Encyclopedia Astronautica
1967.04.05 - Apollo 204 Review Board final report


The Apollo 204 Review Board transmitted its final formal report on the fire to the NASA Administrator. The Board noted that the reliability of the CM and the entire system involved in its operation was a requirement common to both safety and mission success. It followed that protection from fire as a hazard required much more than quick egress. The risk of fire was only one factor pertaining to CM reliability that must receive adequate consideration. Design features and operating procedures intended to reduce the fire risk must not introduce other serious risks to mission success and safety.

- No single ignition source of the fire was conclusively identified.
- The CM contained many classes of combustible material in areas contiguous to possible ignition sources.
- The test conditions were extremely hazardous.
- Because of internal pressure, the CM inner hatch could not be opened before rupture of the CM.
- Deficiencies existed in CM design, workmanship and quality control. These deficiencies created an unnecessarily hazardous condition and their continuation would imperil future Apollo Operations.
- Every effort must be made to ensure the maximum clarification and understanding of the responsibilities of all organizations in the program, the objective being a fully coordinated and efficient program.

Each member concurred in each of the findings, determinations, and recommendations concerning the January 27 spacecraft fire that took the lives of three astronauts.

During the review the Board had adhered to the principle that reliability of the CM and the entire system involved in its operation was a requirement common to both safety and mission success. Once the CM had left the earth's environment the occupants were totally dependent on it for their safety. It followed that protection from fire as a hazard required much more than quick egress. Egress was useful only during test periods on earth when the CM was being readied for its mission and not during the mission itself. The risk of fire had to be faced, but that risk was only one factor pertaining to CM reliability that must receive adequate consideration. Design features and operating procedures intended to reduce the fire risk must not introduce other serious risks to mission success and safety.

The House Committee on Science and Astronautics' Subcommittee on NASA Oversight held hearings on the Review Board report April 10-12, 17, and 21 and May 10. Senate Committee on Aeronautical and Space Sciences hearings were held April 11, 13,and 17 and May 4 and 9.

Findings, determinations, and recommendations of the Apollo 204 Review Board were:

Finding

- A momentary power failure occurred at 6:30:55 p.m. EST (23:30:55 GMT).
- Evidence of several arcs was found in the postfire investigation.
- No single ignition source of the fire was conclusively identified.

Determination

The most probable initiator was an electrical arc in the sector between the -Y and +Z spacecraft axes. The exact location best fitting the total available information was near the floor in the lower forward section of the left-hand equipment bay where environmental control system instrumentation power wiring led into the area between the environmental control unit and the oxygen panel. No evidence was discovered that suggested sabotage.

Finding

- The CM contained many classes of combustible material in areas contiguous to possible ignition sources.
- The test was conducted with a 100-percent oxygen atmosphere at 11.5 newtons per sq cm (16.7 psia).

Determination

The test conditions were extremely hazardous.

Recommendation

The amount and location of combustible materials in the CM must be severely restricted and controlled.

Finding

- The rapid spread of fire increased pressure and temperature, rupturing the CM and creating a toxic atmosphere. "Death of the crew was from asphyxia due to inhalation of toxic gases due to fire. A contributory cause of death was thermal burns."
- Non-uniform distribution of carboxyhemoglobin was found by autopsy.

Determination

Autopsy data led to the medical opinion that unconsciousness occurred rapidly and that death followed soon thereafter.

Finding

Because of internal pressure, the CM inner hatch could not be opened before rupture of the CM.

Determination

The crew was never capable of effecting emergency egress because of the pressurization before the rupture and their loss of consciousness soon after rupture.

Recommendation

The time required for egress of the crew should be reduced and the operations necessary for egress be simplified.

Finding

The organizations responsible for planning, conducting, and safety of this test failed to identify it as being hazardous. Contingency preparations to permit escape or rescue of the crew from an internal CM fire were not made.

- No procedures for this kind of emergency had been established either for the crew or for the spacecraft pad work team.
- The emergency equipment in the White Room and on the spacecraft work levels was not designed for the smoke condition resulting from a fire of this nature.
- Emergency fire, rescue, and medical teams were not in attendance.
- Both the spacecraft work levels and the umbilical tower access arm contained features such as steps, sliding doors, and sharp turns in the egress paths which hindered emergency operations.

Determination

Adequate safety precautions were neither established nor observed for this test.

Recommendations

- Management should continually monitor the safety of all test operations and ensure the adequacy of emergency procedures.
- All emergency equipment (breathing apparatus, protective clothing, deluge systems, access arm, etc.) should be reviewed for adequacy.
- Personnel training and practice for emergency procedures should be given regularly and reviewed before a hazardous operation.
- Service structures and umbilical towers should be modified to facilitate emergency operations.

Finding

Frequent interruptions and failures had been experienced in the overall communication system during the operations preceding the accident.

Determination

The overall communication system was unsatisfactory.

Recommendation

- The ground communication system should be improved to ensure reliable communications among all test elements as. soon as possible and before the next manned flight.
- A detailed design review should be conducted on the entire spacecraft communication system.

Finding

- Revisions in the Operational Checkout Procedure for the test were issued at 5:30 p.m. EST January 26, 1967 (209 pages), and 10:00 a.m. EST January 27, 1967 (4 pages).
- Differences existed between the ground test procedures and the inflight checklists.

Determination

Neither the revision nor the differences contributed to the accident. The late issuance of the revision, however, prevented test personnel from becoming adequately familiar with the test procedure before use.

Recommendations

- Test procedures and pilot's checklists that represent the actual CM configuration should be published in final form and reviewed early enough to permit adequate preparation and participation of all test organizations.
- Timely distribution of test procedures and major changes should be made a constraint to the beginning of any test.

Finding

The fire in CM 012 was subsequently simulated closely by a test fire in a full-scale mockup.

Determination

Full-scale mockup fire tests could be used to give a realistic appraisal of fire risks in flight-configured spacecraft.

Recommendation

Full-scale mockups in flight configuration should be tested to determine the risk of fire.

Finding

The CM environmental control system design provided a pure oxygen atmosphere.

Determination

This atmosphere presented severe fire hazards if the mount and location of combustibles in the CM were not restricted and controlled.

Recommendations

- The fire safety of the reconfigured CM should be established by full-scale mockup tests.
- Studies of the use of a diluent gas should be continued, with particular reference to assessing the problems of gas detection and control and the risk of additional operations that would be required in the use of a two-gas atmosphere.

Finding

Deficiencies existed in CM design, workmanship and quality control, such as:

- Components of the environmental control system installed in CM 012 had a history of many removals and of technical difficulties, including regulator failures, line failures, and environmental control unit failures. The design and installation features of the environmental control unit made removal or repair difficult.
- Coolant leakage at solder joints had been a chronic problem.
- The coolant was both corrosive and combustible.
- Deficiencies in design, manufacture, installation, rework, and quality control existed in the electrical wiring.
- No vibration test was made of a complete flight-configured spacecraft.
- Spacecraft design and operating procedures required the disconnecting of electrical connections while powered.
- No design features for fire protection were incorporated.

Determination

These deficiencies created an unnecessarily hazardous condition and their continuation would imperil any future Apollo Operations.

Recommendations

- All elements, components, and assemblies of the environmental control system should be reviewed in depth to ensure its functional and structural integrity and to minimize its contribution to fire risk.
- The design of soldered joints in the plumbing should be modified to increase integrity or the joints should be replaced with a more structurally reliable configuration.
- Deleterious effects of coolant leakage and spillage should be eliminated.
- Specifications should be reviewed; three-dimensional jigs should be used in manufacture of wire bundles; and rigid inspection at all stages of wiring design, manufacture, and installation should be enforced.
- Flight-configured spacecraft should be vibrationtested.
- The necessity for electrical connections or disconnections with power on within the crew compartment should be eliminated.
- The most effective means of controlling and extinguishing a spacecraft fire should be investigated. Auxiliary breathing oxygen and crew protection from smoke and toxic fumes should be provided.

Finding

An examination of operating practices showed the following examples of problem areas:

- The number of open items at the time of shipment of the CM 012 was not known. There were 113 significant engineering orders not accomplished at the time CM 012 was delivered to NASA; 623 engineering orders were released subsequent to delivery. Of these, 22 were recent releases that were not recorded in configuration records at the time of the accident.
- Established requirements were not followed with regard to the pretest constraints list. The list was not completed and signed by designated contractor and NASA personnel before the test, even though oral agreement to proceed was reached.
- Formulation of and changes in prelaunch test requirements for the Apollo spacecraft program were responsive to changing conditions.
- Noncertified equipment items were installed in the CM at time of test.
- Discrepancies existed between NAA and NASA MSC specifications regarding inclusion and positioning of flammable materials.
- The test specification was released August 1966 and was not updated to include accumulated changes from release date to the January 27 test date.

Determination

Problems of program management and relations between Centers and with the contractor had led to some insufficient responses to changing program requirements.

Recommendation

Every effort must be made to ensure the maximum clarification and understanding of the responsibilities of all organizations in the program, the objective being a fully coordinated and efficient program.

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