massachusetts Institute of Technology Technologies (NCSRT)- Kazakhstan Politecnico di Milano Ernst Messerschmid, Ph.D. University of Stuttgart (ret.) FIELD EDITORS William Ailor, Ph.D. Gary Johnson Erwin Mooij, Ph.D. The Aerospace Corporation Science Application International Corporation Delft University of Technology Christophe Bonnal Barbara Kanki John D. Olivas, PhD, PE Centre National d’Etudes Spatiales National Aeronautics and Space Administration (ret.) University of Texas El Paso Jonathan B. Clark, M.D., M.P.H Bruno Lazare Nobuo Takeuchi Baylor College of Medicine Centre National d’Etudes Spatiales Japan Aerospace Exploration Agency Victor Chang Carine Leveau Brian Weeden Canadian Space Agency Centre National d’Etudes Spatiales Secure World Foundation Paul J. Coleman, Jr., Ph.D. Tobias Lips Paul D. Wilde, Ph.D., P.E. University of California at Los Angeles (Emeritus) Hypersonic Technology Goettingen Federal Aviation Administration Natalie Costedoat Michael Lutomski Uwe Wirt Centre National d’Etudes Spatiales Space Exploration Technologies German Aerospace Center (DLR) AIMS and SCOPE The Journal of Space Safety Engineering (JSSE) provides an authoritative source of information in the field of space safety design, research and develop- ment. It serves applied scientists, engineers, policy makers and safety advocates with a platform to develop, promote and coordinate the science, technol- ogy and practice of space safety. JSSE seeks to establish channels of communication between industry, academy and government in the field of space safety and sustainability. MAIN JSSE TOPICS • Safety by design • Human factors and performance • Space Situational Awareness • Safety on long duration missions • Safety critical software design • Space traffic control • Launch and re-entry safety • Safety risk assessment • Space traffic and air traffic interfaces • Space hazards (debris, NEO objects) • Safety risk management • Space materials safety • Space weather and radiation • Organizational culture and safety • Safe & Rescue • Environmental impacts • Regulations and standards for safety • Safety lessons learned • Nuclear safety for space systems • Space-based safety critical systems Publication information: The Journal of Space Safety Engineering (ISSN Pending) is a quarterly publication of the International Association for the Advancement of Space Safety (IAASS). You can read about IAASS mission, goals, organization, membership and activities at: http://iaass.space-safety. org/. The JSSE is published using an open access publication model, meaning that all interested readers are able to freely access the journal online without the need for a subscription, and authors are not charged. Authors inquiries: For inquiries relating to the submission of articles please contact the Editor-in-Chief at: [email protected]. For all information about the journal, please visit the journal web page http://iaass.space-safety.org/publications/journal/. Authors instructions on preparation and submittal at: http://iaass.space-safety.org/wp-content/uploads/sites/24/2013/07/JSSE-authors_instructions.pdf. Advertising information: if you are interested in advertising or other commercial opportunities please e-mail [email protected] and your inquiry will be passed to the correct person who will respond to you within 48 hours. Copyright and photocopying: Authors retain the copyright of their work. The IAASS maintains the copyright of the Journal as a whole. Single photocopies or electronic scans of single articles may be made for personal use as allowed by national copyright laws. Authors or IAASS permission and the payment of a fee is required for all other photocopying, including multiple or systematic copying, copying for advertising purposes, resale, and all forms of document delivery. For information on how to seek permission please contact the Editor-in-Chief at [email protected]. Notice: No responsibility is assumed by the Publisher IAASS and by Editors and Editorial Board for any injury and/or damage to persons or property from any use or operation of any methods, products, instructions or ideas contained in the journal. Although all advertising material is expected to conform to ethical professional conduct of IAASS, inclusion in this publication does not represent an endorsement of the quality or value of such product or service. Credits: Kristhian Mason, IAASS graphic designer, for cover image, graphic work, layout and paginations. Cover pictures: Orbital-3 Mission, NASA Wallops Flight Facility, Wallops Island, Virginia, America - 27 Oct 2014 - Joel Kowsky/NASA/REX; ss-141029-cygnus-rocket-explosion-mn-04 - SPACE-ORBITAL/Handout International Association for the Advancement of Space Safety Journal of Space Safety Engineering – Vol. 2 No. 2 - December 2015 THE RUSSIAN R-16 NEDELIN DISASTER: AN HISTORICAL ANALYSIS OF FAILED SAFETY MANAGEMENT David E. Gingerich(1), Jeffrey S. Forrest(2), Andrei A. Abiin(2), Taletha M. Maricle-Fitzpatrick(2) (1)Lockheed Martin Space Systems Company, Mail Stop S8700, PO Box 179, Denver, Colorado 80201-0179 USA [email protected] (2)Department of Aviation and Aerospace Science, Metropolitan State University of Denver, Campus Box 30, PO Box 17336, Denver, Colorado 80217-3362 USA [email protected], [email protected], [email protected] ABSTRACT past secrecy surrounding this mission failure, very little information is openly published about the R-16 Nedelin On October 24, 1960, at the USSR’s Baikonur Cosmo- event. With the release of formerly classified reports, the drome, an electrical malfunction led to the deadliest authors are able to synthesize the documented memories of launch accident in space industry history. Shortly before a eyewitnesses to the tragedy, along with relevant data and test launch of the first Soviet R-16 intercontinental rocket, information found in now declassified Soviet documents. the second stage engines prematurely ignited, detonating Witnesses include engineers, military personnel, and ser- the first stage fuel tanks. We hypothesize that the primary vice operators present at the failed launch. Documented contributing factor to the tragedy was a systemic flaw in this study are accounts from Lieutenant Colonel Bo- in safety management caused by cultural and political ris Aleskin; Senior Technician Ivan Koval; Sector Chief values. Through the use of interviews, literature, and a Vladimir Kukushkin; Evgeniya Alya-Brudzinskaya, the chronology of the events leading up to the failure, an in- wife of senior test engineer Captain Ivan Murashko; and terpretive analysis identifying contributing factors to the Chief Engineer of the Yuzhnoye Design Bureau, Mikhail disaster was conducted. This study found that cultural and Yangel. In memoirs and interviews, these eyewitnesses political influences were primary causes to the loss and provide a personal glimpse into the details surrounding also led to a safety management environment that contin- the Nedelin disaster, and when coupled with information ued to threaten the success and integrity of aerospace de- from English and Russian sources, enables the authors to velopment in the USSR and other space-faring countries. present an interpretation of the primary contributing fac- tors to the R-16 Nedelin disaster. 1. INTRODUCTION 2. THE HISTORY OF THE R-16 AND THE In 1921, the USSR established a research and invention LAUNCH SEQUENCE laboratory for the renowned Soviet engineer Nikolai Tik- homirov for the development of “rocket propelled weap- The world’s first intercontinental ballistic missile, the R-7 ons.” [1] The establishment of Tikhomirov’s lab marked Semyorka, officially Glavnoye raketno-artilleriyskoye the beginning of the Soviet Union’s quest for sophisti- upravleniye MO RF (GRAU) (Main Missile and Artil- cated weaponry and, as history would soon document, a lery Directorate of the Ministry of Defense of the Russian leader in manned space flight. During the development of Federation) index 8K71, also known by NATO reporting dirigibles and other airships, early rocketry experienced name SS-6 Sapwood, was created by Sergei Korolev in many failures. In most cases, launch-vehicle failures re- 1957. [2] The R-7 delivered the first artificial satellite, sult in research and development setbacks and economic Sputnik 1, into space and the first cosmonaut, Yuri Gaga- loss. However, the history of rocketry and space flight is rin, into orbit. The missile found a long application in the also marked with failures resulting in the loss of human Soviet and Russian
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