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More Details for 1967-03-19

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The final report of the Ground Emergency Provisions Panel (Panel 13) accepted by the Apollo 204 Review Board submitted 14 findings and determinations.

The panel had been charged with reviewing the adequacy of planned ground procedures for the January 27 spacecraft 012 manned test, as well as determining whether emergency procedures existed for all appropriate activities. The review was to concentrate on activity at the launch site and to include recommendations for changes or new emergency procedures if deemed necessary.

The panel approached its task in two phases. First, it reviewed the emergency provisions at the time of the CM 012 accident, investigating

- the procedures in published documents,

- the emergency equipment inside and outside the spacecraft, and

- the emergency training of the flight crew and checkout test team.

Second, the panel reviewed the methods used to identify hazards and ensure adequate documentation of safety procedures and applicable emergency instructions in the operational test procedures.

Findings and determinations included:

Finding

The applicable test documents and flight crew procedures for the AS- 204 Space Vehicle Plugs-Out Integrated Test did not include safety considerations, emergency procedures, or emergency equipment requirements relative to the possibility of an internal spacecraft fire during the operation.

Determination

The absence of any significant emergency preplanning indicated that the test configuration (pressurized 100-percent-oxygen cabin atmosphere) was not classified as potentially hazardous.

Finding

The propagation rate of the fire in the accident was extremely rapid. Removal of the three spacecraft hatches, from either the inside or the outside, for emergency exit required a minimum of 40 to 70 seconds, respectively, under ideal conditions.

Determination

Considering the rapid propagation of the fire and the time constraints imposed by the spacecraft hatch configuration, it is doubtful that any amount of emergency preparation would have precluded injury to the crew before egress.

Finding

Procedures for unaided egress from the spacecraft were documented and available. The AS-204 flight crew had participated in a total of eight egress exercises employing those procedures.

Determination

The 204 flight crew was familiar with and well trained in the documented emergency crew procedures for effecting unaided egress.

Finding

The spacecraft pad work team on duty at the time of the accident had not been given emergency training drills for combating fires in or around the spacecraft or for emergency crew egress. They were trained and equipped only for a normal hatch removal operation.

Determination

The spacecraft pad work team was not properly trained or equipped to effect an efficient rescue operation under the conditions resulting from the fire.

Finding

Frequent interruptions and failures had been experienced in the overall communications system during the operations preceding the accident. At the time the accident occurred, the status of the system was still under assessment.

Determination

The status of the overall communications was marginal for the support of a normal operation. It could not be assessed as adequate in the presence of an emergency condition.

Finding

Emergency equipment provided at the spacecraft work levels consisted of portable carbon dioxide fire extinguishers, rocket-propellant-fuel-handler's gas masks, and 4.4-centimeter-diameter fire hoses.

Determination

The existing emergency equipment was not adequate to cope with the conditions of the fire. Suitable breathing apparatus, additional portable carbon dioxide fire extinguishers, direct personnel evacuation routes, and smoke removal ventilation were significant items that would have improved the reaction capability of the personnel.

Finding

Under the existing method of test procedure processing at KSC, the safety offices reviewed only the procedures noted in the operational checkout procedure outline as involving hazards. Official approval by KSC and Air Force Eastern Test Range Safety was given after the procedure was published and released.

Determination

The scope of contractor and KSC Safety Office participation in test procedure development was loosely defined and poorly documented. Post-procedure-release approval by the KSC Safety Office did not ensure positive and timely coordination of all safety considerations.