Determination.-The spacecraft had successfully operated at the same cabin conditions in the Chamber for a greater period of time than on the pad up to the time of the accident. Responsible Organization.—MSC. Action.-The possibility of using air on the pad during sea level operation is discussed under Panel Finding 9-b(3). Finding No. 4 Finding. The Plugs Out OCP was not classified as hazardous. Determination.-The hazard level was not recognized and consequently the procedure was processed through the review cycle as a non-hazardous procedure. Responsible Organization.-KSC. Action.-The KSC Safety Office and NAR Safety are presently reviewing and approving (by signature) all spacecraft test procedures. A KSC management instruction (KMI) is in preparation that establishes and defines the requirement for this review. The KSC Safety Office makes the final determination as to the hazardous classification of the test. The total TCP safety review plan is defined in APOP No. G-102, Safety Considerations for Checkout Procedures, released July 17, 1967. This procedure is in effect. Panel Finding 13-1 provides additional discussion on the safety aspects of recognizing hazard levels and the safety review cycle. Finding No. 5 Finding. Only local control is provided for certain systems which may require remote control for safety reasons, such as service structure water and hypergolic supply sources. Determination.-The full potential of the safety systems is not utilized due to the lack of remote control capability. Responsible Organization.-KSC. Action.-Detailed studies have been completed that reviewed the advantages and disadvantages of remote control capability to systems such as the service structure water deluge and hypergolic supply sources. As a result of these studies, it was concluded that in both of these systems, a remote control capability or additional control stations would not improve the safety aspects of systems control. The studies were conducted by KSC Spacecraft Operations, Launch Operations, and Design Engineering personnel. Based on these studies, it is concluded that the full potential of the safety systems in question is currently being used. Finding No. 6 Finding. The open item constraint list was not formalized as required by APOP No. 0-202. Determination.-Pretest constraints were evaluated informally on a system-bysystem basis by the test team. Responsible Organization.-KSC. Action.-Pretest constraints will be formally evaluated and documented by the implementation of APOP No. 0-222, TCP Open Item Reviews, Constraints Listing, Pretest Briefings, and Post-test Debriefings, released August 2, 1967. This procedure, now in effect, provides instructions and assigns responsibilities including the following: (1) A specific definition of the requirements for a pretest open item review. The review will be co-chaired by the NASA spacecraft test conductor or his designee and the spacecraft contractor test project engineer. (2) A system of documenting the constraint items with proper approvals for the test in question or waivers as required. (3) A procedure for indicating items that are closed out between the conclusion of the open item review and the scheduled start of the test. Finding No. 7 Finding. Troubleshooting of the communication problem was not controlled by any one person. At times, it was run independently from the spacecraft, Launch Complex 34 Blockhouse, and the Manned Spacecraft Operations Building. Communications switching, some of which was not called out in the OCP, was performed without the control of the test conductor. Determination. The uncontrolled troubleshooting and switching contributed to the difficulty experienced in attempting to assess the communication problem Responsible Organization.-KSC. Action. KSC Launch Operations Directive No. 8, Control of Operational Intercommunications (OIS) Troubleshooting During Apollo/Saturn Major Test, was re leased October 30, 1967. This directive, now in effect, defines and implements the following requirements: (1) No OIS troubleshooting will take place during major testing (space vehicle overall test, flight readiness test, countdown demonstration test, and countdown) without prior approval of the NASA test supervisor. (2) The NASA spacecraft test conductor will maintain overall direction and control of the troubleshooting effort on all circuits that interface with the spacecraft. APOP No. 0-221, Erection and Acceptance of Test and Checkout Procedures, now in effect, specifically defines the requirement that all S/C OIS troubleshooting activities will be under the control of the NASA spacecraft test conductor. Finding No. 8 Finding.-KSC was not able to insure that the spacecraft launch operations plans and procedures adequately satisfied, on a timely basis, the intent of MSC. Changes to S/C testing by KSC could not be kept in phase with the latest requirements of MSC. Pre-launch checkout requirements (GORP) were not formally transmitted to KSC from MSC. Determination. Pre-launch test requirements control for the Apollo Spacecraft Program is constrained by slow response to changes, lack of detailed KSC-MSC inter-Center agreements, and by the lack of official NASA approved Test Specifications applicable to pre-launch checkout. Responsible Organization-MSC. Action.-Prelaunch test requirements control for the Apollo Spacecraft Program are defined in Apollo Program Directive No. 26, Preparation of Test and Checkout Procedures at KSC, released April 18, 1967. Response to changes has been expedited by conducting a series of reviews and by requiring configuration data to be maintained on a current basis as described in Panel Findings 1-2 and 1-3. Detailed KSC-MSC intercenter agreements have also been developed based on the Apollo program directive mentioned above. MSC is currently required to furnish an MSC-approved test and checkout requirements document to KSC 4 months before delivery, and the test specification and criteria document 2 months before delivery of the first manned spacecraft. For subsequent spacecraft, the requirement is 4 months before delivery for both documents. ÑAR will submit the proposed documents to MSC at least 1 month before the required MSC approval dates. Additional test specification information is furnished under Panel Finding 7-9. Finding No. 9 Finding. The Test Specifications for Spacecraft 012 were not written in a convenient-to-use format, did not contain field tolerances, were not NASA approved, were not maintained up-to-date, and were not transmitted to NASA/KSC. Determination.-The lack of usefulness of the Test Specifications has been recognized by NAA, Downey and measures intended to correct the situation have been initiated. Responsible Organization.—MSC Action.-NAR is preparing a test and checkout requirements document and a test specification and criteria document to cover the checkout activities at KSC. These documents will replace the Ground Operations Requirements Plan (GORP) for Block II spacecraft and will include required tests and prerequisites to each testing phase as well as the field tolerances required to be met for acceptance of tests. These documents will have NASA MSC approval and will be forwarded to KSC for implementation to support the first manned spacecraft. The action was assigned by Apollo Program Directive No. 26. Panel No. 8 Finding No. 1a MATERIALS REVIEW Finding.-Complete documentation which identified potentially combustible nonmetallic materials used in S/C 012 is not available in a single readily usable format. A total of 2,528 different potentially combustible nonmetallic materials which were probably used on S/C 012 were found by a review of available documentation. Determination.-The program for identification and documentation of nonmetallic materials used in the S/C, including their weights and surface areas, was not adequate. There is no system in effect through which nonmetallic materials configuration changes are tracked, reported, evaluated, and controlled in an integrated manner. Responsible Organization.-MSC. 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). The overall objective of the full-scale flammability test program is to ensure that no fire hazards exist in manned spacecraft. If hazards are discovered as a result of this command module mockup test program, materials may be relocated, removed or replaced. The following are specific objectives: (1) Define the degree of propagation and magnitude of each fire resulting from the ignition source; (2) Measure the rate and magnitude of pressure and temperature increases resulting from combustion; (3) Determine length of time a reasonable degree of crew visibility would be retained; (4) Identify toxic products occurring as a result of the ignition. These tests will be performed at 6.2 psia and then at 16.5 psia with a 100% oxygen environment. Ignition will first be attempted by means of a deliberate electrical circuit overload. In the event ignition does not occur, a nichrome wire will be used as an ignition source. The test article consists of boilerplate 1224 with the interior built up simulating a flight command module, including (1) All storage compartments and boxes; (2) The complete internal electrical wire harness including all wire protective wraps, spot ties, clamps, spacers, and conformal coatings; (3) Rotational and translational controllers on the couches; (4) Two suits and oxygen supply hoses with cobra cables; (5) A pump accumulator and reservoir providing water/glycol flow rates and pressures representative of manned spacecraft; (6) Cabin fans and cabin pressure relief valve; (7) All contractor and government-furnished equipment having nonmetallies such as tools, food, procedures manuals, medical supplies, sanitary supplies, clothing, etc. Ignition will be imposed by overloading electrical conductors in wire bundles, at circuit breaker terminal posts, and through potted connections. No systems or circuits will be live other than the ignition source. Oxygen handling procedures are being defined in detail to be in accordance with MSC safety regulations. This full-scale test is being preceded by many component and subsystem tests made in boilerplate 1250. These tests have been run on such items as wiring and wire bundles, specific sections of the crew compartment, and circuit breaker panels. A senior flammability test review board has been established to determine whether the full-scale test configuration is a proper one and whether the test results verify that the spacecraft is fire safe. Dr. Gilruth is chairman and among the senior representatives are key personnel from NAR, OMSF, medical research and operations, flight safety, and flight crew operations. 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 as follows. CCA 1361 was issued April 17, 1967 for the CSM. CCA 428 was issued April 19, 1967 for the guidance and navigation system. Letter PR2/M67-119 was issued May 8, 1967 for government-furnished equipment. Standardized reporting formats have been adopted by implementation of the COMAT Instruction Manual, dated July 7, 1967. Extensive nonmetallic materials revisions have been made to the CSM crew equipment stowage, ECS suit loop, spacesuit, and other CSM equipment as follows: (1) CSM Crew Equipment Stowage-The following stowage bags and boxes have been deleted and redesigned to use a metal box: (a) Forward sanitation supplies stowage box; (b) Aft sanitation supplies stowage box; (c) PLSS cable stowage container; (d) LH upper equipment bay stowage bag; Thermal meteoroid garment stowage bag; (g) Inflatable tool set stowage pouch; (h) The sanitation supplies bag was redesigned to use a Teflon bag; (2) CSM ECS Suit Loop Materials-The following nonmetallic materials used in the ECS suit loop were replaced: (a) Dacron filters in LiOH canister; (b) Polyurethane foam insulation on the ECU; (c) Silicon foam insulation; (d) In addition, NAR was directed by CCA 1323 and CCA 1324 to investigate replacement of the polyurethane seats located in the relief valve and regulator. The dacron filter was replaced with an Armalon filter that meets the requirements of MSC Specifications 66-3A. Environmental Control Unit Specification ME901-0218 was revised June 22, 1967, to effect this change. The polyurethane foam insulation will be replaced by TG 15000 (post-cured fiberglass) wrapped with Beta glass (Pyrolace STFE 40B). (3) Space Suit Materials-Space suit material changes have been made. The materials used in the Block II EMU (space suit) are described in detail in Document CSD-A-523, Materials Report for EMU Garments and Accessories. (4) CSM Nylon Fastener Replacements--Nylon fasteners were replaced by mechanical fasteners in 28 locations. The nylon Velcro was removed from 18 locations in the CSM. Control over nonmetallic 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 acting as major contractors, i.e., for GFE, they will submit deviation requests to the MSC nonmetallic materials selection review board. The contractors have within their own organization, 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 deviations. This Board is located at MSC and is chaired by the chief of the RQ&T 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 NASA-MSC board chairman and has the same type of membership as the NASAMSC board. The contractors board is basically responsible for approving or disapproving deviations and submits all actions to the MSC Board for final approval. 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. 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 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.) Finding No. 1b Finding. Test data providing individual combustion properties in environments of 5 psia to 21 psia oxygen were available for 550 of the potentially combustible nonmetallic materials identified as possibly being used. Data on higher pressure testing were available only on suit materials, Velcro and K-10 flight paper. Determination.-Flammability test requirements were not standardized at the time the reference tests were accomplished. Large numbers of potentially combustible nonmetallic materials were used in the fabrication of S/C 012 without specific correlated combustibility test data. Test data were available at high O2 pressures (to 21 psia) to define the combustion characteristics of some of the major materials which contributed heavily to the fire. Responsible Organization.—MSC. Action.-Flammability test requirements have been standardized as part of the overall fire control program being accomplished on all manned spacecraft. Combustibility test data will be obtained on all nonmetallic materials used in the spacecraft at 16.5 psia with a 100% oxygen environment. These tests and requirements for selection and test verification of nonmetallic materials are discussed in Panel Finding 8-1a. Finding No. 2 Finding.-Raschel Knit, Velcro, Trilock and polyurethane foams burn about twice as fast (in the downward direction) in 16.5 psia as in 5 psia 02. Determination.—The primary fuels for the fire burned over twice as fast in the early stages of the fire in accident conditions (16.5 psia) than in space flight atmosphere for which they were evaluated (5 psia). Responsible Organization.-MSC. Action. All nonmetallic materials will be extensively tested in a 16.5 psia, 100% oxygen atmosphere. Full-scale mockup tests to determine overall flammability characteristics are described in Panel Finding 8-la. mens Finding No. Sa Finding.-Laboratory analyses indicated that solvent retention by test speciwas significant. The analyses also indicate that the evaporation characteristics of the solvent are such that vapor concentration fell below the lean flammability limit after 11⁄2 hours. Determination.-The presence of significant volumes of concentrated vapor in the spacecraft is unlikely. However, the retention of solvents in the surface layers of solid flammable materials could possibly contribute to their ignitability. Responsible Organization.-MSC. Action. Quality assurance requirement MSC-A-D67-5 includes provision for prohibiting the use of dangerous solvents and for limiting those solvents that are required for use to accomplish a process within the crew compartment. Contractual action has been completed. Finding No. 3b Finding.-Odors similar to that of sour milk and methyl-ethyl-ketone were reported before the fire during suit and cabin purge operations. Thresholds of methyl-ethyl-ketone and isopropyl alcohol detection by smell are approximately .01 percent to .03 percent by volume and concentrations described as strong, irritating or sickening range from 1 percent to 4 percent by volume. Determination.-There is no evidence that significant concentrations of organic vapors were present in S/C 012 at the time of the fire. Responsible Organization.-MSC. Action.-Solvent use and control has been included in the new quality assurance requirements developed by MSC as described in Panel Finding 2-2. Criteria for conducting tests on odors emanating from nonmetallic materials at elevated temperatures are now in effect based on MSC-A-D-66-3. (Defined under Panel Finding 8-1a.) Each test is witnessed by the assigned Quality Assurance inspector and each step is verified and stamped as required by the procedure. Other tests have been conducted according to these criteria to determine the organic offgassing products and CO generation of nonmetallic materials. These tests will be culminated in the full-scale testing described in Panel Finding 8-1a. Finding No. 3d Finding. Connecting and disconnecting of spacecraft qualified Cobra connectors at normal loads did not create sufficient energy to ignite concentrations up to saturation (approximately 12 percent) of methyl-ethyl-ketone in 16.4 psia oxygen. An increase in loading to 2.5 times operating amperage in 4.0 percent of MEK yielded no ignition. Determination.-Ignition of flammable concentrations of solvent vapors by connecting and disconnecting Cobra connectors is an unlikely ignition source for the S/C 012 fire. Responsible Organization.-MSC. |