Finding No. 23 Finding. The purge with 100-percent 02 at above sea-level pressure contributed to the propagation of fire in the Apollo 204 Spacecraft. Determination.-This was the planned cabin environment for testing and launch," since prelaunch denitrogenation is necessary to forestall the possibility of bends at the mission ambient pressure of 5 pounds per square inch absolute. A comprehensive review of the operational and physiological trade-offs of the various methods of denitrogenation is in progress. Responsible Organization-MSC. Action. Studies have been made assessing the bends hazard. The operational requirements of using air on the pad and the effects on overall mission and hardware performance have been evaluated. The full-scale command module flammability tests described in Panel Finding 8-1a must be completed before a program decision can be made on the type of atmosphere to be provided for spacecraft ground testing. However, engineering design is providing for hardware that will operate on either 100% oxygen or air on the pad. Additional details on this subject are found in Panel Finding 9-b(3). Finding No. 24 Finding. Rescue personnel were equipped with gas masks designed for protection against hypergolic vapors. They had no heat-protective garments. Determination. Rescue personnel were inadequately equipped for a fire-type rescue. Responsible Organization-KSC. Action.-Emergency rescue personnel are equipped with heat-protective garments and self-contained breathing apparatus, and will be on station in accordance with the revised and more stringent criteria for definition of hazardous procedures per APOP No. G-102, Safety Considerations for TCP'S, released July 17, 1967. Self-contained breathing apparatus will be stored in emergency equipment lockers at selected levels of the service structure and umbilical tower. Emergency equipment to be available for any contingency, including fire, will be available in safety lockers placed at various locations throughout KSC. This equipment is described under Panel Finding 13–9. These actions were in effect for Spacecraft 017 and will be for all subsequent spacecraft. GROUND EMERGENCY PROVISIONS REVIEW Panel No. 13 Finding No. 1 Finding. 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. Determination.-The absence of any significant emergency preplanning indicates that the test configuration (pressurized 100 percent oxygen cabin atmosphere) was not classified as a potentially hazardous operation. Responsible Organization.-KSC. Action.-A procedure has been released that identifies more stringent hazard criteria for any environment that deviates from normal atmosphere (chemical composition, pressure, or temperature). This procedure, APOP No. G-102, Safety Considerations for Checkout Procedure, was released July 17, 1967. An access arm and CM mockup are being set up at KSC for development of emergency crew egress procedures and subsequent training. The CM mockup will be a Block II configuration with the new quick opening unified hatch. This training facility will be operational early in January 1968 to support the first manned spacecraft requirements. APOP No. 0-202, Preparation and Release of Test and Checkout Procedures, was released July 12, 1967. In accordance with this procedure, TCP's will include safety considerations, applicable safety requirements, and emergency procedures when personnel are sealed in the command module in an environment that deviates from normal atmosphere. Flight crew safety emergency procedures will be included in the TCP. TCP's which involve flight crew participation will have MSC coordination and signature approval. The TCP's will be released 30 days prior to the test to support first manned spacecraft test and checkout at KSC. Effectivity is for the first manned and all subsequent spacecraft. Finding No. 2 Finding. There are no documented safety instructions or emergency procedures in existence which are applicable to the possibility of a serious internal spacecraft fire. Determination. The occurrence of an internal spacecraft fire of the magnitude and intensity experienced in this accident was not considered to be a significant possibility under any operational circumstances. Responsible Organization.—KSC. Action.-Test and checkout procedures will contain adequate emergency procedures with respect to the possibility of internal spacecraft fires. The TCP will be released 30 days prior to any test in which personnel are sealed in the command module. Two procedures require that provisions for safety instructions and emergency operations be defined in applicable spacecraft test procedures. These are APOP No. G-102 Safety Considerations for Checkout Procedures, released July 17, 1967, and APOP No. 0-202, Preparation and Release of Test and Checkout Procedures, released July 12, 1967. Additional details on these procedures are provided in Panel Findings 13-1 and 13-13. Finding No. 3 Finding. The propagation rate of the fire involved in the AS-204 accident was extremely rapid. Removal of the three spacecraft hatches to effect emergency egress from either the inside or outside involved a minimum of 40 and 70 seconds respectively under ideal conditions. Determination.-Considering the rapidity of propagation of the fire and the time constraints imposed by the existing spacecraft hatch configuration, it is doubtful that any amount of emergency preparation would have precluded injury to the crew prior to crew egress. Responsible Organization.-MSC. Action. The amount of combustible materials in the command module is being reduced to a minimum and a unified, quick-opening side hatch is being provided. The hatch is outward opening and may be operated from either the interior or exterior. Details on the hatch operation are described in Panel Finding 9-c(1). CCA 1326 to Contract NAS9-150 directed the contractor to incorporate the hatch revisions into ground and flight test spacecraft as well as all manned spacecraft. Hatch qualification will be completed before manned use. Details on the reduction of nonmetallic materials are provided in Panel Finding 8-1a. Finding No. 5 Finding. The Apollo Flight Crew Hazardous Egress Procedures Manual contains procedures relative to unaided, aided and incapacitated flight crew egress. By scope and definition, this document is concerned only with evacuation of the flight crew from the spacecraft and the pad under hazardous conditions occurring primarily external to the spacecraft during a launch operation. Determination.-The Apollo Flight Crew Hazardous Egress Procedures Manual does not contain adequate emergency provisions for significant emergency conditions internal to the spacecraft any time the crew is on board. Responsible Organization.-KSC. Action.-The Hazardous Evacuation Procedures, Apollo/Saturn V, LC-39, (600-40-0006), dated September 25, 1967, includes actions to be taken in the event of an emergency that occurs after space vehicle tanking is completed during Countdown Demonstration Tests (CDDT's) and launch operations. This procedure is in effect. An access arm and command module mockup are being set up at KSC for development of emergency crew egress procedures and training. This training will include simulation of emergency conditions internal to the spacecraft. This training facility will be operational early in 1968. The flight crew hazardous egress procedure will be published 30 days before the test in accordance with APOP No. 0-2-2, Preparation and Release of Test and Checkout Procedures, released July 12, 1967. Development of crew procedures for spacecraft emergencies during test and in flight is underway. These procedures must take into account specific mission requirements and will be provided for use in all manned test operations. Finding No. 6 Finding. 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. Determination.-The spacecraft pad work team was not properly trained or equipped to effect an efficient rescue operation under the conditions resulting from the fire. Responsible Organization.-KSC. Action. The spacecraft pad work team personnel have received special training in the use of fire-fighting equipment located in their respective work areas by the KSC Fire Department. This will be continued on a regularly scheduled basis. Additional details on the training program and emergency equipment to be available at all launch complexes are found in Panel Finding 13-9. The training program and new emergency equipment available will provide team personnel with the capability to conduct an efficient rescue operation under any emergency situation. Finding No. 7 Finding. There was no equipment on board the spacecraft designed to detect or extinguish a cabin fire. Determination. The flight crew had to rely upon physiological cues to detect the presence of a fire. When all face masks were closed, the cues were limited to sight and touch. Once detected, there were no means by which the fire could have been contained or extinguished. Responsible Organization.-MSC. Action. A jelled water foam portable fire extinguisher has been developed and will be stowed in the CM during all manned missions and closed hatch tests. Two of these extinguishers will be carried in the command module and can be used on open fires or on fires behind panels by inserting them into special ports provided for this purpose. Three special oxygen masks to protect the shirtsleeve crew in the command module from toxic fumes will be provided. The command module oxygen system is being modified to provide the capability for this emergency oxygen mask breathing system. All plumbing associated with this system will be protected to preclude damage. A detailed study of fire detection requirements was conducted. The present crew detection and spacecraft instruments were deemed adequate. Finding No. 8 Finding. 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. Determination.-The status of the overall communication systems was marginal for the support of a normal operation. It cannot be assessed as adequate in the presence of an emergency condition. Responsible Organization.-KSC. Action.-The overall ground communication system has been reviewed and modifications have been, and will continue to be, made to improve system adequacy and operational capability, KSC CCBD No. PPR-4-0531, dated July 5, 1967, approves GE ECP No. CM-1779P, including the following changes: (1) Reduction in number of stations on those critical loops now being overloaded during peak periods; (2) Introduction of design changes to ensure reliable operation of the present circuits and equipment; (3) Addition of four-wire intercommunications equipment to provide full duplex links among the flight crew, the blockhouse, the spacecraft checkout station, and the Houston Mission Control Center. The changes will be completed in time to support the first manned launch on LC 34. Additional information is provided in Panel Finding 9-d2. Finding No. 9 Finding Emergency equipment provided at the spacecraft work levels consisted of portable CO2 fire extinguishers, Rockets Propellant Fuel Handler's Gas Masks and 11⁄4-inch diameter fire hoses. Determination. The existing emergency equipment was not adequate to cope with the conditions of the fire. Suitable breathing apparatus, additional portable CO, fire extinguishers, direct personnel evacuation routes and smoke removal ventilation are significant items which would have improved the reaction capability of the personnel involved. Responsible Organization.-KSC. Action. The capability of pad personnel to adequately react to emergencies has been improved by the addition of emergency equipment and smoke removal ventilation, and making personnel evacuation routes more direct. These improve ments are (1) Additional Emergency Safety Equipment.-Emergency safety equipment lockers will be installed at selected levels of the service structure (SS) and umbilical tower (UT). For S/C 017 test and launch operations, the following equipment was available at the spacecraft levels: (a) Twenty emergency explosion proof lights; (b) Fifteen air packs; (e) Two first aid kits; (f) Twenty 15-pound CO2 fire extinguishers. Fifty safety lockers will be placed at various locations throughout the launch complexes and will contain: (a) Two air packs; (1) Two safety belts; (m) Two 6-foot life line lanyards; (n) Two 50-foot braided ropes; (0) One hydraulic jack kit; (p) Two fireman's gloves; (q) One fireman's insulated cutter. This equipment has been procured and will be installed on the launch complexes before the end of this year. (2) Crew Egress Path.-The crew egress path from the command module has been thoroughly reviewed. Modifications that have been made include— (a) Eliminating the step that existed on each end of the Apollo Access Arm; (b) Provision of two-way swinging doors on the Apollo Access Arm and on the Apollo Access Arm cab; (c) Provision of smoke removal ventilation in the Apollo Access Arm cab; (d) Additional Provisions are described in Pane Finding 9-c(2). The access arm and umbilical tower modifications to reduce the fire hazard and delays to emergency crew egress have been authorized by the following KSC documents: (a) LC-34 modifications: KSC CCBD No. PPR-4-0469, effective for the first manned spacecraft (Chrysler will implement); (b) LC-39 modifications: KSC CCBD No. PPR-5-1135, effective for the first Apollo/Saturn V manned flight (Boeing will implement). (3) Slide Wire Escape System.-A slide wire escape system 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 as authorized in KSC CCBD No. PPR-4-0469 (effective for S/C 101). The need for a slide wire system on LC-39 is being evaluated and a decision will be made prior to the effective need date of the first manned Apollo/Saturn V flight. (4) Evacuation Training.-Evacuation routes have been posted and evacuation drills are run on a regularly scheduled basis. A training program has been initiated by NASA-KSC training, safety, and fire departments in cooperation with the spacecraft contractor. This training and practice, to be conducted on a regularly scheduled basis, includes: (a) Use of fire fighting equipment; (b) First aid; (c) Handling of personnel requiring aid in the event of an emergency. (5) Emergency Rescue Personnel.-Emergency rescue personnel are equipped with heat protective garments and self-contained breathing apparatus, and will be on station in accordance with revised and more stringent KSC criteria for definition of hazardous procedures in APOP No. G-102, Safety Considerations for Checkout Procedures, dated July 17, 1967. Finding No. 10 Finding.-There are steps and doorways on the Launch Complex 34 Apollo Access Arm and in the environmental enclosure (White Room) which constitute safety hazards, particularly under emergency conditions. Determination.-The present configuration of the access arm and White Room is not compatible with emergency personnel evacuation requirements or with fast, safe flight crew egress. Responsible Organization.-KSC. Action.-The configurations of the access arm and White Room have been changed to improve compatibility with emergency personnel evacuation requirements and to provide for fast, safe flight crew egress. Included in the changes are (1) The environmental chamber (EC) adapter hood has been reconfigured to provide a flatter egress path from the spacecraft to the EC; (2) The EC is being lowered to eliminate the step from the EC to the Apollo Access Arm (AAA); (3) The umbilical tower (UT) platform is being modified to eliminate the step at the end of the AAA next to the UT; (4) The doorways are being reconfigured to incorporate two-way swinging doors. Additional discussion on this area and relationship to LC-34 and LC-39 is found in Panel Finding 13–9. An access arm and command module mockup (Block II configuration with new, quick-opening hatch) are being set up at KSC for development of emergency crew egress procedures and subsequent training. This training facility will be operational early in 1968. This action will be effective for the first manned and all subsequent spacecraft. Finding No. 11 Finding. During the preparation of S/C test procedures at KSC, safety considerations for hazardous operations and documentation of applicable emergency procedures are limited in most cases to routine safety reference notations and emergency power-down instructions. Determination.—Insufficient emphasis is applied by the test procedure originator upon documenting emergency procedures and identifying specific hazards and applicable safety requirements. Responsible Organization.-KSC. Action.-Procedures defining and implementing applicable safety requirements, emergency procedures, hazard identification, and assigning responsibilities for preparation, review, and approval have been released. APOP No. G-102, Safety Considerations for TCP's, released July 17, 1967, and APOP No. 0-202, Preparation and Release of Test and Checkout Procedures, released July 26, 1967, are described in detail in Panel Findings 13-1 and 13-13. Finding No. 12 Finding. Under the existing method of test procedure processing at KSC, the cognizant Safety Offices review only those procedures which are noted in the OCP outline as involving hazards. Official approval by KSC and AFETR Safety is accomplished after the procedure is published and released. Determination.-The scope of contractor and KSC Safety Office participation in test procedure development is loosely defined and poorly documented. Postprocedure-release approval by the KSČ Safety Office does not insure positive and timely coordination of all safety consideration. Responsible Organization.-KSC. Action.-The KSC Safety Office and NAR Safety are presently reviewing and approving, by signature, all spacecraft test procedures before they are released. The KSC Safety Office makes the final determination concerning the hazardous classification of the test. The scope of contractor and KSC Safety Office test development participation is defined in APOP No. G-102, Safety Considerations for TCP's, dated July 17, 1967. Finding No. 13 Finding.-Criteria for defining hazardous test operations are not complete. |