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More Details for 1967-03-31

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The final report of the Medical Analysis Panel (No. 11) to the Apollo 204 Review Board was processed for printing.

The panel had been assigned to provide a summary of medical facts with appropriate medical analysis for investigation of the January 27 fire. Examples were cause of death, pathological evidence of overpressure, and any other areas of technical value in determining the cause of accident or in establishing corrective action.

The panel report indicated that at the time of the accident two NASA physicians were in the blockhouse monitoring data from the senior pilot. Upon hearing the first voice transmission indicating fire, the senior NASA physician turned from the biomedical console to look at the bank of television monitors. When his attention returned to the console the bioinstrumentation data had stopped. The biomedical engineer in the Acceptance Checkout Equipment (ACE) Control Room called the senior medical officer for instructions. He was told to make the necessary alarms and informed that the senior medical officer was leaving his console. The two NASA physicians left the blockhouse for the base of the umbilical tower and arrived there shortly before ambulances and a Pan American physician arrived at 6:43 p.m. The three physicians went to the spacecraft; time of their arrival at the White Room was estimated to be 6:45 p.m. EST.

By this time some 12 to 15 minutes had elapsed since the fire began. After a quick evaluation it was evident that the crew had not survived the heat, smoke, and burns and it was decided that nothing could be gained by attempting immediate egress and resuscitation.

Panel 11's 24 findings included:

Finding

Biomedical data at the time of the accident were received from only the senior pilot. The data consisted of one lead of electrocardiogram, one lead of phonocardiogram, and impedance pneumogram (respiration). The data was received by telemetry and from the onboard medical data acquisition system.

Determination

This configuration was normal for the test.

Finding

At 6:31:04 p.m. there was a marked change in the senior pilot's respiratory and heart rates on the biomedical tape. There was also evidence of muscle activity in the electrocardiogram and evidence of motion in the phonocardiogram. The heart rate continued to climb until loss of signal.

Determination

This physiological response is compatible with the realization of an emergency situation.

Finding

Voice contact with the crew was maintained until 6:31:22.7

Determination

At least one crew member was conscious until that time.

Finding

Hatches were opened at approximately 6:36 p.m. and no signs of life were detected. Three physicians looked at the suited bodies at approximately 6:45 p.m. and decided that resuscitation efforts would be to no avail.

Determination

Time of death could not be determined from this finding.

Finding

"The cause of death of the Apollo 204 Crew was asphyxia due to inhalation of toxic gases due to fire. Contributory cause of death was thermal burns."

Determination

It could be concluded that death occurred rapidly and that unconsciousness preceded death by some increment of time. The fact that an equilibrium had not been established throughout the circulatory system indicated that blood circulation stopped rather abruptly before an equilibrium could be reached.

Finding

Panel 5 had estimated that significant levels (more than two percent) of carbon monoxide were in the spacecraft atmosphere by 6:31:30 p.m. EST. By this time at least one spacesuit had failed, introducing cabin gases to all suit loops.

Determination

The crew was exposed to a lethal atmosphere when the first suit was breached.

Finding

The distribution of carbon monoxide in body organs indicated that circulation stopped rather abruptly when high levels of carboxyhemoglobin reached the heart.

Determination

Loss of consciousness was caused by cerebral hypoxia due to cardiac arrest from myocardial hypoxia. Factors of temperature, pressure, and environmental concentrations of carbon monoxide, carbon dioxide, oxygen, and pulmonary irritants were changing at extremely rapid rates. It was impossible from available information to integrate these variables with the dynamic physiological and metabolic conditions they produced, to arrive at a precise statement of the time when consciousness was lost and when death supervened. Loss of consciousness was estimated as at between 15 and 30 seconds after the first suit failed. Chances of resuscitation decreased rapidly thereafter and were irrevocably lost within 4 minutes.

Finding

The purge with 100-percent oxygen at above sea-level pressure contributed to the propagation of fire in the Apollo 204 spacecraft.

Determination

The oxygen level was the planned cabin environment for testing and launch, since prelaunch denitrogenation was necessary to forestall the possibility of the astronauts' suffering the bends. A comprehensive review of operational and physiological tradeoffs of various methods of denitrogenation was in progress.