VOLUME I-STATUS OF ACTIONS TAKEN ON APOLLO 204 REVIEW BOARD FINDINGS AND RECOMMENDATIONS

REFERENCE INFORMATION

The actions reported in this volume are based on the findings, determinations, and recommendations found in Part VI of the Report of The Apollo 204 Review Board to the Administrator, National Aeronautics and Space Administration, dated April 5, 1967.

AS-204 Review Board Findings 1 and 3 contained findings and determinations only.

The Review Board findings, determinations, and recommendations are reproduced at the heading of each page as they appear in the report referenced above. The ACTION section describes the actions taken by the Apollo Program Office to implement each recommendation of the Review Board.

Board Finding No. 2

Finding. (a) The Command Module contained many types and classes of combustible material in areas contiguous to possible ignition sources.

(b) The test was conducted with a 16.7 pounds per square inch absolute, 100 percent oxygen atmosphere.

Determination.-The test conditions were extremely hazardous.

Recommendation.-The amount and location of combustible materials in the Command Module must be severely restricted and controlled.

Action.-The amount of combustible materials in the command module has been greatly reduced. There were 1412 nonmetallic materials identified in the CSM. Seventy-nine percent or 1113 have been deleted, replaced, redesigned, or determined to be acceptable. The remaining nonmetallic materials are currently being evaluated and work on this effort is scheduled for completion early in 1968. This effort includes flammability tests to be conducted early next year at MSC on a full-scale command module boilerplate (BP-1224). These tests are fully described under Board Finding No. 8, which deals specifically with fullscale mockup flammability testing. Descriptions of the extensive nonmetallic material changes that have been made to the CSM crew equipment stowage, ECS Suit Loop, space suit and other CSM equipment are provided in Volume II, Panel Finding 8-la.

The requirement for identification of all nonmetallic materials, their location, weight, and surface area has been imposed on all organizations furnishing equipment for use in the CSM crew compartment. Standardized reporting formats have been adopted and a central source to provide materials data has been established.

The basic discipline being applied throughout the spacecraft program is to limit the selection and placement of materials in the crew bay so that if a fire should start, it could not propagate or burn sufficiently to incapacitate the crew or result in critical structural or functional damage to the spacecraft.

Control over non metallic materials is exercised by both the contractor and MSC. The contractor bears the primary design responsibility for the selection of materials. NASA bears the responsibility for the review of the selection of certain classes of materials. Where NASA organizational elements are supplying GFE they will submit change requests to the MSC Nonmetallic Materials Selection Review Board. The contractors have within their own organizations, and have established at their subcontractors installations, one or more cognizant materials engineers who will be responsible for reviewing materials problems, formulating deviation requests and submitting them to the MSC Materials Selection Review Board. The NASA-MSC Materials Selection Review Board has the final responsibility for approval of changes. This Board is located at MSC and is chaired by the Chief of the R&QA Division. Representation is from all cognizant technical areas including flight safety, space medicine, materials reliability and control and materials engineering. A second board is located at the spacecraft contractor's facility. This board has as its chairman, the contractor's counterpart to the NASAMSC board chairman and has the same type of membership as the NASA-MSC

board. The contractors board is basically responsible for approving or disapproving changes and submits all actions to the MSC Board for final approval. Materials selection guidelines and test procedures have been prepared and implemented through the following basic documents:

ASPO-RQTD-D67-5, Nonmetallic Materials Selection Guidelines dated April 10, 1967, Revision A, issued May 5, 1967. (This document establishes acceptance guidelines and test requirements for nonmetallic materials in the spacecraft. It includes general fire control criteria and eight categories of materials classified according to functional application and distribution in the spacecraft. Toxicity, flammability, design, and test requirements are also defined.)

MSC-A-D-66-3, Revision A, Procedures and Requirements for the Evaluation of Spacecraft Nonmetallic Materials, dated June 5, 1967. (This document contains detailed test procedures and requirements for combustion rate, flammability, odor, offgassing and ignition tests that conform to the more rigid selection requirements of the Nonmetallic Materials Selection Guidelines described above.)

Board Finding No. 4

Finding. Due to internal pressure, the Command Module inner hatch could not be opened prior to rupture of the Command Module.

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

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

Action. A new hatch has been designed to replace the two-cover hatch system on Block II command modules. The single door is called a "unified hatch" and is made of aluminum with added fiber glass and ablative material. The hatch has flexible thermal seals, a latch and linkage mechanism, hinges, window, and a boost-protective hatch cover that swings open on separate hinges. There is a single cabin vent valve for ground testing or cabin purging. The door development mechanism contains a counter-balancing device to offset gravity, and a linkage that locks the hatch in full open position. The door unlatching mechanism can be operated either by the flightcrew in less than 3 seconds or by the ground crew for emergency or normal operations in less than 10 seconds.

Ground and flight tests are in progress to qualify the new hatch to assure the following items: (a) effective operation, (b) integrity in the vibration environment encountered during launch and reentry, (c) compatability with crew requirements including EVA, (d) integrity during reentry heating, and (e) emergency operations. These tests are being conducted on ground test articles, on the thermal vacuum model, and on unmanned Saturn V flights.

This hatch will be incorporated in all manned spacecraft.

Board Finding No. 5a

Finding. Those organizations responsible for the planning, conduct 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 Command Module fire were not made. No procedures for this type of emergency had been established either for the crew or for the spacecraft pad work team.

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

Recommendation.-Management continually monitor the safety of all test operations and assure the adequacy of emergency procedures.

Action. All spacecraft test procedures are required to contain applicable emergency procedures. These procedures are reviewed during the test checkout procedure safety review activity defined in APOP No. G-102 Safety Considerations for TCP's, released July 17, 1967.

The KSC Safety Office and NÁR Safety are presently reviewing and approving by signature all spacecraft test procedures. The KSC Safety Office makes the final determination as to the hazardous classification of all tests, based on the stringent criteria for definition of hazardous procedures provided in APOP No. G-102. The procedures that have been evaluated as hazardous are then compared against a set of checklists to ensure compliance with safety practices.

Emergency equipment to be added to all launch complexes to improve escape and rescue operations is described in Board Finding 5b. Personnel training and practice for emergency procedures are described in Board Finding 5c. Changes made to the service structure and umbilical tower to improve emergency egress are described in Board Finding 5d.

Management will continually monitor the safety of all test operations and ensure the adequacy of emergency procedures through the review and approval cycle described.

Board Finding No. 5b

Finding. Those organizations responsible for the planning, conduct 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 Command Module fire were not made. The emergency equipment located in the White Room and on the spacecraft work levels was not designed for the smoke condition resulting from a fire of this nature.

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

Recommendation. All emergency equipment (breathing apparatus, protective clothing, deluge systems, access arm, etc.) be reviewed for adequacy.

Action. All emergency equipment has been reviewed for adequacy and improvements are being made by the addition of equipment at the launch complexes. Emergency safety lockers, containing air packs, fire blankets, gas masks, axes, tools, special fire extinguishers and other emergency items are being installed at selected levels of the service structure, umbilical tower and other key locations on the launch complexes. A detailed description of all items to be included in the safety lockers is provided in Volume II, Panel Finding 13-9. Lockers and equipment will be installed to support manned flight requirements on both LC-34 and LC-39.

Emergency rescue personnel are equipped with heat protective garments and self-contained breathing apparatus.

A slide wire emergency escape system for the flight crew and ground closeout crew is being provided on LC-34 from the Apollo access arm level of the umbilical tower to a point on the ground 1200 feet away from the base of the tower. The operational ready date will be in early 1968. This system is also being evaluated for possible use on LC-39.

The water deluge system on the service structure has been evaluated in detail and has been found to be adequate both as to the number and location of control stations. The hypergolic servicing systems at the launch complexes have also been completely reviewed from the standpoint of remote control capability and the present systems were found to be adequate.

Emergency procedure improvements are described in Board Finding 5a. Personnel training and practice for emergency procedures are described under Board Finding 5c. Changes made to the service structure and umbilical tower to improve emergency egress are described in Board Finding 5d.

Board Finding No. 5c

Finding. Those organizations responsible for the planning, conduct 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 Command Module fire were not made. Emergency fire, rescue and medical teams were not in attendance.

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

Recommendation.-Personnel training and practice for emergency procedures be given on a regular basis and reviewed prior to the conduct of a hazardous operation.

Action.-Personnel emergency procedure training and practice have been and will continue to be given on a regular basis. Training proficiency will be reviewed before conducting all hazardous operations.

Evacuation routes have been posted and evacuation drills are run on a scheduled basis.

A training program has been initiated by NASA KSC Training, Safety, and Fire Departments in cooperation with the spacecraft contractors that includes the use of fire-fighting equipment, first aid and the handling of personnel requiring aid in the event of an emergency.

An access arm and command module mockup (in the Block II CSM configuration with the new quick-opening unified hatch) are being set up at KSČ for development of emergency crew egress procedures and training. This training facility will be operational early in 1968.

Changes made to the service structure and umbilical tower to improve emergency egress are described in Board Finding 5d. Emergency equipment to be added to all launch complexes to improve escape and rescue operations is described in Board Finding 5b. Emergency procedure improvements are described in Board Finding 5a.

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Board Finding No. 5d

Finding. Those organizations responsible for the planning, conduct 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 Command Module fire were not made. Both the spacecraft work levels and the umbilical tower access arm contain features such as steps, sliding doors and sharp turns in the egress paths which hinder emergency operations.

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

Recommendation.-Service structures and umbilical towers be modified to facili

tate emergency operations.

Action.-Service structures and umbilical towers are being modified to improve emergency personnel and crew evacuation capability. Changes were authorized to be made on LC-34 on April 21, 1967 and include

(1) Reconfiguring the environmental chamber (EC) adapter hood to provide a flatter egress path from the spacecraft to the EC;

(2) Eliminating the step at each end of the Apollo access arm;

(3) Incorporating two-way swinging doors on the Apollo access arm and on the access arm cab;

(4) Providing smoke removal ventilation in the Apollo access arm cab; (5) Changing the arm retraction sequence to rotate the arm to a park position near the latch position at T-30 minutes to permit quick return to the command module. At T-4 minutes the arm will be swung to the stowed position;

(6) Incorporating fire-resistant materials inside the Apollo access arm. Effectivity for LC-34 is for the first manned spacecraft. The operational ready date is early in 1968. Effectivity for LC-39 is for the first manned Apollo/Saturn V flight. The operational ready date is in the second quarter of 1968.

Emergency procedure improvements are described in Board Finding 5a. Emergency equipment to be added to all launch complexes to improve escape and rescue operations is described in Board Finding 5b. Personnel training and practice for emergency procedures are described in Board Finding 5c.

Board Finding No. 6

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. Recommendations.-a. The Ground Communication System be improved to assure reliable communications between all test elements as soon as possible and before the next manned flight.

b. A detailed design review be conducted on the entire spacecraft communication system.

Action.-The ground communications system has been reviewed in detail and improvements are being made to ensure reliable communications between all test elements. Specific equipment modifications include—

(1) For Launch Complex 34:

(a) Undesirable coupling in the astronaut communications panels has been eliminated and duplex communications to the spacecraft umbilical cable have been provided with minimum use of VOX devices; (b) Headset frequency response has been improved and its efficiency raised;

(c) Central testing facilities are being added to permit continuous monitoring of circuit quality;

(d) Continuous recordings of critical voice communication loops will be provided. Effectivity is for the first manned spacecraft and the operational ready date is the second quarter of 1968. Additional changes made to this launch complex ground communications system are described under Panel Finding 9-d(2).

(2) For Launch Complex 39:

(a) Evaluations are currently being made of Launch Complex 39 communications based on the changes being incorporated in Launch Complex 34.

(b) Effectivity for all changes to the LC-39 ground communications system will be for the first manned Apollo/Saturn V flight.

(3) Procedural changes to be made for all launch complexes:

(a) Reduction in the number of stations on critical communication loops;