Part 1 (H)
Preparation for Flight, the Accident, and Investigation
March 16 through April 5, 1967
The Apollo 204 Review Board accepted the final report of its
Administrative Procedures Panel (No. 15). The panel had been established
February 7 to establish and document such activities as control of
spacecraft work, logging and filing exhibits, logging Board activities,
scheduling meetings, preparing agendas, and arranging for secretarial
services and reproduction. During the investigation into the January 27
spacecraft fire, the panel had:
"Board Proceedings" and Append. D. "Panels 12 thru
17," Report of Apollo 204 Review Board, pp. 3-29 and
D-15-3 through D-15-5.
- Issued 25 Board administrative procedures.
- Established the administrative and Secretarial Support Office, which
had provided support in two shifts seven days a week, unless otherwise
required, with some additional third-shift support.
- Established the Photographic Data Control Center to correlate and
distribute photographs and maintain a film library.
- Processed letters, telegrams, and telephone messages received
offering assistance, recommendations, and comments.
- Periodically issued approved schedules of work.
- Established the Audio Magnetic Tape Library to control
0.64centimeter voice-transmission tape recordings about spacecraft 012
during the Space Vehicle Plugs-Out Integrated Test.
The Apollo 204 Review Board accepted the final report of the Fracture
Areas Panel (No. 10). The panel had been charged with inspecting
spacecraft 012 for structural failures in the January 27 fire and
analyzing them from the standpoint of local pressure, temperature
levels, direction of gas flow, etc.
The panel inspected the spacecraft structures while they were still at
Launch Complex 34 and continued through removal of the CM heatshield.
Structural damage reports were made coinciding with spacecraft
disassembly phases. As major subsystems were removed from the spacecraft
they were visually inspected. Buckles, fractures, cracks, melted areas,
localized arcing or pitting in metal components, and obvious direct wire
shorts were noted and documented.
Panel findings and determinations included:
"Board Proceedings" and Append. D, "Panels 6 thru
10," Report of Apollo Review Board, pp. 3-30 and
D-10-3 through D-10-7.
- Spacecraft data during the Plugs-Out Test gave indications from
which a spacecraft pressure history could be estimated.
- The CM cabin structure had ruptured at 6:31:19.4 (±0.1) p.m.
EST January 27 at an estimated minimum cabin pressure of 20 newtons per
sq cm (29 psia).
- The CM cabin structure had sustained cabin pressure in excess of its
designed ultimate pressure of 8.9 newtons-per-sq-cm (12.9-psi)
differential (19 newtons per sq cm; 27.6 psia). Cabin pressure at
rupture probably reached 20 to 26 newtons per sq cm (29 to 37.7 psia).
- The estimated average gas temperature at rupture exceeded 644 kelvins
(700 degrees F).
- The CM cabin ruptured in the aft bulkhead adjacent to its juncture
with the aft sidewall.
- The failure occurred because of excessive meridional tensile stress
in the inner face sheet at the junction of the weld land to the thinner
face sheet. The fracture originated on the right-hand side of the
- The CM cabin structure was penetrated in the aft bulkhead beneath
the environmental control unit and the aft sidewall.
- The loss of structural integrity at these penetrations occurred
after the primary rupture.
- Failure of the water glycol and oxygen lines near the environmental
control unit resulted in local burning and melting of the adjacent
- The aft heatshield stainless-steel face sheets were melted and
- The temperature of the flame and gas exiting from the fracture
origin exceeded 1640 K (2500 degrees F).
The final report of the Spacecraft and Ground Support Equipment
Configuration Panel (No. 1) was accepted by the Apollo 204 Review Board.
The panel had been assigned the task of documenting the physical
configuration of the spacecraft and ground support equipment immediately
before and during the January 27 fire, including equipment, switch
position, and nonflight items in the cockpit. The panel was also to
document differences from the expected launch configuration and
configurations used in previous testing (such as altitude-chamber
During the investigation the panel had discovered a number of items
which might have had relevance to flame propagation:
The panel's summary of findings and determinations included:
- An engineering order, released at North American Aviation's Downey
facility on January 20, provided direction to inspect the polyurethane
foam in specified areas and coat the silicone rubber to meet
flammability requirements. The direction was not recorded in the
configuration verification record as of the start of the Space Vehicle
Plugs-Out Integrated Test and was not accomplished on spacecraft 012.
This item was considered as possibly significant in terms of fuel for
the fire and a medium for flame propagation.
- Polyethylene bags covered the hose fitting for the drinking water
dispenser and the battery-instrumentation cable and connectors and
transducer, which were placed on the aft bulkhead near the batteries.
The bags were made of nonflight materials.
- Two polyurethane pads, covered with Velostat, were stowed over couch
struts. The pads were placed in the spacecraft to protect the struts,
wiring, and aft bulkhead during the planned emergency egress at the end
of the test. These items were of nonflight material and were not
documented by quality inspection records.
- Three packages of switching checklists from the Operational Checkout
Procedure and one package of system malfunction procedures, in a manila
folder, were stowed on the crew couches and on a shelf. These items were
on unqualified paper and, while required for the test, they were not
documented by quality inspection records.
- Nylon protective sleeves were covering all three crewmen's oxygen
umbilicals. These sleeves were nonflight items.
- Three ground-support-equipment window covers had been temporarily
installed to protect the windows and were nonflight items in the
spacecraft at the time of the accident. Another such cover for the side
hatch window was removed by the crew and stowed inside the command
module. These covers were of nylon fabric; flight covers were made of
- Velcro pile had been installed to protect the Velcro hood on the
command module floor. It would have been removed before the flight.
- "Remove before flight" streamers installed in the command
module interior were additional nonflight items.
- Polyethylene zipper tubing, installed to protect hand controller
cables, was a nonflight item and was additional material in the command
"Board Proceedings" and Append. D, "Panels I thru
4," Report of Apollo 204 Review Board, pp. 3-30 and
D-1-5 through D-1-19.
- Eighty engineering orders effective for spacecraft 012 had not been
carried out at the time of the accident. Of these, twenty were specified
to be completed after the test; four did not affect configuration.
- Test requirements had no defined relationships with the open status
of 56 engineering orders. The reason not all work items and engineering
orders were closed was late receipt of changes or further work scheduled
to be completed before launch.
- Items not documented by quality inspection records had been placed
on board the spacecraft during preparation for the Space Vehicle Plugs-
Out Integrated Test.
- Procedures for controlling entry of items into the spacecraft were
not strictly enforced.
The Apollo 204 Review Board accepted the final report of the Security
Operations Panel (No. 14). The panel had been assigned to review
existing security practices at KSC and supporting areas for adequacy and
recommend any needed changes. Practices included access control,
personnel sign-in requirements, buddy systems, and background
The panel's report submitted six findings and determinations, which
"Board Proceedings" and Append. D,"Panels 12 thru
17," Report of Apollo 204 Review Board, pp. 3-30 and
D-14-3 through D-14-7.
- KSC security personnel or uniformed security personnel had been
assigned to all locations requiring safeguarding measures, including
launch vehicle stages and spacecraft from the time of arrival at KSC
until the time of the January 27 accident.
- The number of KSC and uniformed security personnel members used was
- The Apollo Preflight Operations Procedures - dated October 17, 1966,
and January 24, 1967 - for access control of test and work areas,
- access controls to spacecraft work areas be exercised by the
- the contractor maintain a log of all personnel permitted access
during off-shift and nonwork periods; and
- the contractor control and log command module ingress and egress.
- The procedures established in the Apollo Preflight Operations
Procedures were not followed for spacecraft 012 in that
- the contractor failed to exercise adequate access controls on the
fifth, sixth, and seventh spacecraft levels;
- the contractor failed to maintain an off-shift log; and
- the command module ingress-egress log was inadequately maintained.
The Apollo 204 Review Board accepted the final report of its Origin and
Propagation of Fire Panel (No. 5). The panel task had been to
"conduct inspections, chemical analyses [and] spectrographic
analysis of spacecraft, parts or rubble, or use any other useful
techniques to establish point of [the CM 012] fire origin, direction
and rate of propagation, temperature gradients and extremes. The nature
of the fire, the type of materials consumed, the degree of combustion
shall be determined."
Following an intensive study - which considered ignition sources,
description, and course of the fire - the panel listed 10 findings and
determinations in its final report, including:
"Board Proceedings" and Append. D, "Panel 5,"
Report of Apollo 204 Review Board, pp. 3-30 and D-5-3
- Severe damage to wiring was found at the bottom of the power
equipment bay along the aft bulkhead. Evidence of arcing was found and
damage was less severe in the right-hand direction of this bay.
- Electrical arcing in the extreme lower left-hand comer of this bay
could have provided a primary ignition source.
- Right-hand portions of the left-hand equipment bay were severely
damaged. Wiring, tubing, and components in the carbon dioxide absorber
compartment and oxygen/water panel compartment were burned and melted.
Penetrations in the aft bulkhead and pressure vessel wall were observed.
The carbon dioxide absorber compartment showed heavy fire damage;
failure was due to pressure overload and melting caused by the fire in
- Electrical arcing in the right-hand portion of this bay could have
provided a primary ignition source.
- Evidence of electrical arcs from conductor to conductor and from
conductor to structure were found.
- No arc could be positively identified as the unique ignition source.
Three were found that had all the elements needed to cause the disaster.
Two of these showed evidence of poor engineering and installation.
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
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.
- 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.
Findings and determinations included:
"Board Proceedings"; Append. A, "Board Minutes";
and Append. D, "Panels 12 thru 17," in Report of Apollo
204 Review Board, pp. 3-28 through 3-30, A-1 12, and D-13-3
- 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.
- The absence of any significant emergency preplanning indicated that
the test configuration (pressurized 100-percent-oxygen cabin atmosphere)
was not classified as potentially hazardous.
- 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.
- 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.
- 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.
- The 204 flight crew was familiar with and well trained in the
documented emergency crew procedures for effecting unaided egress.
- 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.
- The spacecraft pad work team was not properly trained or equipped to
effect an efficient rescue operation under the conditions resulting from
- 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.
- 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.
- 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
- 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.
- 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.
- 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.
The Materials Work Panel (Panel 8, also referred to as Materials Review'
Panel) in its final report accepted by the Apollo 204 Review Board cited
a number of findings on flammable materials in spacecraft 012. The
panel's task had included the following, from its detailed work
Panel 8 classified its findings in six categories: Materials
Configuration; Routine Materials Test; Fire Initiation Special
Investigation; Fire Propagation Special Investigation; Materials
Installation Criteria and Controls; and Technical Data and Information
Availability. The findings and determinations included:
- "Assemble, summarize, compare and interpret requirements and
data describing the flammability of nonmetallic materials exposed to
the crew bay environment of the spacecraft and in related applications.
- "Specify and authorize performance of tests and/or analyses to
furnish additional information as to flammability characteristics of
these materials alone, and in combination with fluids known or
postulated to have been in the spacecraft 012 cabin.
- "Panel No. 8, in support of Panel No. 5 (Origin and
Propagation of Fire) shall interpret and implement the requirements for
analyses of debris removed from the spacecraft."
"Board Proceedings"; Append. A, "Board Minutes";
and Append. D, "Panels 6 thru 10," in Report of Apollo
204 Review Board, pp. 3-30, A-112, and D-8-3 through D-8-35.
- Complete documentation identifying potentially combustible
nonmetallic materials in spacecraft 012 was not available in a single
readily usable format. A total of 2,528 different potentially
combustible nonmetallic materials that were probably used on spacecraft
012 was found by a review of available documentation.
- The program for identifying and documenting nonmetallic materials
used in the spacecraft, including their weights and surface areas, was
- Raschel Knit, Velcro, Trilock, and polyurethane foams burn about
twice as fast (in the downward direction) in oxygen at a pressure of
11.4 newtons per sq cm (16.5 psia) as at 3.5 newtons per sq cm (5 psia).
- The primary fuels for the fire burned more than twice as fast in the
early stages of the spacecraft 012 fire in accident conditions (pressure
of 11.4 newtons per sq cm) as in the space flight atmosphere for which
they were evaluated (3.5 newtons per sq cm).
- Surface and bulk damage of materials in spacecraft 012 varied from
melting and blistering of aluminum alloys, combustion of Velcro, and
burning of Teflon wire insulation to slight surface damage and melting
of nylon fabrics.
- The fire filled the spacecraft interior. The most intense heat was
in the lower left front area around the environmental control unit.
Surface temperatures in excess of 800 kelvins (1,000 degrees F) were
reached in areas such as the front and left side of the spacecraft.
Surface temperatures were less than 500 K (400 degrees F) in isolated
pockets above the right-hand couch.
- The rate of flame propagation, the rate of pressure increase, the
maximum pressures achieved, and the extent of conflagration in 3.5
newtons-per-sq-cm (5-psia) oxygen boilerplate tests was much less severe
than observed in the 11.4-newton (16.5-psia) oxygen boilerplate tests.
Burning or charring was limited to approximately 29 percent of the
nonmetallic materials by oxygen depletion.
- The conflagration that occurred in spacecraft 012 at a pressure of
11.4 newtons per sq cm would be far less severe and slower in a
spacecraft operating with an oxygen environment at 3.5 newtons, if
additional large quantities of oxygen are not fed into the fire.
- North American Aviation materials selection specification requires
that a material pass only a 500 K (400 degrees F) spark-ignition test in
oxygen at 10.1 newtons per sq cm (14.7 psia).
- NAA criteria for materials flammability control were inadequate.
- No flammability criteria or control existed covering nonflight items
installed in CM 012 for test.
- Lack of control of nonflight material could have contributed to the
- The NASA materials selection criteria required that a material pass
a 500 K (400 degrees F) spark-ignition test and a 1.27-an-per-sec
combustion rate (measured downward in oxygen at 3.5 newtons per sq cm).
Raschel Knit and Velcro (hook) pass this test.
- The NASA criteria for materials flammability were not sufficiently
- The system for control of nonmetallic materials use at MSC during
the design and development of government furnished equipment used in CM
012 depended on identification of noncompliance with criteria by the
- The NASA materials control system was permissive to the extent that
installation or use of flammable materials were not adequately reviewed
by a second party.
- Nonmetallic materials selection criteria used by North American and
NASA were not consistent. The NASA criteria, although more stringent,
were not contractually imposed on the spacecraft contractor.
- Materials were evaluated and selected for use in CM 012 using
different criteria. Application of the NASA criteria to the command
module would have reduced the amount of the more flammable materials
(Velcro and Uralane foam).
- Alternate materials that are nonflammable or significantly less
flammable than those used on spacecraft 012 were available for many
- The amount of combustible material used in command modules can be
- Current information and displays of the potentially flammable
materials configuration of spacecraft 012 were not available before the
- Maintenance of data and displays at central locations and test sites
for management visibility and control of flammable materials is feasible
NASA announced it would use the Apollo-Saturn 204 launch vehicle to
launch the first lunar module on its unmanned test flight. Since the 204
vehicle was prepared and was not damaged in the Apollo 204 fire in
January, it would be used instead of the originally planned AS-206.
NASA News Release 67-67, March 20, 1967.
The Deputy Administrator of NASA designated Langley Research Center
custodian of all materials dealing with the investigation and review of
the January 27 Apollo 204 accident. Review Board Chairman Floyd
Thompson, LaRC, who had the responsibility of determining the materials
to be included in the final repository, determined that the following
categories of materials were to be preserved:
Category 1 materials would be stored at LaRC, Category 2 at MSC, and
Category 3 at KSC.
- Reports, files, and working materials;
- Medical reports;
- Spacecraft 012 command module, its systems, components, and related
In other actions Robert W. Van Dolah, Chairman of the Origin and
Propagation of Fire Panel, reported on a test being conducted in CM 014
to attempt to establish the amount of static electricity that might be
generated by a suited crewman; and members of the Board met with MSC
Director Robert R. Gilruth and members of his staff, as well as
management and engineering personnel of North American Aviation, for a
presentation concerning solder joints in the CM.
"Board Proceedings," pp. 3-30, 3-31.
Final report of the Disassembly Activities Panel (No. 4) was accepted by
the Apollo 204 Review Board. Panel 4 had been assigned to develop
procedures for disassembly of spacecraft 012 for inspection and failure
analysis. Disassembly was to proceed step by step in a manner permitting
maximum information to be obtained without disturbing the evidence - in
both the cockpit and the area outside the pressure hull. Cataloging
documentary information within the spacecraft and displaying the removed
items were a part of the required procedures.
Procedures followed included the following actions:
The Disassembly Activities Panel cataloged and displayed the 1,261 items
removed from spacecraft 012 during the investigation. The Pyrotechnics
Installation Building (PIB) at KSC was assigned as an area in which
components removed from the command module could be placed in bonded
storage yet still be available for inspection by investigative
personnel. The following areas were established in the PIB:
- Immediately after the January 27 accident, NASA KSC Security placed
Launch Complex 34 under additional security. Special guards were
assigned to the service structure and to the adjustable level at the
entrance of the CM. Controls were established for personnel access to
the service structure and the CM.
- After the accident, before disturbing any items in the spacecraft, a
series of photographs was taken. A step-by-step photography method was
established as a standard operating procedure for the Disassembly
- The first step toward an orderly disassembly was to ensure safe
working conditions at the spacecraft. A meeting with KSC and Air Force
Eastern Test Range Safety personnel established procedures and safety
- After the couches were removed, a special false floor was suspended
from the couch strut fittings to provide access to the entire inside of
the spacecraft without disturbing any evidence. The false floor was
fabricated from aluminum angles supporting 2-centimeter-thick,
46-centimeter plexiglass squares.
- The Review Board appointed a Panel Coordination Committee to carry
out new procedures to ensure closely controlled and coordinated
"Board Proceedings," and Append. D, "Panels 1 thru
4," Report of Apollo 204 Review Board, pp. 3-31 and
D-4-3 through D-4-8.
- Bond room - a bonded area to receive components as they were removed
from CM 012. This area was provided with a receiving table; 10 storage
cabinets for small components; and areas for large components and items
associated with the investigation but not from the command module
- Astronaut equipment room and work room - an area in which the
spacesuits and other government furnished crew equipment were
- Bonded display area - an area in which components could be displayed
under controlled conditions to permit investigators to examine CM 012
- Command module 012 work area - The command module was placed in a
supporting ring within an existing workstand in the PIB and remained in
this area until the aft heatshield was removed. The CM was then
transferred to a standard support ring in the north end of the building.
Technicians continued the disassembly activities while the CM was in
- Spacecraft 014 CM - Spacecraft 014 CM (identical in configuration to
spacecraft 012) was shipped to KSC on February 1 to assist the Apollo
204 Review Board in the investigation. This CM was placed in the PIB and
was used for practicing difficult removals of CM 012 components.
- Mockup No. 2 - Mockup No. 2, a full-scale plywood command module,
was brought to KSC and placed in the PIB February 8. The mockup had been
configured with Velcro, debris traps, couch positioning, etc., to
duplicate CM 012 configuration at the time of the fire.
- Half-scale mockup - A half-scale mockup of the CM interior was
placed in the bonded display area February 8 to display half-scale
interior surface photographs taken after the fire in CM 012.
The Apollo 204 Review Board accepted the final report of its Test
Environment Panel (Panel 2). Panel 2 had been assigned responsibility
for the history of all test environments encountered by spacecraft 012
that were considered germane to system validation from a fire hazard
standpoint, including qualification testing of systems and subsystems.
The panel was particularly to emphasize qualification tests in pure
oxygen with regard to pressures, temperature, time of exposure, and
simulation of equipment malfunctions. It was also to indicate any
deficiencies in the test program related to the problem; comparison with
previous tests of appropriate flight, house, or boilerplate spacecraft;
and documentation of any problems encountered which related to fire
The panel reviewed all tests pertinent to the investigation. The
qualification tests were reviewed at MSC, covering more than 1,000
documents. Vehicle tests were reviewed at North American Aviation's
Downey, Calif., facility, covering more than 500 documents. Summaries of
these efforts were reviewed by the panel at KSC to determine any test
The final report of the panel included six findings and determinations.
Among them were:
"Board Proceedings" and Append. D, "Panels 1 thru
4," Report of the Apollo 204 Review Board, pp. 3-32
and D-2-3 through D-2-8.
- Not all crew compartment equipment had been tested as explosion
- Testing of possible ignition sources had been insufficient.
- Some CM equipment exhibited arcing or shorting either during
certification or during spacecraft 012 testing. There was no positive
way to determine from the records reviewed whether spacecraft anomalies
(possibly caused by an arc or a short) were reviewed by system engineers
and the test conductor before a test.
- Review of possible ignition sources before manned testing was
- Not all equipment installed in CM 012 at the time of the accident
was intended for flight (some components were installed for test
- The suitability of this equipment in the CM for this test was not
March 25 - April 24
NASA Hq. Office of Manned Space Flight informed KSC, MSFC, and MSC of
approved designations for Apollo and Apollo Applications missions:
A memorandum to the NASA space flight Centers, North American Aviation,
and certain Headquarters personnel from the NASA Assistant Administrator
for Public Affairs on April 3 stated that the Project Designation
Committee had approved the Office of Manned Space Flight's
recommendations and that Mueller had begun implementation of the
- all Apollo missions would be numbered sequentially in the order
flown, with the next mission to be designated Apollo 4, the following
one Apollo 5, etc., and
- the Apollo Applications missions would be designated sequentially as
AAP-1, AAP-2, etc. The number designations would not differentiate
between manned and unmanned or uprated Saturn I and Saturn V missions.
In a letter to George E. Mueller, OMSF, on March 30, MSC Deputy Director
George M. Low offered two suggestions, in keeping with the intent of the
NASA instruction yet keeping the designation Apollo 1 for spacecraft
012. NASA Hq. had approved that designation before the January 27 fire
claimed the lives of Astronauts Virgil I. Grissom, Edward H. White II,
and Roger B. Chaffee; and their widows requested that the designation be
retained. The suggestions were:
- Consider the AS-201, 202, and 203 missions part of the Saturn I (as
opposed to uprated Saturn I) series; reserve the designation Apollo 1
for spacecraft 012; and number the following flights Apollo 2, etc., or
- Designate the next flight Apollo 4, as indicated by Headquarters,
but apply the scheme somewhat differently for missions already flown.
Specifically, put the Apollo 1 designation on spacecraft 012 and then,
for historic purposes, designate 201 as mission 1-a, 202 as mission 2
and 203 as mission 3.
On April 24, OMSF further instructed the Centers that AS-204 would be
officially recorded as Apollo 1, "first manned Apollo Saturn
flight - failed on ground test." AS-201, AS-202, and AS-203 would
not be renumbered in the "Apollo" series, and the next
mission would be Apollo 4.
TWX, Mueller, NASA OMSF, to KSC, MSFC, MSC, "Apollo and AAP
Mission Designation," March 25 and April 24, 1967; ltr., Low to
Mueller, March 30, 1967; memo, Julian Scheer, NASA Assistant
Administrator for Public Affairs, to distr., April 3, 1967.
A meeting at MSC considered fire detection systems and fire
extinguishers. Participants were G. M. Low, K. S. Kleinknecht, A. C.
Bond, J. N. Kotanchik, J. W. Craig, M. W. Lippitt, and G. W. S. Abbey.
Craig and Lippitt had visited Wright Field, Ohio, and from their
findings the following conclusions were reached:
Memo for the Record, George M. Low, "Fire
detection/extinguishment," March 27, 1967.
- no fire detection system was available for incorporation into the
- a reliable system would be desirable, but the system must not give
false alarms when used in a closed spacecraft environment and yet must
give adequate warning of fire;
- two kinds of systems appeared to be in varying states of development
- systems using infrared or ultraviolet sensors and systems sensing
ionized particles or condensation nucleii in the atmosphere;
- a work statement should be prepared, with the help of personnel at
Wright Field, for the purpose of receiving specific proposals on
available systems; and
- the ultimate goal should be to develop a system ready for flight use
within six months.
Apollo 204 Review Board Chairman Floyd Thompson asked for a report on
the Pyrotechnic Installation Building activity. Disassembly of
spacecraft 012 had been completed March 27. Of 1,261 items logged
through the bond room for display to Board and panel personnel, about
1,000 items were from the CM.
The final report of the Screening Committee was distributed to the Board
by George T. Sasseen, KSC, for review. Sasseen stated that the following
items would be retained as Category A (items damaged or identified as
suspect or associated with anomalies).
Maxime A. Faget, MSC, advised the Board that the lithium hydroxide
cartridge had been sent to MSC for analysis. Hubert D. Calahan, OMSF,
was appointed courier to handcarry the item to MSC and Richard S.
Johnston, MSC, was designated the Board's witness for the analysis.
MSC's Crew Systems Laboratory was to make the analysis and report to the
Board. The analysis was to identify contaminants to determine the
quantity of carbon dioxide in the lithium hydroxide.
- Lower equipment bay junction box cover plate
- Command pilot's torso harness
- Velcro and Raschel netting
- Static inverter 2
- Main display control panel 8
- Instrumentation data distribution panel J800/J850
- Octopus cable.
William D. Mangan, Langley Research Center, joined the legal staff
supporting the Board.
"Board Proceedings," pp. 3-32, 3-33.
At the request of the Manager of the MSC Lunar Surface Programs Office,
NASA Associate Administrator for Space Science and Applications Homer E.
Newell considered alternate Array B configurations of the Apollo Lunar
Surface Experiments Package to alleviate a weight problem. Instead of a
single array, he selected two configurations for ALSEP III and ALSEP IV:
Newell requested that both configurations be built but that, if program
constraints permitted the fabrication of only one array for ALSEP II and
IV, ALSEP III should be given the preference. The Apollo Program
Director concurred in the Newell recommendation.
- ALSEP III Experiments:
- Passive Seismic, Heat Flow (w/Lunar Drill), Cold Cathode Gauge, and
Charged Particle Lunar Environment.
- ALSEP IV Experiments:
- Passive Seismic, Active Seismic, Suprathermal Ion Detector/Cold
Cathode Gauge, and Charged Particle Lunar Environment.
Ltr., Apollo Program Director, NASA Hq., to R. O. Piland, MSC, March
The Apollo Site Selection Board meeting at NASA Hq. March 29 heard MSC
presentations on lunar landing site selection constraints, results of
the Orbiter II screening, and reviews of the tasks for
site analysis. MSC made recommendations for specific sites on which to
concentrate during the next four months and recommended that the
landing sites for the first lunar landing mission be selected by August
1. The Board accepted the recommendations. A Surveyor and Orbiter
meeting the following day considered the targeting of the Surveyor C
mission and the Lunar Orbiter V mission. MSC representatives at the two
meetings were John Eggleston and Owen E. Maynard.
Memo, Chief, Mission Operations Div., MSC, to Manager, ASPO, "Trip
Report - Apollo Site Selection Board and Surveyor/Orbiter Utilization
Committee Meetings," April 20, 1967.
March 29 - April 4
H. C. Creighton, A. R. Goldenberg, and Guy N. Witherington, all of KSC,
inspected spacecraft 101 wire bundles March 29 at the request of CSM
Manager Kenneth S. Kleinknecht of MSC. Kleinknecht had asked that they
give him a recommendation as to whether the bundles should be removed or
whether they could be repaired in place. On April 4, they reported to
Kleinknecht that time had not been sufficient to determine the complete
status of the wiring. A superficial inspection about five-percent
complete had indicated some serious discrepancies, for which they made
some recommendations, but they recommended a more detailed inspection of
the spacecraft 101 wire bundles.
Memo, Creighton, Goldenberg, and Witherington to Kleinknecht,
"Condition of Spacecraft 101 Wire Bundles," April 4, 1967.
The Apollo 204 Review Board accepted the report of its Sequence of
Events Panel (No. 3), which had been charged with analyzing data from
immediately before and during the January 27 fire, including digital,
analog, voice communications, and photography. The data was required to
display significant events as they occurred with the precise time tag.
Time histories of all continuous or semicontinuous recorded parameters
and correlation of parameter variations and events were to be recorded,
as well as interpretation of the analysis results. Where pertinent,
normal expected variations were to be compared with those actually
Panel 3 had served as a separate panel from January 31 through February
23, when it was merged with the Integration Analysis Panel (No. 18).
Panel 3 reported one finding and one determination:
"Board Proceedings" and Append. D, "Panels 1 thru
4," Report of Apollo 204 Review Board, pp. 3-33 and
D-3-3 through D-3-6.
- The data recorded from the spacecraft and ground instrumentation
system during the Spacecraft Plugs-Out Test were found to be valid
except for three brief dropouts after 6:31:17 EST, January 27 (13
seconds after the pilot reported "fire in the cockpit"). All
onboard data transmission ended about 6:31:22 EST.
- The onboard instrumentation system functioned normally before and
during the initial phase of the fire. There were no indicated
malfunctions in any of the instrumentation sensors during this period.
The Apollo 204 Review Board met with its Test Procedures Review Panel
(Panel No. 7) to complete acceptance of the panel's final report. The
panel had been established February 7 to document test procedures
actually employed during the day of the January 27 accident and to
indicate deviations between planned procedures and those used. The panel
was to determine changes that might alleviate fire hazard conditions or
that might provide for improved reaction or corrective conditions and
review the changes for applicability to other tests.
Among the panel's findings and determinations were:
"Board Proceedings" and Append. D, "Panels 6 thru
10," Report of Apollo 204 Review Board, pp. 3-33 and
D-7-3 through D-7-13.
- 209 pages of the 275-page Operational Checkout Procedure (OCP) were
revised and released on the day before the test. However, less than 25
percent of the line items were changed. Approximately one percent of the
change was due to errors in technical content in the original issue of
the procedure. In addition, 106 deviations were written during the test.
- Neither the revision nor the deviations were known to have
contributed specifically to the incident. The late timing of the change
release, however, prevented test personnel from becoming adequately
familiar with the test procedure before use.
- During the altitude chamber tests, the cabin was pressurized at
pressures greater than sea level with an oxygen environment two and a
half times as long as the cabin was pressurized with oxygen before the
accident during Plugs-Out Test.
- The spacecraft had successfully operated with the same cabin
conditions in the chamber for a greater period of time than on the pad
up to the time of the accident.
- Troubleshooting the communication problem was not controlled by any
one person, and was at times independently run from the spacecraft,
Launch Complex 34 Blockhouse, and the Manned Spacecraft Operations
Building. Communications switching, some of which was not called out in
OCP, was performed without the control of the Test Conductor.
- The uncontrolled troubleshooting and switching contributed to the
difficulty experienced in attempting to assess the communication
- KSC was not able to ensure that the spacecraft launch operations
plans and procedures adequately satisfied, in a timely way, the intent
of MSC. Changes in spacecraft testing by KSC could not be kept in phase
with the latest requirements of MSC. Prelaunch checkout requirements
were not formally transmitted to KSC from MSC.
- Prelaunch-test-requirements control for the Apollo spacecraft
program was constrained by slow response to changes, lack of detailed
KSC-MSC inter-Center agreements, and lack of official NASA-approved test
specifications applicable to prelaunch checkout.
- The decision to perform the Plugs-Out Test with the flight crew,
closed hatch, and pure oxygen cabin environment made on October 31,
1966, was a significant change in test philosophy.
- There was no evidence that this change in test philosophy was made
so late as to preclude timely incorporation into the test procedure.
The Apollo 204 Review Board was scheduled to review the final report of
its Historical Data Panel (Panel No. 6). The panel had been assigned to
assemble, summarize, and interpret historical data concerning the
spacecraft and associated systems pertinent to the January 27 fire. The
data were to include such records as the spacecraft log, failure
reports, and other quality engineering and inspection documents. In
addition the panel prepared narratives to reflect the relationship and
flow of significant review and acceptance points and substantiating
documentation and presented a brief history of prelaunch operations
performed on spacecraft 012 at Kennedy Space Center.
In its final report to the Review Board the Historical Data Panel
submitted eight findings and determinations. Among them were:
"Board Proceedings" and Append. D, "Panels 6 thru
10," Report of Apollo 204 Review Board, pp. 3-33 and
D-6-3 through D-6-7.
- The Ingress-Egress Log disclosed several instances where tools and
equipment were carried into the spacecraft, but the log did not indicate
these items had been removed.
- Maintenance of the Ingress-Egress Log was inadequate.
- Inspection personnel did not perform a prescheduled inspection with
a checklist before hatch closing.
- Inspection personnel could not verify specific functions during that
- At the time of the spacecraft 012 shipment to KSC, the contractor
submitted an incomplete list of open items. A revision of that list
significantly and substantially enlarged the list of open items.
- The true status of the spacecraft was not identified by the
The Apollo 204 Review Board accepted the final report of its Design
Review Panel (No.9), whose duty had been to conduct Critical Design
Reviews of systems or subsystems that might be potential ignition
sources within the Apollo command module cockpit or that might provide a
combustible condition in either normal or failed conditions. The panel
was also to consider areas such as the glycol plumbing configuration;
electrical wiring and its protection, physical and electrical; and such
potential ignition sources as motors, relays, and corona discharge.
Other areas would include egress augmentation and the basic cabin
atmosphere concept (one-gas versus two-gas).
The contemplated spacecraft configuration for the next scheduled manned
flight (spacecraft 101, Block II) was significantly different from that
of spacecraft 012 (Block I), in which the January 27 fire had occurred.
Therefore, both configurations were to be reviewed - the Block I
configuration as an aid in determining possible sources for the fire,
the Block II to evaluate the system design characteristics and
potential design change requirements to prevent recurrence of fire.
The panel's final report to the Review Board contained findings on
ignition and flammability, cabin atmosphere, review of egress process,
and review of the flight and ground voice communications. Among them
"Board Proceedings" and Append. D, "Panels 6 thru
10," Report of Apollo 204 Review Board, pp. 3-33 and
D-9-3 through 3-9-13.
- Flammable, nonmetallic materials were used throughout the
spacecraft. In the Block I and Block II spacecraft design, combustible
materials were contiguous to potential ignition sources.
- In the Block I and Block II spacecraft design, combustible materials
were exposed in sufficient quantities to constitute a fire hazard.
- The spacesuit contained power wiring to electronic circuits. The
astronauts could be electrically insulated.
- Both the power wiring and potential for static discharge constituted
possible ignition sources in the presence of combustible materials. The
wiring in the suit could fail from working or bending.
- Residues of RS89 (inhibited ethylene glycol/water solution) after
drying were both corrosive and combustible. RS89 was corrosive to wire
bundles because of its inhibitor.
- Because of the corrosive and combustible properties of the residues,
RS89 coolant could, in itself, provide all of the elements of a fire
hazard if it leaked onto electrical equipment.
- Water/glycol was combustible, although not easily ignited.
- Leakage of water/glycol in the cabin would increase risk of fire.
- Deficiencies in design, manufacture, and quality control were found
in the postfire inspection of the wire installation.
- There was an undesirable risk exposure, which should have been
prevented by both the contractor and the government.
- The spacecraft atmosphere control system design was based on
providing a pure oxygen environment.
- The technology was so complex that, to provide diluent gases,
duplication of the atmosphere control components as well as addition of
a mechanism for oxygen partial-pressure control would be required. These
additions would introduce additional crew-safety failure modes into the
- Sixty seconds were required for unaided crew egress from the CM. The
hatch could not be opened with positive cabin pressure above
approximately 0.17 newtons per sq cm (0.25 psi). The vent capacity was
insufficient to accommodate the pressure buildup in the Apollo 204
- Even under optimum conditions emergency crew egress from Apollo 204
spacecraft could not have been accomplished in sufficient time.
- During the January 27 Apollo 204 test, difficulty was experienced in
communicating from ground to spacecraft and among ground stations.
- The ground system design was not compatible with operational
The Integration Analysis Panel (No. 18) was rewriting its final report
to the Apollo 204 Review Board. Panel 18 had been assigned to review
information from all task groups and make the final technical
integration of the evidence. Panels 3 and 16 had been merged with Panel
18 on February 23. In its final report to the Review Board, Panel 18
"Board Proceedings" and Append. D, "Panel 18,"
Report of Apollo 204 Review Board, pp. 3-33 and D-18-3
- Several arcing indications were observed in the CM left front sector
and a voltage transient was noted in all three phases of AC Bus 2. This
transient was most closely simulated by a power interruption or short
circuit on DC Bus B. Physical evidence and witness statements indicated
the progress of the fire to be from the left side of the spacecraft.
Simulations and tests indicated that combustion initiation by
electrostatic discharge or chemical action was not probable. No physical
evidence of prefire overheating of mechanical components or heating
devices was found.
- No single ignition source could be conclusively identified. The most
probable initiator was considered to be the electrical arcing or
shorting in the left front sector of the spacecraft. The location best
fitting the total available information was that where environmental
control system instrumentation power wiring ran into the area between
the environmental control unit and the oxygen panel.
- All spacecraft records were reviewed by the various panels and the
results were screened by Panel 18.
- No evidence was found to correlate previously known discrepancies,
malfunctions, qualification failures or open work items with the source
- At the time of the observed fire, data including telemetry and voice
communications indicated no malfunctioning spacecraft systems (other
than the live microphone).
- Existing spacecraft instrumentation was insufficient by itself to
provide data to identify the source of ignition.
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
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:
"Board Proceedings" and Append. D, "Panel
11," Report of Apollo 204 Review Board, pp. 333 and
D-11-3 through D-11-9.
- 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
- This configuration was normal for the test.
- 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.
- This physiological response is compatible with the realization of an
- Voice contact with the crew was maintained until 6:31:22.7
- At least one crew member was conscious until that time.
- 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.
- Time of death could not be determined from this 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
- 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.
- 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.
- The crew was exposed to a lethal atmosphere when the first suit was
- The distribution of carbon monoxide in body organs indicated that
circulation stopped rather abruptly when high levels of
carboxyhemoglobin reached the heart.
- 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.
- The purge with 100-percent oxygen at above sea-level pressure
contributed to the propagation of fire in the Apollo 204 spacecraft.
- 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.
ASPO Manager Joseph F. Shea requested that the White Sands Test Facility
be authorized to conduct the descent propulsion system series tests
starting April 3 and ending about May 1. The maximum expected test
pressure would be 174 newtons per sq cm (253 psia), normal maximum
operating pressure. The pressure could go as high as 179 newtons per sq
cm (260 psia) according to the test to be conducted.
Required leak check operations were also requested at a maximum pressure
of 142 newtons per sq cm (206 psia), with a design limit of 186 newtons
per sq cm (270 psia). The test fluids would be compatible with the
titanium alloy at the test pressures. The test would be conducted in the
Altitude Test Stand, where adequate protection existed for isolating and
containing a failure. MSC Director Robert R. Gilruth approved the
request the same day.
Memo, Shea to Gilruth, "Request for authorization to conduct a
pressure test," March 31, 1967.
In reply to a request from NASA Hq., CSM Manager Kenneth S. Kleinknecht
told Apollo Program Director Samuel C. Phillips that replacement of the
service module 017 oxidizer tank was based on a double repair weld of
the method 2 kind in that tank. This kind of repair, he said, resulted
in a weld chemistry similar to the weld on the S-IVB helium bottle that
had failed, as had only recently been determined by examination of the
secondary-propulsion-system tank repair weld. There was insufficient
proof that titanium hydride concentrations could not occur in the double
method-2 repair weld, and replacement of the tank would preclude any
question as to the integrity of the tank. The decision was delayed as
long as possible in the hope of developing technical justification of
weld integrity. When that was not achieved and there was little
confidence that justification could be developed in the near future, the
decision was made directing the tank change. The activity would not
cause additional schedule time loss, as it was already necessary to
repeat the spacecraft integrated test because of wiring rework.
Ltr., Kleinknecht to Phillips, "Delay in Direction to Effect
Service Module Tank Change," April 1, 1967.
The mission profile for the first manned Apollo flight would be based
on that specified in Appendix AS-204 in the Apollo Flight Mission
Assignments Document dated November 1966, the three manned space flight
Centers were informed. Apollo Program Director Samuel C. Phillips said
the complexity of the mission was to be limited to that previously
planned, and therefore consideration of a rendezvous exercise would be
dependent upon the degree of complication imposed on the mission.
"There will be no additions that require major new commitments
such as opening a CM hatch in space or exercising the docking
TWX, Phillips to MSC, MSFC, and KSC, "First Manned Mission,"
April 5, 1967.
The Apollo 204 Review Board transmitted its final formal report to NASA
Administrator James E. Webb, each member concurring in each of the
findings, determinations, and recommendations concerning the January 27
spacecraft fire that took the lives of three astronauts.
The Apollo 204 Review Board studied Apollo spacecraft 014 (above) in its investigation of the January 27, 1967, fire in the similar CM 012 (below, photographed after the fire). The interior view shows the forward section of the left-hand equipment bay, below the environmental control unit in each spacecraft. The DC power cable crosses over aluminum tubing and under a lithium hydroxide access door (removed in the photo of the damaged CM 012). The board determined this was the area of the most probable initiator of the fire.
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 (see May 9-10,
1967, and Appendix 8).
Findings, determinations, and recommendations of the Apollo 204 Review
Report of Apollo 204 Review Board to the Administrator, National
Aeronautics and Space Administration, April 5, 1967, transmittal
letter and pp. 6-1 through 6-3 ; House Committee on Science and
Astronautics, Subcommittee on NASA Oversight, Investigation into
Apollo 204 Accident: Hearings, 90th Cong., 1st sess., vols. 1-3,
April 10, 11, 17, 21, May 10, 1967; Senate Committee on Aeronautical
and Space Sciences, Apollo Accident: Hearings, 90th
Cong., 1st sess., pts. 3-7, April 11, 13, and 17, May 4 and 9, 1967.
- A momentary power failure occurred at 6:30:55 p.m. EST (23:30:55
- Evidence of several arcs was found in the postfire
- No single ignition source of the fire was conclusively
- 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.
- 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).
- The test conditions were extremely hazardous.
- The amount and location of combustible materials in the CM must be
severely restricted and controlled.
- 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 data led to the medical opinion that unconsciousness
occurred rapidly and that death followed soon thereafter.
- Because of internal pressure, the CM inner hatch could not be opened
before rupture of the CM.
- The crew was never capable of effecting emergency egress because of
the pressurization before the rupture and their loss of consciousness
soon after rupture.
- The time required for egress of the crew should be reduced and the
operations necessary for egress be simplified.
- 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
- 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.
- Adequate safety precautions were neither established nor observed
for this test.
- 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.
- Frequent interruptions and failures had been experienced in the
overall communication system during the operations preceding the
- The overall communication system was unsatisfactory.
- 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.
- 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
- 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
- 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
- Timely distribution of test procedures and major changes should be
made a constraint to the beginning of any test.
- The fire in CM 012 was subsequently simulated closely by a test
fire in a full-scale mockup.
- Full-scale mockup fire tests could be used to give a realistic
appraisal of fire risks in flight-configured spacecraft.
- Full-scale mockups in flight configuration should be tested to
determine the risk of fire.
- The CM environmental control system design provided a pure oxygen
- This atmosphere presented severe fire hazards if the mount and
location of combustibles in the CM were not restricted and controlled.
- 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.
- Deficiencies existed in CM design, workmanship and quality control,
- 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 design and operating procedures required the
disconnecting of electrical connections while powered.
- No design features for fire protection were incorporated.
- These deficiencies created an unnecessarily hazardous condition and
their continuation would imperil any future Apollo Operations.
- 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
- 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.
- 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
- 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
- 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
- Problems of program management and relations between Centers and
with the contractor had led to some insufficient responses to changing
- 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