Q & A Case Study Analysis: The Vasa

CASE STUDY ANALYSIS: THE VASA CAPSIZES
The Vasa was a custom-built warship by King Gustav of Sweden in 1625. This case study analysis will inspect the factors that led to the ultimate capsizing of the Vasa on its maiden voyage in 1628, in her own harbor.

Discussion/Analysis

Case Study Questions
1. Why did the Vasa capsize? What contributing role did the various parties play? Who was responsible?
The Vasa was capsized because it was not seaworthy. The customer specifications for the Vasa mentioned only the fairly accurate dimensions of the ship and the armaments it would hold, not as per the requirement to be seaworthy. It was shipbuilder responsibility to ensure that Vasa would float and be able to sail under power of the wind.
The

parties involved in building a ship that should have been seaworthy were:
• King Gustavus – The “customer” well-known for his ever-changing requirements.
• Henrik Hybertsson – Shipbuilder contractor who is responsible to build the Vasa, died during the construction period.
• Hein Jacobsson – Hyertsson’s assistant Hein Jacobsson who had a very little managerial experience was became “project manager” after Hybertson’s death and had taken the aid of his young assistant Johan Isbrandsson.
• Captain Hansson – Captain of the Vasa.
• Admiral Fleming – Head of Sweden’s navy.

Before the Vasa was allowed to sail, it was required to undergo a stability test. The test was ordered by Admiral Fleming and witnessed by Boatswain Matsson who admitted to Admiral that “the ship was narrow at the bottom and lacked enough. Admiral responded that ship builder have built ships before so no need to worry. Neither Jacobsson nor his assistant Isbrandsson were present during the crucial test. While the stability test was being conducted, the armament was still in the process of being produced and the artists were still working anxiously to complete the decorations that were against a today project closing process. At this critical juncture of test failure, the shipbuilders should have been notified and allowed to conduct further tests and improvements. As their involvement was usurped by an ambitious military officer, they were rightfully acquitted by a court of law. The Captain was also relieved of any findings of wrong-doing. One would wonder why Admiral Fleming (son of the governor of Finland) was not held responsible, but to attain the rank of Admiral in such times required much personal influence, which he no doubt used to divert attention from his involvement in the debacle. He was also one of King Gustavus’ most trusted military adviser and served as Governor of Sweden until his death in 1644.

2. In what ways is the Vasa story like other large-scale systems failures you are familiar with? Does the building of the Vasa differ from the Bhopal, Chernobyl, or Challenger disasters?
The story of the Vasa’s sinking at port is in some ways different from, and in other ways similar to, the large-scale disasters such as the Bhopal gas leak, the Chernobyl nuclear reactor explosion, and the Challenger Space Shuttle’s explosion on launch. Though the cause of the failure of each of these systems’ infrastructure varies, there are similarities shared by them all with that of the Vasa.
The Bhopal gas leak was the result of what was deemed deliberate sabotage by someone familiar enough with the system to know to rapidly introduce large quantities of water into the system to cause a seriously adverse chemical reaction. Measures put into place to prevent system failures and dangerous situations (specifically resulting from the unintentional introduction of water to the system) were essentially overridden by something for which the designing engineers did not foresee the need to incorporate a fail-safe – human tampering with destructive intent.
Although there was no deliberate sabotage to the Vasa’s design, construction, or launching, the ship’s sinking nonetheless resulted from gross design flaws and seaworthy inconsistencies which led to its listing broadside and rapidly taking on much water, sinking immediately. As the Bhopal’s disaster was blamed on someone intimately familiar with the system, the Vasa’s chief shipbuilders, Jacobsson and Isbrandsson, were the most familiar with the specific designs of the Vasa, yet they failed to impart their knowledge onto those that succeeded them in overseeing the vessel’s final construction and stability test, which was a miserable failure. As well, rather than push back when the King moved up the vessel’s construction timeline as well as made numerous modifications to its design – modifications Jacobsson knew were not standard or seaworthy for a vessel of the Vasa’s size and magnitude – Jacobsson yielded to the King’s requests and committed to delivering a boat of dimensions his better judgment otherwise told him was unsafe and unsound. This was due to King Gustav’s leadership style which set the tone for passive, obedient followership, instilling in his subjects a level of fear of his wrath that naturally precluded their having any level of comfort with disagreeing with him, much less suggesting he abandon the modifications he was making to the ship’s designs in haste to outfit their country with vessels for an ongoing war he was waging.
Likewise, the leadership style of Anatoli Dyatlov, Deputy Chief Engineer of the Chernobyl Nuclear Reactor Plant, set a tone that precluded the otherwise better judgment and taking of action on the parts of his subordinates. Dyatlov, known as an irate taskmaster, was particularly bothered on the night of the reactor failure. Amidst late night hours and a new shift of personnel unfamiliar with the inputs leading up to the tests thus far, he nonetheless continued the tests which resulted in confusion amongst the engineers and staff, themselves unsure what to make of the reactor’s unexplainable responses to their inputs and tests. Due to the nature of the communist regime at that time, and because the tests had already succumbed to delays, further delay due to “confusion” was not an option. When the system began to fail, a subordinate pushed what was known as the “AZ” button, the right thing to do under “normal” emergency circumstances, but the worse thing to do given the system’s abnormalities. It essentially resulted in insertion of positive reactivity in the reactor, and the rest is history.
Similarly, in the case of the Space Shuttle Challenger, the launch had already been delayed for several days due to unfavorable weather and technical difficulties.

The temperature on the morning of the launch was unusually cold and engineers warned supervisors that components, such as the O-rings which sealed rocket booster joints, were subject to failure at low temperatures. From NASA supervisors and managers, to the company that designed the rocket boosters, these warnings and vulnerabilities were ignored, minimized, and excused. Similarly, as was the case with the Vasa, the King pressed and pressed on the shipbuilders to hasten the construction of the Vasa, when resources and materials were their most constrained, including the master shipbuilders themselves, not part of the major portion of construction effort. To wit, Admiral Fleming had to conduct the stability test in their absence and he is on record as having stated “the shipbuilder has built ships before”, in an attempt to excuse and wave off the Boatswain’s warnings that the ship was too narrow at its bottom to be stable under way. As well, Fleming wished the King, himself, had witnessed the test, himself likely believing this was the only way to convey the potential risk of proceeding with the vessel’s launch under rushed conditions, literally pieced together in haste with the wrong sized materials because the correct lumber pieces were not on hand to construct it according to the Kings numerous design revisions. The King didn’t care and no one dared to make him. The result, like as in the three cases to which the Vasa has been herein compared, was a preventable disaster, but for leadership’s negative influence and the “it’s safer to be silent” culture it seemed to imbue in

subordinates.