The Vasa Disaster

A few years ago, I was working for a client in Stockholm and in some free time, I visited the wreck of the Vasa, the world’s best-preserved 17th-century ship. She’s housed in a museum built specifically around her – enormous and (mostly) intact, after spending nearly 350 years under the sea. I’d known the Vasa’s story for a while and had even used it in workshops, but standing next to the thing itself is different. I found myself looking up at this huge beast of a construction, wondering how many people who were involved in building it knew that it would sink.

Understanding why the Vasa sank also gets to something important about how organisations fail.

The Vasa and the King

On 10 August 1628, the Vasa set sail from Stockholm harbour on her maiden voyage as the newest and most expensive ship in the Royal Swedish Navy. Commissioned by King Gustavus Adolphus, she was laden with ornate carvings, towering masts and 64 bronze cannons; one of the most formidable displays of naval power in Europe, and a deliberate statement of Swedish ambition. The crowds who had gathered to watch her depart included plenty of foreign ambassadors; in effect, spies of Sweden’s allies and enemies, there to report back on the launch.

What they witnessed was not what anyone had planned. After sailing roughly 1,300 metres, and still within sight of the king’s palace, a gust of wind caught her sails and she heeled sharply to port. Water rushed in through the many open gunports. Within minutes, the Vasa had sunk to the bottom of the harbour with between 30 and 50 lives lost out of a crew of around 150. The wind that sank her was later estimated at about 8 knots, which is not by any means a strong wind. Subsequent calculations suggest she might even have gone over in a breeze of just 4 knots.

The captain, who survived, was thrown into jail the following morning and a formal inquiry was convened.

Scope Creep and Production Pressure

The Vasa’s instability wasn’t a single mistake. It was the accumulated result of years of changing requirements, “scope creep“, poor coordination, production pressure, and crucially, an organisation in which bad news could not travel upwards.

The ship had started life as something quite different. In January 1625, the King had contracted for four ships: two smaller vessels with keels of around 108 feet, and two larger ones at 135 feet (the keel is the structural backbone running along the bottom of a ship’s hull, from bow to stern, like a spine). Then, in the autumn of that year, the Swedish navy lost ten ships in a storm, and the king ordered the smaller ships to be built first, on an accelerated schedule. The Vasa’s keel was laid in early 1626 as a relatively modest vessel.

What followed was scope creep in its extreme. The king learned that Denmark was building a large warship with two enclosed gun decks (something no Swedish shipbuilder had so far attempted) and ordered the Vasa enlarged to match. The 111-foot keel already in the ground was physically extended: a fourth scarf joint was added, where a traditional ship would have three. The hull was widened, but only in the upper sections, because the keel was already fixed. No formal specifications were drawn up for any of these changes. The lead shipwright, Henrik Hybertsson, who had never built a two-gun-deck ship, appears to have scaled up his original plans by proportion and instinct rather than calculation, partly because, in 1628, there were no known methods for calculating a ship’s centre of gravity or stability characteristics. You found out how a ship sailed by sailing it.

Hybertsson fell seriously ill in 1626 and died in 1627, leaving his assistant Hein Jacobsson to complete the project. At the time of Hybertsson’s death, around 400 people across five different teams were working on the ship with apparently little coordination between them. The armament specification changed repeatedly: the final configuration crammed 24-pound guns onto an upper deck that had been built for lighter 12-pound guns, pushing the centre of gravity higher still. The ornate oak carvings the king had ordered, hundreds of them, added yet more weight above the waterline. You can still see these carvings all over the ship today.

There was also a detail that came to light only after the ship was raised in 1961: the construction teams had used four different rulers, two calibrated in Swedish feet (twelve inches) and two in Amsterdam feet (eleven inches). The resulting asymmetry made the ship heavier to port than to starboard. It is, in a way, a perfect metaphor for the whole project: four groups of people, working on the same ship, without any shared and agreed standard.

The Stability Test 

What makes the Vasa story extra impactful is that the failure wasn’t hidden. Shortly before the maiden voyage, a stability test was conducted in front of Admiral Fleming and the ship’s captain. Thirty men ran back and forth across the upper deck. After just three traversals, the test was stopped because the ship was rocking so violently that those present feared she would capsize on the spot.

However, there was no good solution available. The hold had no room for additional ballast; the shallow keel, a consequence of extending the original 111-foot design, had required extra bracing timbers that filled the space. In any case, had more ballast somehow been added, it would have pushed the lower gunports below the waterline. The ship was, structurally, beyond rescue at the point of launch. When we think of sunk cost or plan continuation bias, this example should loom large.

And yet, the launch went ahead. The shipwright and the shipbuilder, it later emerged, had not been present at the stability test and were never told about the results. The boatswain, Matsson, who had raised concerns about the ship’s ballast, was told by Admiral Fleming: “the shipbuilder has built ships before and you should not be worried.” Matsson’s response, recorded in the subsequent inquiry, was: “God grant that the ship will stand upright on her keel.”

Fleming, for his part, had reportedly lamented after the failed test: “If only the King were here.” It’s a small window into the bind these men were in. The king had ordered the Vasa ready by 25 July; the maiden voyage on 10 August was already more than two weeks late. Failure to launch meant facing the king’s displeasure. Was it better to face the certainty of the King’s wrath, or the potential risk of the ship capsizing?

The King’s Power Gradient

The Vasa Museum’s own account of the inquest notes that “it was rarely a good idea to disappoint the king.” That’s an understatement, but it points at something real. When we talk about authority gradients in organisations, we’re often talking about the positional power distance between a frontline worker and a senior manager, for example. The gradient between the people building the Vasa and King Gustav was of a categorically different order. Speaking up against a steep power gradient in a modern workplace is uncomfortable and often carries real risk. Kings were appointed by God. Speaking up against a king, in 1628, was unthinkable.

And yet the dynamic is recognisable. To quote Lars Axelsson, “a problem that stays with whoever discovers it is a problem that remains unknown.” The Vasa’s problems were known – to the boatswain, to the men who ran the stability test, almost certainly to Jacobsson, who had always suspected the Vasa was too narrow. What those problems lacked was a path upward. Every layer of the hierarchy had more reasons to ignore or dismiss the concern rather than pass it on, so the information that could have prevented the disaster never reached anyone with the power and the will to act on it.

The formal inquiry in September 1628 found no one to blame, partly because blame was genuinely difficult to assign: the king had approved all plans and armaments, the shipwright was dead, the admiral had conducted a stability test and still let the ship sail; and partly because the structure of the organisation had distributed responsibility so thoroughly that no single decision looked, in isolation, like the fatal one. That, too, is a pattern worth recognising.

VASA SYNDROME: The organisational pattern in which power gradients, production pressure, and the absence of psychological safety prevent the people doing the work from challenging unrealistic demands, so latent flaws go uncorrected until disaster occurs.

Kessler et al, 2004

Vasa Syndrome:

1: Lack of external learning capability
2: Goal confusion
3: Obsession with speed
4: Feedback system failure
5: Communication barriers
6: Poor organisational memory
7: Top-management meddling

After The Disaster

There is a coda to the story that I find almost as interesting as the disaster itself. Hein Jacobsson – the man who completed the Vasa after Hybertsson’s death – had suspected, even before she was launched, that her proportions were wrong. When he was commissioned to build her sister ship, Äpplet, in 1629, he built her a metre wider. Äpplet went on to serve in the Swedish navy for around 30 years.

The lesson there is not that the builders couldn’t learn. They clearly could, and did. The lesson is what it took to make that learning happen: a catastrophic, public, entirely avoidable disaster, witnessed by thousands. Jacobsson already knew what needed to change. He simply hadn’t felt able to say so with sufficient authority until the failure was so large and so visible that a change of approach was essential. That’s a high price for an organisation to pay for a lesson its own people already knew.

The Vasa Organisational Pattern

When I was in the museum in Stockholm, what struck me most wasn’t the scale of the ship, though she is vast (somewhat bigger than the narrowboats I used to live on!). It was how incredibly grand and unseaworthy she looked, with rows and rows of gundecks, crammed together, apparently very close to the waterline. It looks like a demonstration ship – one designed to satisfy an ego rather than to perform. People had to build it and sign off on it. And the people closest to the work, the ones who could see the issues most clearly, were the ones least able to say anything about them.

That is the pattern we see repeated all too often in organisations, in workplaces where the distance between the people at the sharp end and the blunt end is large, and where the cost of carrying bad news upward feels higher than the cost of absorbing it quietly. Projects and programmes become “greenwashed”, so everything looks on track for the leadership who are monitoring, whilst those at the sharp end are crucially aware of multiple real and potential failures. Psychological safety is the structural condition that allows that knowledge to move vertically, and problems to be surfaced before they become disasters.

There were many component causes of the Vasa’s demise: changing designs, the mixed measurement systems, the too-heavy guns, the impossible timeline, but ultimately the Vasa sank because the people who knew it would sink didn’t feel able to say so to the people who could have done something about it. 

(Written in collaboration by Tom Geraghty, Bea Poyton and Jade Garratt)

References:

Axelsson, L. (2006) ‘Structure for management of weak and diffuse signals’, in Hollnagel, E., Woods, D.D. and Leveson, N. (eds.) Resilience engineering: concepts and precepts. Aldershot: Ashgate, ch. 10.

Fairley, R.E. (n.d.) Why the Vasa sank: 10 lessons learned. Oregon Graduate Institute. [Unpublished manuscript.]

Hollnagel, E., Woods, D.D. and Leveson, N. (eds.) (2006) Resilience engineering: concepts and precepts. Aldershot: Ashgate.

Kessler, E.H., Bierly, P.E. and Gopalakrishnan, S. (2004) ‘Vasa syndrome: insights from a 17th-century new-product disaster’, IEEE Engineering Management Review, 32(1), pp. 38–48. Available at: https://doi.org/10.1109/EMR.2004.25008

Vasamuseet (no date) The Vasa — history and the inquest. Available at: https://www.vasamuseet.se/en/explore/vasa-history/inquest

Vrak – Museum of Wrecks (2022) Vasa’s sister ship Äpplet discovered. Available at: https://www.vrak.se/en/about-vrak/pressroom/vasas-sister-ship-applet-discovered–world-unique-find/

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