Apollo 1 Tragedy
Jan. 27, 1967, tragedy struck on the launch pad at Cape Kennedy during a preflight test for Apollo 204 (AS-204). The mission was to be the first crewed flight of Apollo, and was scheduled to launch Feb. 21, 1967. Astronauts Virgil Grissom, Edward White and Roger Chaffee lost their lives when a fire swept through the command module, or CM.
The exhaustive investigation of the fire and extensive reworking of the Apollo command modules postponed crewed launches until NASA officials cleared them for flight. Saturn IB schedules were suspended for nearly a year, and the launch vehicle that finally bore the designation AS-204 carried a lunar module, or LM, as the payload, instead of a CM. The missions of AS-201 and AS-202 with Apollo spacecraft aboard had been unofficially known as Apollo 1 and Apollo 2 missions. AS-203 carried only the aerodynamic nose cone.
In the spring of 1967, NASA’s Associate Administrator for Manned Space Flight, Dr. George E. Mueller, announced that the mission originally scheduled for Grissom, White and Chaffee would be known as Apollo 1, and said that the first Saturn V launch, scheduled for November 1967, would be known as Apollo 4. The eventual launch of AS-204 became known as the Apollo 5 mission. No missions or flights were ever designated Apollo 2 or 3.
The second launch of a Saturn V took place on schedule in the early morning of April 4, 1968. Known as AS-502, or Apollo 6, the flight was a success, though two first-stage engines shut down prematurely, and the third-stage engine failed to reignite after reaching orbit.
12 Selected For Coming NASA Missions
WASHINGTON D.C. March 21, 1966 — Twelve astronauts were named to flight crews today — including the first manned Apollo mission — and two others assigned earlier were shifted to a different mission.
Prime crewman for the Apollo Earth-orbital mission, tentatively scheduled in the first quarter of 1967, are Lt. Col. Virgil I. “Gus” Grissom, USAF; Lt. Col. Edward H. White II, USAF; and Navy Lt. Roger B. Chaffee. Their backups are Lt. Col. James A. McDivitt, USAF; Maj. David R. Scott, USAF; and Russell L. Schweickart, a civilian employee of NASA.
Assigned as prime crewman for the Gemini II mission scheduled in the last quarter of this year, are Navy Cmdr. Charles ” Pete” Conrad, Jr., command pilot; and Navy Lt. Cmdr. Richard F. Gordon, Jr., pilot. Backups are Neil A. Armstrong, command pilot; and USAF Capt. William A. Anders, pilot.
Backup crewman for the Gemini 10 flight, Navy Capt. James A. Lovell, Jr., and USAF Maj. Edwin E. “Buzz” Aldrin, Jr., were reassigned as backup crew for Gemini 9. The original Gemini 9 backups, USAF Lt. Col. Thomas P. Stafford and Navy Lt. Cmdr. Eugene A. Cernan, became prime crewman for that mission after the deaths of civilian astronaut Elliot M. See, Jr., and USAF Maj. Charles A. Bassett II, last Feb. 28.
Replacing Lovell and Aldrin as the backup crew for Gemini 10 are Navy Lt. Cmdr. Alan L. Bean, and Marine Maj. Clifton C. Williams, Jr.
The first manned Apollo mission could come as early as the fourth flight of Saturn IB. The first Saturn IB flew successfully on Feb. 26.
Duration of the first manned Apollo mission, as presently conceived, will be determined on an orbit-by-orbit basis for the first six orbits, then on a day-by-day basis for up to 14 days maximum. Its orbit is to carry as high as 265 statute miles with a perigee of 100 statute miles. Prime goal of the flight will be to verify spacecraft, crew and ground support compatibility.
As presently planned, Gemini 11 will be a rendezvous and docking flight of up to three days duration. Rendezvous is scheduled in the first revolution, with the flight crew using onboard systems to compute their own trajectories and maneuvers. Ground systems will be used as a backup.
Plans call for the spacecraft to re-rendezvous with the Gemini 11 Agena vehicle, which procedurally will be a passive target the second time. The re-rendezvous also will be accomplished with the use of onboard systems.
Extravehicular activity is planned, using a hand-held maneuvering unit similar to the one which was to have been used on Gemini 8. Duration of extravehicular activity and tasks to be performed will be based on experience in Gemini 9 and Gemini 10.
Approximately eight experiments are tentatively scheduled for Gemini 11. All will be repeats of experiments flown previously but a list of specific experiments will not be available until a re-evaluation is completed. The Gemini 11 Agena will be parked in a high orbit for possible use during Gemini 12.
The launch profile and orbital parameters will be essentially the same in Gemini 11 as those in Gemini 8. The Agena will be launched into a 185-statute-mile orbit and rendezvous will be accomplished at that altitude.
Navy Cmdr. John W. Young, command pilot, and USAF Michael Collins, pilot, remain as the previously announced prime crew of Gemini 10.
The Apollo spacecraft is the entire structure atop the launch vehicle. It is 82 feet tall and has five distinct parts: the command module, the service module, the lunar module, the launch escape system, and the spacecraft-lunar module adapter.
The three modules make up the basic spacecraft; the launch escape system and adapter are special purpose units which are jettisoned early in the mission after they have fulfilled their function. The launch escape system is essentially a small rocket which will thrust the command module–with the astronauts inside–to safety in case of a malfunction in the launch vehicle on the pad or during the early part of boost. The spacecraft lunar module adapter serves as a smooth aerodynamic enclosure for the lunar module during boost and as the connecting link between the spacecraft and the launch vehicle.
The basic difference in the two versions was in the addition, in Block II, of some equipment and systems designed specifically for the lunar mission.
TRAGEDY AND RECOVERY
Nestled beside an umbilical tower, surrounded by a service structure, and encased in a clean room at Cape Kennedy’s Launch Complex 34, spacecraft 012 sat atop a Saturn IB on Friday morning, 27 January 1967. Everything was ready for a launch simulation, a vital step in determining whether the spacecraft would be ready to fly the following month. During this “plugs out” test, all electrical, environmental, and ground checkout cables would be disconnected to verify that the spacecraft and launch vehicle could function on internal power alone after the umbilical lines dropped out.
By 8:00 that morning, a thousand men, to support three spacesuited astronauts–Virgil Grissom, Edward White, and Roger Chaffee–were checking systems to make sure that everything was in order before pulling the plugs. In the blockhouse, the clean room, the service structure, the swing arm of the umbilical tower, and the Manned Spacecraft Operations Building, this army of technicians was to go through all the steps necessary to prove that this Block I command module was ready to sustain three men in earth-orbital flight. Twenty-five technicians were working on level A-8 of the service structure next to the command module and five more. mostly North American employees, were busy inside the clean room at the end of the swing arm. Squads of men gathered at other places oil the service structure. If interruptions and delays stretched out the test, as often happened, round-the-clock shifts were ready to carry the exercise to a conclusion. Throughout the morning, however, most of the preparations went smoothly, with one group after another finishing checklists and reporting readiness.
After an early lunch, Grissom, White, and Chaffee suited up, rode to the pad (arriving an hour after noon), and slid into the spacecraft couches. Technicians sealed the pressure vessel inner hatch, secured the outer crew access hatch, and then locked the booster cover cap in place. All three astronauts were instrumented with biomedical sensors, tied together on the communications circuit, and attached to the environmental control system. Strapped down, as though waiting for launch, they began purging their space suits and the cabin atmosphere of all gases except oxygen–a standing operating procedure.
STALKED BY THE SPECTRE
For almost a year, the Grissom crew had watched its craft go through the production line, test program, and launch pad preparations. After participating in a multitude of critiques, reading numerous discrepancy reports, and going through several suited trials in the spacecraft in altitude chambers at Downey and the Cape, Grissom’s group had learned almost all the idio- syncracies of spacecraft 012. The astronauts knew, if not every nut and bolt, at least the functions of its 88 subsystems and the proper positions for hundreds of switches and controls inside the cockpit. They also knew that the environmental unit had been causing trouble. Indeed, Grissom’s first reports on entering the cabin were of a peculiar odor–like sour milk.
As all traces of sea-level atmosphere were removed from the suit circuit and spacecraft cabin, pure oxygen at a pressure of 11.5 newtons per square centimeter (16.7 pounds per square inch) was substituted. The crew checked lists, listened to the countdown, and complained about communications problems’ that caused intermittent delays. The men could speak over four channels, either by radio or telephone line, but the tie-in with the test conductors and the monitors was complicated and troublesome. Somewhere there was an unattended live microphone that could not be tracked down and turned off. Other systems, Grissom’s crew noted, seemed to be operating normally. At four in the afternoon, one shift of technicians departed and another came on duty.
Near sunset, early on this winter evening, communications problems again caused a delay, this time for ten minutes, before the plugs could be pulled. Thus, the test that should have been finished had not really started, and an emergency egress practice was still to come. The crew was accustomed to waiting, however, having spent similar long hours in trouble-plagued training simulators. About 6:30, Grissom may have been thinking about the jest he had played on Riley McCafferty by hanging a lemon on the trainer.
Donald Slayton sat half a kilometer away at a console in the blockhouse next to Stuart Roosa, the capsule communicator. On the first floor of the launch complex, Gary W. Propst, an RCA employee, watched a television monitor that had its transmitting camera trained on the window of the command module. Clarence A. Chauvin, the Kennedy Space Center test conductor, waited in the automated checkout equipment room of the operations building, and Darrell O. Cain, the North American test conductor, sat next door. NASA quality control inspector Henry H. Rogers boarded the Pad 34 elevator to ride up to the clean room. There, at the moment, were three North American employees: Donald O. Babbitt, pad leader; James D. Gleaves, mechanical technician; and L. D. Reece, systems technician. Reece was waiting to pull the plugs on signal. Just outside on the swing arm, Steven B. Clemmons and Jerry W. Hawkins were listening for Reece to call them to come and help. All of these men and several others in the vicinity at 6:31 heard a cry over the radio circuit from inside the capsule: “There is a fire in here.
Stunned, pad leader Babbitt looked up from his desk and shouted to Gleaves: “Get them out of there!” As Babbitt spun to reach a squawk box to notify the blockhouse, a sheet of flame flashed from the spacecraft. Then he was hurled toward the door by a concussion. In an instant of terror, Babbitt, Gleaves, Reece, and Clemmons fled. In seconds they rushed back, and Reece and Clemmons searched the area for gas masks and for fire extinguishers to fight little patches of flame. All four men, choking and gasping in dense smoke, ran in and out of the enclosure, attempting to remove the spacecraft’s hatches.
Meanwhile, Propst’s television picture showed a bright glow inside the spacecraft, followed by flames flaring around the window. For about three minutes, he recalled, the flames increased steadily. Before the room housing the spacecraft filled with smoke, Propst watched with horror as silver-clad arms behind the window fumbled for the hatch. “Blow the hatch, why don’t they blow the hatch?” he cried. He did not know until later that the hatch could not be opened explosively.” Elsewhere, Slayton and Roosa watched a television monitor, aghast, as smoke and fire billowed up. Roosa tried and tried to break the communications barrier with the spacecraft, and Slayton shouted furiously for the two physicians in the blockhouse to hurry to the pad.
In the clean room, despite the intense heat, Babbitt, Gleaves, Reese, Hawkins, and Clemmons, now joined by Rogers, continued to fight the flames. From time to time, one or another would have to leave to gasp for air. One by one, they removed the booster cover cap and the outer and inner hatches–prying out the last one five and a half minutes after the alarm sounded. By now, several more workers had joined the rescue attempt. At first no one could see the astronauts through the smoke, only feel them. There were no signs of life. By the time firemen arrived five minutes later, the air had cleared enough to disclose the bodies. Chaffee was still strapped in his couch, but Grissom and White were so intertwined below the hatch sill that it was hard to tell which was which. Fourteen minutes after the first outcry of fire, physicians G. Fred Kelly and Alan C. Harter reached the smoldering clean room. The doctors had difficulty removing the bodies because the spacesuits had fused with molten nylon inside the spacecraft.
As anguished officials gathered, the pad was cleared of unnecessary personnel, guards were posted, and official photographers were summoned. All through the night, physicians labored to complete their grim task. After the autopsies were finished, the coroner reported that the deaths were accidental, resulting from asphyxiation caused by inhalation of toxic gases. The crew did have second and third degree burns, but these were not severe enough to have caused the deaths.
Most persons who had been connected with the space program in any way remember that the tragedy caught them by surprise. In six years of operation, 19 Americans had flown in space (7 of them, including Grissom, twice) without serious injury. Procedures and precautions had been designed to foresee and prevent hazards; now it was demoralizing to realize the limits of human foresight. Several other astronauts had died, but none in duties directly associated with space flight. Airplane crashes had claimed the lives of Elliot See, Charles Bassett, and Theodore Freeman. These were traumatic experiences, but the loss of three men during a ground test for the first manned Apollo flight was a more grievous blow.
Memorial services for the AS-204 crewmen were held in Houston 30 January, although their bodies had been flown north from Kennedy for burial. Grissom and Chaffee were buried in Arlington National Cemetery and White at the Military Academy at West Point. Amid these last rites, a similar tragedy took the lives of two men in an oxygen-filled chamber at Brooks Air Force Base in San Antonio. Airman 2/c William F. Bartley and Airman 3/c Richard G. Harmon were drawing blood samples from rabbits when a fire suddenly swept through the enclosure. The spacecraft and chamber tragedies pinpointed the dangers inherent in advanced space-simulation work.
The accident that took the lives of Grissom, White, and Chaffee was heartrending, and some still insist totally unnecessary; but NASA had always feared that, in manned space flight, danger to pilots could increase with each succeeding program. Space flight officials had warned against undue optimism for years, pointing out that any program that large inevitably took its toll of lives–from accident, overwork, or illness brought on by the pressures of such an undertaking. Man was fallible; and a host of editorial cartoons reiterated this axiom for several months after the fire. One, by Paul Conrad in the Los Angeles Times, showed the spectre of death clothed in a spacesuit holding a Mercury spacecraft it one hand, a Gemini in the other, and with the smoldering Apollo in the background. It was captioned “I thought you knew, I’ve been aboard on every flight.”
While preaching the need to promote quality workmanship, NASA managers had relied on their contractors to invoke effective measures. NASA executives knew they had tried to inspire the whole Apollo team to strive for perfection, but the haunting question now was: Had they tried hard enough? Every company and organization had a management scheme to increase personal motivation by giving recognition to faultless performance. North American had its “PRIDE” program, standing for “Personal Responsibility in Daily Effort,” and NASA had “MFA” for “Manned Flight Awareness.” The NASA program also featured what was called the “Lunar Roll of Honor”; the first lunar landing party would carry a microfilm listing 300 000 names, honoring the exceptional service of those who had aided significantly in the achievement. After the fire, the idea was dropped. Just as it became obvious how difficult it was to fix the blame for failure, it would later be come apparent that it would be equally hard to pinpoint responsibility for success.
In Washington on the day of the accident, an Apollo Executives’ Conference was in session, attended by NASA leaders James Webb, Robert Seamans, and George Mueller and by top Gemini and Apollo corporate officials, to mark the transition from two- to three-man space flight operations. That morning the conferees had been invited to the White House to witness the signing of a space treaty. President Johnson described this event as the “first firm step toward keeping outer space free forever from the implements of war.” Later, as the tragic news from Pad 34 spread, the executives considered disbanding. Administrator Webb, however, decided to carry on; Mueller would stay in Washington and Seamans and Samuel Phillips would go to the Cape. The next day, Mueller reported the first few meager facts to the meeting and then gave a paper that Phillips had intended to present.
Ironically, Phillips had listed troubles with quality assurance among the top ten problems faced in Apollo.
After the fire, amid all the grief and the shock that it could have happened, a thorough fact-finding investigation was conducted. Webb and Seamans asked Floyd L. Thompson, Director of Langley Research Center, to take charge of the inquiry. Thompson and Seamans met at Kennedy at noon on 28 January for a brief session with other Headquarters, Houston, and Cape officials and then adjourned to Complex 34 to see the scene of the accident.
Seamans returned to Washington that evening, consulted with Webb, and drafted a memorandum formalizing the AS-204 Review Board with Thompson as chairman. Members were astronaut Frank Borman and Max Faget of the Manned Spacecraft Center, E. Barton Geer of Langley Research Center, George W. Jeffs of North American, Franklin A. Long of Cornell University and the President’s Science Advisory Committee, Colonel Charles F. Strang of the Air Force Inspector General’s office, George C. White of NASA Headquarters, and John J. Williams of Kennedy Space Center.
The board quickly established tight security at Complex 34, impounded documents pertaining to the accident, and collected eyewitness reports. News media representatives swarmed in to cover the story, and their unofficial investigations and semifactual innuendos filled newsprint and airwaves throughout the following weeks. Many looked for quick answers and simple explanations, but by 3 February it was obvious to NASA officials, at least, that no single cause for the accident could be isolated immediately. Seamans and Thompson set lap 21 panels to assist the review board. When he realized that full-time participation was expected. Long asked to be excused. He was replaced by Robert W. Van Dolah, an explosives expert from the Bureau of Mines. In other personnel actions, Seamans asked Jeffs to serve as a consultant rather than as a board member and George T. Malley, chief counsel at Langley, to act as legal advisor.
Anticipating public clamor for answers and reforms, if not postponement of Apollo, NASA officials asked leading members of Congress to hold off on a full-scale investigation until the review board finished its report. Senator Clinton P. Anderson. Chairman, agreed to call the Senate Committee on Aeronautical and Space Sciences into executive session only, for its early investigations. And Representative George P. Miller, Chairman of the House Committee on Science and Astronautics, said Olin Teague’s Subcommittee on NASA Oversight would not begin hearings until the Thompson Board had submitted its report. Many newsmen charged that the full story would never be known, since most of the board members were NASA employees; others conjectured that Apollo might be grounded altogether. Meanwhile, the Apollo 204 Review Board went systematically about its business.
Seamans returned to Florida on 2 February to prepare a preliminary report for Webb. Although this was made public just few days later, accusations still swirled that the NASA investigation could not be impartial since it was a probe of the agency by itself. There were also sensationalistic charges such as those in Eric Bergaust’s book, Murder on Pad 34, a year and a half later. Bergaust said that NASA, even while denying that it was in a space race, had nevertheless placed speed above safety.
But there was plenty of evidence that meeting schedules was not the whole story. “We’re in a risky business,” Grissom himself had said in an interview several weeks before the fire, ” and we hope if anything happens to us, it will not delay the program. The conquest of space is worth the risk of life.” He was later quoted as saying, “Our God-given curiosity will force us to go there ourselves because in the final analysis only man can fully evaluate the moon in terms understandable to other men. ”
Congressional leaders did not entirely share the views and misgivings of the press. In a bipartisan move, Senators Anderson and Margaret Chase Smith arranged for publication of the executive hearings of 7 February with Seamans, Mueller, Charles A. Berry (Houston’s medical director of manned space flight), and Richard Johnston (spacesuit and life support systems expert). This openness of congressional deliberations helped to defuse media criticism about the objectivity of the ongoing investigation.
Spacecraft 014, nearly identical to 012, was shipped from California to Florida. There the Thompson Board and its panels had the vehicle dismantled for comparison with the remains of 012, which was being taken apart and every piece studied and analyzed. Thompson took advantage of the background and experience of his board members, assigning some to monitor several of the panels. While technicians worked around the clock for the first few weeks, the board held daily recorded and transcribed sessions to consider the findings. Strang was an effective vice-chairman, drawing on his background as an inspector to organize proceedings and prepare comprehensive reports. Van Dolah, the mining explosives expert, had only one panel–origin and propagation of the fire–to monitor, emphasizing the importance of finding that answer. Thompson reserved a single panel, medical analysis, for himself.
Faget had the heaviest load of panels: sequence of events, materials review, special tests, and integration analysis. Borman drew the teams on disassembly, ground emergency provisions, and inflight fire emergency provisions. Williams monitored the spacecraft and ground support equipment configuration, test procedures review, and service module disposition. George White, quality and reliability chief from Headquarters, was responsible for investigations into test environments, design reviews, and historical data. An associate of Thompson’s from Langley, Geer handled the groups on the analysis of spacecraft fractures, the board’s administrative procedures, and the safety of the investigation operations themselves. Strang was left with the panels taking statements from witnesses, handling the security operations of the inquiry, and writing up the final report.
When Seamans made a second preliminary report to Webb, on 14 February, it was clear that the fire was indeed a fire, and not an explosion leading to a fire. Physical evidence indicated that the conflagration had passed through more than one stage of intensity before the oxygen inside the cabin was used up. By mid-February, the work of tearing down the command module had reached a point where a two-shift six-day week could replace round-the-clock operations.
On the day of the scheduled launch of AS–204, 21 February, the board gave preliminary briefing to George Mueller and a dozen other top NASA officials in preparation for a major briefing of Seamans. Thompson told Seamans the next day that 1500 persons were directly supporting the investigation–600 from government and 900 from industry and the universities–and that the board planned to complete its report by the end of March. Although the history of the fire after it started had been minutely reconstructed, the specific source of ignition had not been–and might never be–determined. On 25 February, Seamans prepared a memorandum for Webb, listing early recommendations by the board that the Administrator could present to Congress:
That combustible materials now used be replaced wherever
possible with non-flammable materials, that non-metallic
materials that are used be arranged to maintain fire
breaks, that systems for oxygen or liquid combustibles be
made fire resistant, and that full flammability tests be
conducted with a mockup of the new configuration.
That a more rapidly and more easily operated hatch be
designed and installed.
That on-the-pad emergency procedures be revised to
recognize the possibility of cabin fire.
The astronaut member of the Thompson Board assured NASA’s top officials that he would not have been afraid to enter the Grissom crew’s spacecraft that January day. Working with the board, however, Borman and everyone else had come to realize the substantial hazards that had been present but not recognized before the fire.
As its final report was being put together, the review board recognized that there had been ignorance, sloth, and carelessness, but the key word in, all the detailed information was “oversight.” No one, it seemed, realized the extent of fire hazards in an overpressurized oxygen-filled spacecraft cabin on the ground, according to the summary report the board issued on April:
Although the Board was not able to determine conclusively the specific initiator of the Apollo 204 fire, it has identified the conditions which led to the disaster–:
A sealed cabin, pressurized with an oxygen atmosphere.
An extensive distribution of combustible materials in the cabin.
Vulnerable wiring carrying spacecraft power.
Vulnerable plumbing carrying a combustible and corrosive coolant,
Inadequate provisions for the crew to escape,
Inadequate Provisions for rescue or medical assistance,
Having identified the conditions that led to the disaster, the Board addressed itself to the question of how these conditions came to exist. Careful consideration of this question leads the Board to the conclusion that in its devotion to the many difficult problems of space travel, the Apollo team failed to give adequate attention to certain mundane but equally vital questions of crew safety. The Board’s investigation revealed many deficiencies in design and engineering, manufacture and quality control.
The Thompson Board report came to almost 3000 pages; divided into 14 booklets, it made up a stack about 20 centimeters high. The six appendixes were: (A) the minutes of the board’s own proceedings; (B) eyewitness statements and releases; (C) the Operations Handbook for spacecraft 012; (D) final reports of all 21 panels; (E) a brief summary of management and organization; and (F) a schedule of visible evidence.
But even before the board issued its report, its conclusions were essentially already public. For instance, a month after the fire Mueller had admitted to Congress that, after six safe years of manned flight experience, it was now obvious that NASA’s approach to fire prevention had been wrong. Minimizing the possibility of ignition had not been enough. Safeguards against the spreading of any fire must also be developed. Since it would be nearly impossible to design equipment that would protect the crews both on the ground and in space,* any nonmetallic, and perhaps flammable, materials would have to be carefully screened. In particular, the “four Fs”– fabrics, fasteners, film, and foams–required further investigation. Wiring, plumbing, and packaging must be reevaluated, even if it meant reviving the old debate about a one- versus two-gas environmental control system. ”
As they delved deeper into the reasons behind the tragedy, NASA officials were confronted by some “skeletons in their closet.” Senator Walter F. Mondale raised the question of negligence on the part of management and the prime contractor by introducing the “Phillips report” of 1965-1966. The implication was that NASA had been thinking of replacing North American. But the charges were vague; and, for the next several weeks, no one seemed to know exactly what the Phillips report was. In fact, Webb at first denied that there was such a report. (See Chapter 8.) Mondale also alluded to a document (The Baron Report) by a North American employee, Thomas R. Baron, that was critical of the contractor’s operations at the Cape.
Baron was a rank and file inspector at Kennedy from September 1965 until November 1966, when he asked for and received a leave of absence. He had made observations; had collected gossip, rumor, and critical comments from his fellow employees; and had written a set of condemnatory notes. He had detailed, but not documented, difficulties with persons, parts, equipment, and procedures. Baron had observed the faults of a large-scale organization and apparently had performed his job as a quality inspector with a vengeance. He noted poor workmanship, spacecraft 012 contamination, discrepancies with installations, problems in the environmental control system, and many infractions of cleanliness and safety rules.
Baron passed on these and other criticisms to his superiors and friends; then he deliberately let his findings leak out to newsmen. North American considered his actions irresponsible and discharged him on 5 January 1967. The company then analyzed and refuted each of Baron’s charges and allegations. In the rebuttal, North American denied anything but partial validity to Baron’s wide-ranging accusations, although some company officials later testified before Congress that about half of the charges were well-grounded. When the tragedy occurred, Baron was apparently in the process of expanding his 55-page paper into a 500-page report.
When his indictments were finally aired before Teague’s subcommittee, during a meeting at the Cape on 21 April, Baron’s credibility was impaired by one of his alleged informants, a fellow North American employee named Mervin Holmburg. Holmburg denied knowing anything about the cause of the accident, although Baron had told the committee that Holmburg “knew exactly what caused the fire.” Holmburg testified that Baron “gets all his information from anonymous phone calls, people calling him and people dropping him a word here and there. That is what he tells me.” Ironically, Baron and all his family died in a car-train crash only a week after this exposure to congressional questioning.
Beyond the Phillips and Baron reports, however, recollections of events and warnings during the past six years made each Apollo manager wonder if he had really done all in his power to prevent the tragedy. It, March 1965, for instance, Shea and the crew systems people in Houston had wrestled with the question of the one–or two-gas atmosphere and the likelihood of fire– most of the studies were, admittedly, based on the possibility of fire in space–and concluded that a pure oxygen system was safer, less complicated, and lighter in weight. The best way to guard against fire was to keep flammable materials out of the cabin. Hilliard W. Paige of General Electric had, as a matter of fact, warned Shea about the likelihood of spacecraft fires us, the ground as recently as September 1966; and, just three weeks before the accident, Medical Director Charles Berry had complained that it was certainly harder to eliminate hazardous materials from the Apollo spacecraft than it had been in either Mercury or Gemini.
Although the Senate committee had begun its hearings while the board investigation was in progress, the House subcommittee waited until the final report was ready. By then, the Senate had touched on most of the major issues. As expected, the exact cause of the fire in spacecraft 012 was never determined, but the analysis of all possibilities led to specific corrective actions that eventually satisfied Congress. Throughout the hearings, Borman, still wearing two hats–as an astronaut and as a member of the Apollo 204 Review Board–was very effective. In the course of his testimony, Borman reiterated that the cause of the fire was oversight, rather than negligence or overconfidence. Fire in flight, he said, had been a matter of grave concern since the early days of aviation and the subject of numerous studies. But the notion that a fire hazard was increased on the ground by the use of flammable materials and an overpressure of pure oxygen had never been seriously considered.
On one occasion, when astronauts Walter Schirra, Slayton, Alan Shepard, and James McDivitt had expressed their confidence in NASA’s future safety measures, Borman answered a congressman’s doubts by saying:
You are asking us do we have confidence in the spacecraft, NASA management, our own training, and…our leaders. I am almost embarrassed because our answers appear to be a party line. Everything I said last week has been repeated by the people I see here today. The response we have given is the same because it is the truth…. We are trying to tell you that we are confident in our management, and in our engineering and in ourselves. I think the question is really: Are you confident in us?
When Borman made a plea on 17 April to stop the witch hunt and get on with Apollo, both NASA and North American had responded to the criticisms of the Thompson Board and of Congress. Top-level personnel changes were direct outgrowths of the charges of negligence and mismanagement: Everett E. Christensen at NASA Headquarters resigned as Apollo mission director; George Low replaced Shea as Apollo Spacecraft Program Manager in Houston; and William D. Bergen (formerly of the Martin Company) took over from Harrison Storms as president of North American’s Space and Information Systems Division. Bergen brought with him two associates from Martin: Bastian Hello to run the Florida facility for North American and John P. Healy to manage the first manned Block II command module at Downey. Healey was expected to set precedents in guiding a nearly perfect spacecraft through, the factory.
Most North American officials weathered congressional criticism and pointed out that they agreed, in part, with the formal findings and recommendations of the Thompson Board.* But North American objected to the word “chronic” in describing problems with the environmental control system and defended its electrical wiring practices as functional rather than beautiful. Concurring that the fire probably started from an electrical spark somewhere near the environmental unit, the manufacturers also agreed with NASA on why the fire spread:
Not withstanding this emphasis on the potential problems created by combustibles in the spacecraft, it can be seen in retrospect that attention was principally directed to individual testing of the material. What was not fully understood by either North American or NASA was the importance of considering the fire potential of combustibles in a system of all materials taken together in the position which they would occupy in the spacecraft and in the environment of the spacecraft.
Leland Atwood and Dale Myers used charts to emphasize to Congress the changes that the company intended to make in both construction and test operations. North American would assign a spacecraft manager and a personalized team to each vehicle, appoint an assistant program manager whose only concern was safety, place additional controls on changes made during modification and checkout phases, and assign personal responsibility to specific inspectors. The company would also revise its fabrication and inspection criteria; expand its quality standards, issuing a handbook with better visual aids; install more protected wiring and plumbing; and insist upon additional major inspections. Myers then discussed fire-related hardware changes: the new unified hatch, materials reevaluation, fluids and plumbing reassessment, electrical system improvements, revised on-the-pad operations, and flammability tests.
In Houston, Faget’s engineering and development activity ran all sorts of tests on materials and components, and Robert Gilruth sent Borman with a Houston “tiger team” to Downey in mid-April.* The astronaut was to make on-the-spot decisions on contractual changes for the unified hatch, better wiring and plumbing techniques, and other improvements that had been planned even before the accident. Borman’s tiger team watched closely, lending its assistance when necessary, as North, Americas, engineers went over the spacecraft piece by piece.
What had happened to the command module, obviously, could just as well happen to the lunar module. Immediately after the fire, Thomas J. Kelly and a host of Grumman workers began a comprehensive review of materials in the lunar lander. Low sent Robert L. Johnston, a materials expert, to help Kelly’s group. Grumman replaced nylon cloth in the spacecraft, relying mostly on Beta fiber (an inorganic substance developed by the Corning Glass Works, that would not catch fire nor produce toxic fumes) Perhaps the most important application of this material was as “booties” around circuit breakers, to lessen the possibilities of electrical shorts. In other areas, Grumman worked on its forward hatch, to ensure a crew exit within 10 seconds; the environmental control system; and a cabin and ex- terior pressure equalization system. All in all, the changes would add a three– to four–month delay in deliveries to the schedule trouble the lauder was in even before the fire. Phillips sent a group headed by Roderick O. Middleton of Kennedy to look into Grumman s quality control and inspection procedures.. Middleton’s audit team completed its report in mid-May, giving rumman generally good marks in the manufacturing process.
In Washington, on 9 May, Webb was again called on the carpet by the Senate committee. The Phillips report was again a major subject for debate, this time in a context that made it appear that the NASA–North American relationship was in danger of becoming a political football. The very next day, however, congressional questioning began to wind down. As Congressman John W. Wydler put it:
Essentially the story of the Apollo accident is known to the American people. We have admissions and statements about the things that NASA … and … North American Aviation [were] doing wrong. . . . . But I want to say this to you, Mr. Webb. Over the past few years….I probably have been one of the most critical members on this committee of NASA. It appeared to me. . . . that you have had it too easy for your own good from this committee. This is not a criticism being directed at you or the Space Agency, but a criticism being directed inwardly at the Congress and this committee. I feel right now that you got less criticism than you deserved fin the past, but now] you are getting more criticism than you deserve. I don’t intend to add to it for that reason.
Wydler did not really stop there, of course, but the investigation did begin to fade away. NASA and North American began implementing the technical recommendations. To some degree, the accident actually bought time for some pieces of Apollo–the lunar module, the Saturn V, the guidance and navigation system, the computers, and the mission simulators–to catch up with and become adapted to the total configuration.”
Meanwhile, on 23 April 1967 the Soviet Union announced the launching of Vladimir M. Komarov aboard a new spacecraft. Soyuz I appeared to be functioning normally at first. On its second day of flight, however, the craft began to tumble, and Komarov had to use more attitude fuel than he wanted to get the ship under control. He tried to land during his 17th circuit but could not get the proper orientation for retrofire. Komarov succeeded in reentering on the 18th revolution, but his parachute shroud lines entangled. The cosmonaut was killed on impact. So both Soystz I and Apollo 1 put their programs through traumatic reassessments. No one found any consolation in a “rebalanced” space race. In fact, Webb took the occasion to emphasize the need for international cooperation by asking: “Could the lives already lost have been saved if we had known each other’s hopes, aspirations and plans? Or could they have been saved if full cooperation had been the order of the day?”
THE SLOW RECOVERY
Within days after the Thompson Board’s report, more than a thousand of those at the Manned Spacecraft Center who were working directly in support of the formal investigation began making suggestions for meeting the board’s recommendations. Materials selection, substitution, and stowage inside the command module were thoroughly restudied; and all cloth parts made of nylon were replaced by Beta fiber, teflon, or fiber glass. These substitutes were chosen after more than 3000 laboratory tests had been run on more than 500 different kinds of materials.
Of immediate importance was the new unified hatch–unified meaning that the complicated two-hatch system was redesigned into a single hatch. The new component was heavier than the old, but it would open outward in five seconds, had a manual release for either internal or external operation, and would force the boost cover cap out of the way on opening. It could also be opened independently of internal overpressure and would be protected against accidental opening by a mechanism and seal similar to those used on Gemini.
The management of all industrial safety offices within NASA was revamped, with responsibilities flowing directly to the top at each location. At the launch center, fire and safety precautions were upgraded and personnel emergency preparations were emphasized as never before. Also, at the launch complex itself, a sliding wire was added to the service structure to permit a rapid descent to the ground. Reliability and test procedures were more firmly controlled, making it difficult to inject any last minute or unnecessary changes.
At the Manned Spacecraft Center, full-scale flammability testing continued, first to try to duplicate the conditions present on 27 January and then to find ways to improve the cabin atmosphere and the environmental control system. The tests led to replacing all aluminum oxygen lines that had solder joints with stainless steel tubing that used brazed joints. Aluminum tubing solder joints that could not be eliminated from the coolant system were armored with sleeves and seals wherever exposed. NASA decided to keep the water-glycol coolant fluid (covering it with flame resistant outer insulation) and added emergency oxygen masks for protection from smoke and fumes.
At NASA Headquarters, Webb directed Mueller to revamp and reorganize the major supporting and integrating contractors to put more pressure on North American, as well as on those manufacturing the other Apollo vehicles. Boeing was given a technical integration and evaluation contract, to act as a watch dog for NASA; and General Electric was told to assume a much greater role in systems analysis and ground support.
The contract situation with North Americas, had reached a peculiar stage even before the fire. The cost-plus.incentive.fee contract NASA had negotiated with North American in October 1965 had expired on 3 December 1966. In late January 1967, the legal status of relations was in some doubt. The objectives of the incentive contract had been to reverse the trend of continuing schedule slips, to get Block I vehicles delivered from the factory, to speed up Block II manufacturing, and to bring costs under control. Progress had been made on all fronts by the end of 1966; the flights of Block I spacecraft 002, 009, and 011 had been 80 percent successful, Block II work had moved along, and the cost spiral had stopped.
Despite the fire, John J. McClintock, chief of the Apollo office program control division, advocated in April 1967 that NASA negotiate a follow-on incentive contract, placing heaviest emphasis on flight performance and quality and less on schedules. North American’s business negotiators had already conceded that no incentive fee could be expected for spacecraft 012. The closeout cost for the Block I series was set at $37.4 million. This meant that the learning phase of Apollo had cost $616 million. Furthermore, North American agreed that there would be no charge for changes resulting from the AS-204 accident–such as the wire harnesses, environmental control system improvements, and the unified hatch. Changes that would enhance mts5ion success or operational flexibility–changes in the reaction control system, revised inspection criteria, or features to increase mission longevity–would cost money.
After the uncertain days of February, NASA officials began to sense that a recovery from the tragedy was under way. Drawing together, workers at all NASA centers, representing a vast amount of technical, recovered their morale through hard work more rapidly than might have been expected. Much of Apollo’s chance for recovery rested on the fact that the Block II advanced version of the command module was well along in-manufacturing and that most of its features were direct improvements over-the faults of the earth-orbital Block I. Moreover, the Saturn V, after experiencing difficulties in the development of its stages, seemed on the track now.
By early May, Webb and his top staff were looking for ways to show Congress that Apollo was on the road to recovery. Mueller proposed flying a Saturn V as soon as possible. Phillips stressed the building and delivery of standard vehicles. Any modifications of support missions other–than the lunar landing (such as Apollo Applications) should, he and Mueller agreed, be entirely separate from the mainstream of Apollo. Moreover, the science program in Apollo should be carried strictly as supercargo.
At the time of the accident, the flight schedule had listed a possible lunar landing before the end of 1968. After the impounding of material evidence and the halting of oxygen chamber testing until the investigation was over, that Apollo schedule was obviously no longer valid. Several weeks after the fire Seamans told blueller to scrap all official flight schedules for manned Apollo missions, using only at, internal working schedule to prevent avoidable slips and cost overruns. By March, Mueller had told Seamans that NASA could commit a Saturn V to a mission. In June Low said he believed that the spacecraft had turned the corner toward recovery, since the changes related to the fire had been identified and were being made. Even if everything went perfectly, however, more than 14 months would be needed for complete recovery.
To make certain of stronger program control in the future, Low decided that all proposals for changes would have to pass an exceedingly tough configuration control board before being adopted. He asked George W. S. Abbey, his technical assistant, to draft a strongly worded charter for the control board. Low next announced that he, Faget, Chris Kraft, Slayton, Kenneth Kleinknecht, William Lee, Thomas Markley, and Abbey (as secretary) would meet for several hours every Friday. When medical and scientific affairs were on the agenda, Berry and Wilmot N. Hess would join the group. Low himself would make all final decisions, and his new board members had the authority to ensure that his decisions were carried out.
If Apollo had seemed complicated before the fire, it appeared even more so afterward. If it gave an impression of being hurried in late 1966, it gathered still more momentum in late 1967. If an extreme level of attention had been given to aspects of crew safety and mission success before the deaths of Grissom and his crew, it rose yet higher after they were gone. But among the Apollo managers there were still nagging fears that something might slip past them, something might be impossible to solve. By mid-1967, however, they were so deep in their work that they could not avoid a growing confidence.
Atwood said the biggest mistake had been locking the crew inside the spacecraft and pumping in oxygen at a higher than sea-level pressure. There was no way to eliminate fire hazards under such conditions. So NASA and North American substituted a nitrogen-and-oxygen atmosphere at ground level, replacing the nitrogen gradually with pure oxygen after launch. Bergen, who had taken over the leadership of North American’s Downey division from Storms, moved into the factory while recovery work was going on. He made a practice of appearing on the plant floor, walking around asking questions, during each of the three shifts. Some of the workers wondered if he ever slept. During visits to Downey, Low was often to be seen watching plant activities on Saturdays. Many doubted, Bergen later said, that the recovery could be made in a reasonable time because “everything had come to screeching halt.” Bergen credited Gilruth’s assignment of Borman and his group and Healey’s performance as manager of spacecraft 101 as the keys to getting the command module back into line.
NASA’s leaders, after reviewing the progress, decided that it was time for a flight demonstration to prove that the bits and pieces of Apollo had been picked up and were being put back together. Apollo-Saturn Mission 501, with command module 017, was set for early autumn of 1967. If the first flight of the Apollo–Saturn V combination was successful, the rest would follow in due course.
As early as 9 May 1967, Houston proposed four manned missions–one with only the command and service modules, the other three with all the vehicles–before any attempt at a lunar landing. Headquarters in Washington believed that the lunar-landing mission might be possible on the fourth manned flight, which Houston thought was unrealistic–“all-up” should not mean “all-out.” Kraft warned Low that a lunar landing should not be attempted “on the first flight which leaves the earth’s gravitational field”:
THE FIRE THAT SEARED THE SPACEPORT
The thirteenth Saturn flight (the third Saturn IB) on 25 August 1966 was the thirteenth success. It fulfilled all major mission objectives. For the first manned mission NASA had selected two veterans and one rookie. Command Pilot Virgil Ivan Grissom had flown Mercury’s Liberty Bell 7, America’s second suborbital flight, in July 1961, and Molly Brown, the first manned Gemini, in March 1965. Edward White had become the first American to walk in space while on the fourth Gemini flight, three months later. Flying with these two would be the youngest American ever chosen to go into space, Roger B. Chaffee, 31 years of age.
NASA gave Grissom the option of an open-ended mission. The astronauts could stay in orbit up to 14 days, depending on how well things went. The purpose of their flight was to check out the launch operations, ground tracking and control facilities, and the performance of the Apollo-Saturn. Grissom was determined to keep 204 up the full 14 days if at all possible.
North American Aviation constructed the Apollo command and service modules. The spacecraft, 11 meters long and weighing about 27 metric tons when fully fueled, was considerably larger and more sophisticated than earlier space vehicles, with a maze of controls, gauges, dials, switches, lights, and toggles above the couches. Unlike the outward-opening hatches of the McDonnell-built spacecraft for Mercury and Gemini flights, the Apollo hatches opened inward. They required a minimum of ninety seconds for opening under routine conditions.
Predictions of Trouble
Many men, including Grissom, had presumed that serious accidents would occur in the testing of new spacecraft. A variety of things could go wrong. But most who admitted in the back of their minds that accidents might occur, expected them somewhere off in space.
Some individuals had misgivings about particular aspects of the spacecraft. Dr. Emmanuel Roth of the Loveface Foundation for Medical Education and Research, for instance, prepared for NASA in 1964 a four-part series on “The Selection of Space-Cabin Atmospheres.” He surveyed and summarized all the literature available at the time. He warned that combustible items, including natural fabrics and most synthetics, would burn violently in the pure oxygen atmosphere of the command module. Even allegedly flame-proof materials would burn. He warned against the use of combustibles in the vehicle.
In 1964 Dr. Frank J. Hendel, a staff scientist with Apollo Space Sciences and Systems at North American and the author of numerous articles and a textbook, contributed an article on “Gaseous Environment during Space Missions” to the Journal of Spacecraft and Rockets, a publication of the American Institute of Aeronautics and Astronautics. “Pure oxygen at five pounds per square inch of pressure,” he wrote, “presents a fire hazard which is especially great on the launching pad. . . . Even a small fire creates toxic products of combustion; no fire-fighting methods have yet been developed that can cope with a fire in pure oxygen.”
Further, oxygen fires had occurred often enough to give safety experts cause for extra-careful procedures: at Brooks Air Force Base and at the Navy’s Equipment Diving Unit at Washington, D.C., in 1965; and at the Airesearch Facility in Torrance, California, in l964, 1965, and 1966.
One man saw danger on earth, from hazards other than fire. In November 1965, the American Society for Testing and Materials held a symposium in Seattle on the operation of manned space chambers. The papers gave great attention to the length of time spent in the chambers, to decompression problems, and to safety programs. The Society published the proceedings under the title of Factors in the Operation of Manned Space Chambers (Philadelphia, 1966). In reviewing this publication, Ronald G. Newswald concluded: “With reliability figures and flight schedules as they are, the odds are that the first casualty in space will occur on the ground.”
Since Newswald was a contributing editor of Space/Aeronautics, it may well be that he contributed the section entitled “Men in Space Chambers: Guidelines Are Missing” in the “Aerospace Perspective” section of that magazine during the same month that his review appeared in Science Journal. The editorial reflects the ideas and the wording of his review. The “Guidelines” writer began: “The odds are that the first spaceflight casualty due to environmental exposure will occur not in space, but on the ground.” He saw no real formulation of scientific procedures involving safety – such as automatic termination of a chamber run in the event of abnormal conditions. “By now,” he stated, “NASA and other involved agencies are well aware that a regularly updated, progressive set of recommended practices-engineering, medical and procedural – for repressurization schedules and atmospheres, medical monitoring, safety rescue and so on, would be welcome in the community.”
Gen. Samuel Phillips, Apollo Program Director, had misgivings about the performance of North American Aviation, the builder of the spacecraft, as early as the fall of 1965. He had taken a task force to Downey, California, to go over the management of the Saturn-II stage and command-service module programs. The task force included Marshall’s Eberhard Rees and the Apollo Spacecraft Program Manager, Joseph Shea; they had many discussions with the officials of North American. On 19 December 1965, Phillips wrote to John Leland Atwood, the President of North American Aviation, enclosing a “NASA Review Team Report,” which later came to be called the “Phillips Report.”The visit of the task force was not an unusual NASA procedure, but the analysis was more intensive than earlier ones.
In the introduction, the purpose was clearly stated: “The Review was conducted as a result of the continual failure of NAA to achieve the progress required to support the objective of the Apollo program.” The review included an examination of the corporate organization and its relationship to the Space Division, which was responsible for both the S-II stage and the command-service module, and an examination of North American Aviation’s activities at Kennedy Space Center and the Mississippi Test Facility. The former area belongs more properly to the relations of North American Aviation with NASA Headquarters, but the latter directly affected activities at Kennedy Space Center.
Despite the elimination of some troublesome components and escalations in costs, both the S-II stage and the spacecraft were behind schedule. The team found serious technical difficulties remaining with the insulation and welding on stage II and in stress corrosion and failure of oxidizer tanks on the command-service module. The “Report” pointed out that NAA’s inability to meet deadlines had caused rescheduling of the total Apollo program and, with reference to the command-service module, “there is little confidence that NAA will meet its schedule and performance commitments.”
Phillips and his task force returned to Downey for a follow-up week in mid-April 1966. He did not amend the original conclusions; but he told President Atwood that North American was moving in the right direction.
The astronauts themselves suggested many changes in the block I spacecraft design. In April 1967, Donald K. Slayton was to tell the Subcommittee on NASA Oversight of the House Committee on Science and Astronautics that the astronauts had recommended 45 improvements, including a new hatch. North American had acted on 39 of these recommendations. They were introducing the other six into later spacecraft. “Most of these,” Slayton testified, “were of a relatively minor nature.” The only major change for later spacecraft was to have been a new hatch. And the astronauts had recommended this not so much for safety as for ease in getting out for space-walks and at the end of flights.
The Spacecraft Comes to KSC
In July and August 1966, NASA officials conducted a customer acceptance readiness review at North American Aviation’s Downey plant, issued a certificate of worthiness, and authorized spacecraft 012 to be shipped to the Kennedy Space Center. The certificate listed incomplete work: North American Aviation had not finished 113 significant engineering orders at the time of delivery.
The command module arrived at KSC on 26 August and went to the pyrotechnic installation building for a weight and balance demonstration. With the completion of the thrust vector alignment on 29 August, the test team moved the command module to the altitude chamber in the operations and checkout building and began mating the command and service modules. Minor problems with the service module had already showed up, and considerable difficulties with the new mating hardware caused delays.
On 7 September NASA released a checkout schedule. By 14 September, while the Saturn launch vehicle moved on schedule, the Apollo spacecraft already lagged four days behind. On the same day, a combined systems test was begun. Discrepancy reports numbered 80 on 16 September and had risen to 152 within six days. One of the major problems was a short in the radio command system. In the meantime, the test team had installed all but one of the flight panels. At Headquarters during this time, a board chaired by the Associate Administrator for Manned Space Flight, Dr. George Mueller, and made up of OMSF center directors, conducted a detailed review of the spacecraft. On 7 October this board certified the design as “flightworthy, pending satisfactory resolution of listed open items.”
The simulated altitude run, originally scheduled for 26 September, had gradually slipped back in schedule. It was run on 11 October, but plans for an unmanned altitude run on 12 October, a flight crew altitude run on 14 October, and a backup crew run on 15 October also slipped. So did the projected dates of mechanical mating of the spacecraft with the launch vehicle and the launch itself.
The unmanned altitude chamber run finished satisfactorily on 15 October. The first manned run in the altitude test chamber, on 18 October, experienced trouble after reaching a simulated altitude of 4,000 meters because of the failure of a transistor in one of the inverters. With the replacement of the inverter, the system functioned satisfactorily. The prime crew of Grissom, White, and Chaffee repeated the 16-hour run the next day with only one major problem developing in the oxygen cabin supply regulator. This problem caused a delay of the second manned run with the backup crew scheduled for 21 October. Continued trouble with the new oxygen regulator caused the indefinite suspension of the second manned test before the end of October. By this time it had become clear that the spacecraft needed a new environmental control unit. Technicians removed the old unit on 1 November.
Meanwhile, at North American Aviation’s Downey plant a propellant tank had ruptured in the service module of spacecraft 017. This provoked a special test of the propellant tanks on the 012 service module at KSC. In order to conduct this testing in parallel with further checking of the command module, the test team removed the command module from the altitude chamber. Later they removed the fuel tanks from the service module in the chamber. After pressure-integrity tests, they replaced the tanks and returned the command module to the chamber. The test team installed and fit checked the new environmental control unit on 8 November and hooked up the interface lines two days later. But this did not completely solve the difficulties. Problems in the glycol cooling system surfaced toward the end of November and on 5 December forced a removal of the second environmental control unit.
The Apollo Review Board was to say of this glycol leakage several months later,
water/glycol coming into contact with electrical connectors can cause corrosion of these connectors. Dried water/glycol on wiring insulation leaves a residue which is electrically conductive and combustible. Of the six recorded instances where water/glycol spillage or leakage occurred (a total of 90 ounces leaked or spilled is noted in the records) the records indicate that this resulted in wetting of conductors and wiring on only one occasion. There is no evidence which indicates that damage resulted to the conductors or that faults were produced on connectors due to water/glycol.
The difficulties in the materials that already had arrived at KSC and the endless changes that came in from North American Aviation – 623 distinct engineering orders – presented major problems for the NASA-NAA test teams. As many workmen as could possibly function inside the command module continually swarmed into it to replace defective equipment or make the changes that NAA suggested and Houston approved. The astronauts came and went, sometimes concerned with major and sometimes with minor matters on the spacecraft.
These difficulties at KSC and concurrent problems at Mission Control Center, Houston, forced two revisions to the schedule, one on 17 November, the next on 9 December. The test team kept up with or moved ahead of the latter schedule during the ensuing weeks. The third environmental control unit arrived for installation on 16 December.
The test teams had been working on a 24-hour basis since the arrival of the spacecraft at Kennedy, taking off only on Christmas and New Year’s Day. On 28 December, while conducting an unmanned altitude run, the test team located a radio frequency communications problem and referred it to ground support technicians for correction. On 30 December a new backup crew of Schirra, Eisele, and Cunningham (McDivitt’s original backup crew had received a new assignment) successfully completed a manned altitude run. Six major problems on the spacecraft surfaced, one in very-high-frequency radio communications; but a review board was to give a favorable appraisal not long afterward: “This final manned test in the altitude chamber was very successful with all spacecraft systems functioning normally. At the post-test debriefing the backup flight crew expressed their satisfaction with the condition and performance of the spacecraft.”
By 5 January the mating of the spacecraft to the lunar module adapter and the ordnance installation were proceeding six days ahead of schedule. The following day the spacecraft was moved from the operations and checkout building to LC-34. KSC advanced the electrical mating and the emergency detection system tests to 18 January, and these were completed that day. The daily status report for 20 January 1967 reported that no significant problems occurred during the plugs-in overall test. A repeat of the test on 25 January took 24 hours. A problem in the automatic checkout equipment link-up caused the delay. Further, the instrument unit did not record simulated liftoff – a duplication of an earlier deficiency. The schedule called for a plugs-out test at 3:00 p.m. on 26 January, a test in which the vehicle would rely on internal power. NASA did not rate the plugs-out test as “hazardous,” reserving that label for tests involving fueled vehicles, hypergolic propellants, cryogenic systems, high-pressure tanks, live pyrotechnics, or altitude chamber tests.
The Hunches of Tom Baron
All the tests and modifications in the spacecraft did not go far enough or fast enough in the view of one North American employee, Thomas R. Baron of Mims, Florida. Baron’s story has significance for two reasons. His attitude reflected the unidentified worries of many who did not express them until too late. Also, the reaction of KSC managers indicated a determination to check every lead that might uncover an unsafe condition. The local press at the time gave ample but one-sided coverage of the Baron story.
Baron had a premonition of disaster. He believed his company would not respond to his warnings and wanted to get his message to the top command at KSC. While a patient at Jeff Parrish Hospital in Titusville, Florida, during December 1966, and later at Holiday Hospital in Orlando, Baron expressed his fears to a number of people. His roommate at Jeff Parrish happened to be a KSC technical writer, Michael Mogilevsky. After Baron claimed to have in his possession documentary evidence of deficiencies in the heat shield, cabling, and life support systems, Mogilevsky went to see Frank Childers in NASA Quality Control on 16 December. Childers called in an engineer of the Office of the Director of Quality Assurance, and Mogilevsky related Baron’s complaints and fears again.
That evening Rocco Petrone asked John M. Brooks, the Chief of NASA’s Regional Inspections Office, to locate and interview Baron. Brooks interviewed Baron twice and briefed Debus, Albert Siepert, and Petrone on Baron’s complaints: poor workmanship, failure to maintain cleanliness, faulty installation of equipment, improper testing, unauthorized deviations from specifications and instructions, disregard for rules and regulations, lack of communication between Quality Control and engineering organizations and personnel, and poor personnel practices.
Baron claimed to possess notebooks that would substantiate his charges. He promised to cooperate with KSC and with North American Aviation if someone above his immediate supervisor would listen to what he had to say. He did not believe his previous complaints had ever gone beyond that supervisor. He asked to be allowed to talk to John Hansel, Chief of Quality Control for North American. Baron’s complaints were against North American, not KSC. He believed that the center needed additional personnel to enforce compliance with procedures in the Apollo program. Brooks later reported: “Baron was assured that an appropriate level of NAA management would be in touch with him in the next day or two.”
On 22 December 1966, Petrone and Wiley E. Williams, Test and Operations Management Office, Directorate for Spacecraft Operations, received a briefing on Baron’s complaints. The two men recognized that these were primarily North American Aviation in-house problems and that the company should inquire into Baron’s complaints and advise KSC officials of the results. NAA officials W. S. Ford, James L. Pearce, and John L. Hansel met with Petrone that same day. They arranged to talk with Baron the following day.
Since Baron had confidence in Hansel, who was an expert in Quality Control, Hansel’s testimony is especially valuable. Baron had lots of complaints but, Hansel insisted, no real proof of major deficiencies, either in the papers Baron had in his possession or in the report that Baron wrote (and Hansel was to read) a short time later. Lastly, Hansel stated, Baron was not working in a critical area at that time.
North American informed Petrone of the interview by 4 January, but sent no written report to Petrone’s office. On 5 January a North American spokesman told newsmen that the company was terminating Baron’s services. Since his clearance at the space center had been withdrawn, Baron phoned John Brooks, the NASA inspector, on 24 January and invited him to his home. Brooks accepted the invitation, and Baron gave him a 57-page report for duplication and use. Brooks duplicated it and returned the original to Baron on 25 January. Brooks assured Baron that KSC and NAA had looked into his allegations and taken corrective action where necessary.
Petrone received a mimeographed copy of Baron’s report on 26 January. John Wasik of the Titusville Star Advocate telephoned Brooks to ask about KSC’s interest in Baron’s information. Wasik indicated that he was going to seek an interview with Petrone. On the following morning, Gordon Harris, head of the Public Affairs Office at KSC, heard that Wasik had spent approximately one and one-half hours with Zack Strickland, of the North American Aviation Public Relations Information Office, going over the Baron report.
That same day Hansel, North American’s head of Quality Control – the man Baron had hoped his report would reach – told Wasik that Baron was one of the most conscientious quality control men he ever had working for him and that his work was always good. “If anything,” Hansel related in the presence of Strickland, “Baron was too much of a perfectionist. He couldn’t bend and allow deviations from test procedures – and anyone knows that when you’re working in a field like this, there is constant change and improvement. The test procedures written in an office often don’t fit when they are actually applied. Baron couldn’t understand this.” Wasik also stated: “Hansel readily agreed that Baron’s alleged discrepancies were, for the most part, true.” What Wasik did not say was that none of the discrepancies, true though they were, was serious enough to cause a disaster.
Hansel was not alone in his misgivings about Baron. Hansel did not know of Frank Childers’s report nor had he ever talked to Childers about Baron. Childers, too, had doubts about the man’s reliability. Even though he had sympathetically reported to NASA officials the fears of the North American employee, Childers admitted that Baron, who signed himself T. R. Baron, had the nickname “D. R. (Discrepancy Report) Baron.”
- E. Reyes, an engineer in KSC’s Preflight Operations Branch, said Baron filed so many negative charges that, had KSC heeded them all, NASA would not have had a man on the moon until the year 2069. To confirm the opinions of these men, Baron himself admitted before a congressional investigating committee a short time later that he had turned in so many negative reports that his department ran out of the proper forms. Further – in confirmation of Hansel’s view of Baron’s report – Baron based his testimony on hearsay, not on any personal records in his possession. Baron’s forebodings were to prove correct, but not for any reason he could document.
Both NASA and North American Aviation, a historian must conclude, gave far more serious consideration to Baron’s complaints than a casual perusal of newspapers during the succeeding weeks, or even close reading of such books as Mission to the Moon, would indicate.
Disaster at Pad 34
While top administrators were checking out the fears of Tom Baron, two NASA men, Clarence Chauvin and R. E. Reyes, and two North American Project Engineers, Bruce Haight and Chuck Hannon, met on the morning of 26 January at launch complex 34 to review the general spacecraft readiness and configuration for one of the last major previews, the plugs-out test. The craft looked ready.
That same night the prime and backup crews studied mission plans. The next day a simulated countdown would start shortly before liftoff and then the test would carry through several hours of flight time. There would be no fuel in the Saturn. Grissom, White, and Chaffee would don their full spacesuits and enter the Apollo, breathing pure oxygen to approximate orbital conditions as closely as possible. After simulated liftoff, the spacecraft center in Houston would monitor the performance of the astronauts. The plugs-out test did not rate a hazardous classification; the spacecraft had successfully operated in the test chamber for a greater period of time than it would on the pad.
The astronauts entered the Apollo at 1:00 p.m., Friday, 27 January 1967. Problems immediately arose. NASA Spacecraft Test Conductor Clarence Chauvin later described them: “The first problem that we encountered was when Gus Grissom ingressed into the spacecraft and hooked up to his oxygen supply from the spacecraft. Essentially, his first words were that there was a strange odor in the suit loop. He described it as a ‘sour smell’ somewhat like buttermilk.” The crew stopped to take a sample of the suit loop, and after discussion with Grissom decided to continue the test.
The next problem was a high oxygen flow indication which periodically triggered the master alarm. The men discussed this matter with environmental control systems personnel, who believed the high flow resulted from movements of the crew. The matter was not really resolved.
A third serious problem arose in communications. At first, faulty communications seemed to exist solely between Command Pilot Grissom and the control room. The crew made adjustments. Later, the difficulty extended to include communications between the operations and checkout building and the blockhouse at complex 34. “The overall communications problem was so bad at times,” Chauvin testified, “that we could not even understand what the crew was saying.” William H. Schick, Assistant Test Supervisor in the blockhouse at complex 34, reported in at 4:30 p.m. and monitored the spacecraft checkout procedure for the Deputy of Launch Operations. He sat at the test supervisor’s console and logged the events, including various problems in communications. To complicate matters further, no one person controlled the trouble-shooting of the communications problem. This failure in communication forced a hold of the countdown at 5:40 p.m. By 6:31 the test conductors were about ready to pick up the count when ground instruments showed an unexplained rise in the oxygen flow into the spacesuits. One of the crew, presumably Grissom, moved slightly.
Four seconds later, an astronaut, probably Chaffee, announced almost casually over the intercom: “Fire. I smell fire.” Two seconds later, Astronaut White’s voice was more insistent: “Fire in the cockpit.”
In the blockhouse, engineers and technicians looked up from their consoles to the television monitors trained at the spacecraft. To their horror, they saw flames licking furiously inside Apollo, and smoke blurred their pictures. Men who had gone through Mercury and Gemini tests and launches without a major hitch stood momentarily stunned at the turn of events. Their eyes saw what was happening, but their minds refused to believe. Finally a near hysterical shout filled the air: “There’s a fire in the spacecraft!”
Procedures for emergency escape called for a minimum of 90 seconds. But in practice the crew had never accomplished the routines in the minimum time. Grissom had to lower White’s headrest so White could reach above and behind his left shoulder to actuate a ratchet-type device that would release the first of a series of latches. According to one source, White had actually made part of a full turn with the ratchet before he was overcome by smoke. In the meantime, Chaffee had carried out his duties by switching the power and then turning up the cabin lights as an aid to vision. Outside the white room that totally surrounded the spacecraft, Donald O. Babbitt of North American Aviation ordered emergency procedures to rescue the astronauts. Technicians started toward the white room. Then the command module ruptured.
Witnesses differed as to how fast everything happened. Gary W. Propst, an RCA technician at the communication control racks in area D on the first floor at launch complex 34, testified four days later that three minutes elapsed between the first shout of “Fire” and the filling of the white room with smoke. Other observers had gathered around his monitor and discussed why the astronauts did not blow the hatch and why no one entered the white room. One of these men, A. R. Caswell, testified on 2 February, two days after Propst. In answer to a question about the time between the first sign of fire and activity outside the spacecraft in the white room, he said: “It appeared to be quite a long period of time, perhaps three or four minutes. . . .”
The men on the launch tower told a different story. Bruce W. Davis, a systems technician with North American Aviation who was on level A8 of the service structure at the time of the fire, reported an almost instantaneous spread of the fire from the moment of first warning. “I heard someone say, ‘There is a fire in the cockpit.’ I turned around and after about one second I saw flames within the two open access panels in the command module near the umbilical.” Jessie L. Owens, North American Systems Engineer, stood near the pad leader’s desk when someone shouted: “Fire.” He heard what sounded like the cabin relief valve opening and high velocity gas escaping. “Immediately this gas burst into flames somewhat like lighting an acetylene torch,” he said. “I turned to go to the white room at the above-noted instant, but was met by a flame wall.”
Spacecraft technicians ran toward the sealed Apollo, but before they could reach it, the command module ruptured. Flame and thick black clouds of smoke billowed out, filling the room. Now a new danger arose. Many feared that the fire might set off the launch escape system atop Apollo. This, in turn, could ignite the entire service structure. Instinct told the men to get out while they could. Many did so, but others tried to rescue the astronauts.
Approximately 90 seconds after the first report of fire, pad leader Donald Babbitt reported over a headset from the swing arm that his men had begun attempts to open the hatch. Thus the panel that investigated the fire concluded that only one minute elapsed between the first warning of the fire and the rescue attempt. Babbitt’s personal recollection of his reporting over the headset did not make it clear that he had already been in the white room, as the panel seemed to conclude. Be that as it may, for more than five minutes, Babbitt and his North American Aviation crew of James D. Gleaves, Jerry W. Hawkins, Steven B. Clemmons, and L. D. Reece, and NASA’s Henry H. Rodgers, Jr., struggled to open the hatch. The intense heat and dense smoke drove one after another back, but finally they succeeded. Unfortunately, it was too late. The astronauts were dead. Firemen arrived within three minutes of the hatch opening, doctors soon thereafter. A medical board was to determine that the astronauts died of carbon monoxide asphyxia, with thermal burns as contributing causes. The board could not say how much of the burns came after the three had died. Fire had destroyed 70% of Grissom’s spacesuit, 25% of White’s, and 15% of Chaffee’s. Doctors treated 27 men for smoke inhalation. Two were hospitalized.
Rumors of disaster spread in driblets through the area. Men who had worked on the day shift returned to see if they could be of help. Crewmen removed the three charred bodies well after midnight.
The sudden deaths of the three astronauts caused international grief and widespread questioning of the space program. Momentarily the whole manned lunar program stood in suspense. Writing in Newsweek, Walter Lippman immediately deplored what he called the pride-spurred rush of the program. The Washington Sunday Star spoke of soaring costs and claimed that “know-who” had more to do than “know-how” in the choice of North American over Martin Marietta as prime contractor for the spacecraft. A long-time critic of the space program, Senator William J. Fulbright of Arkansas, Chairman of the Senate Foreign Relations Committee, placed the “root cause of the tragedy” in “the inflexible, but meaningless, goal of putting an American on the moon by 1970” and called for a “full reappraisal of the space program.” The distinguished scientist Dr. James A. Van Allen, discoverer of radiation belts in space, charged that NASA was “losing its soul.” It had become “a huge engineering, technological and operational agency with less and less devotion to the true spirit of exploration and to the advancement of basic knowledge.” A lead editorial in the New York Times spoke of the incompetence and negligence that became apparent as the full story of disaster came to light, but put the central blame on “the technically senseless” and “highly dangerous” dedication to the meaningless timetable of putting a man on the moon by 1970. An article in the American Institute of Chemical Engineers Journal had the long-anticipated title: “NASA’s in the Cold, Cold Ground.” But President Johnson held firm to the predetermined goal and communicated his confidence to NASA.
The Review Board
After removal of the bodies, NASA impounded everything at launch complex 34. On 3 February, NASA Administrator Webb set up a review board to investigate the matter thoroughly. Except for one Air Force officer and an explosives expert from the Bureau of Mines, both specialists in safety, all the members of the board came from NASA. North American Aviation had a man on the board for one day. At least George Jeffs, NAA’s chief Apollo engineer, thought he was on the board. After consultation with Shea and Gilruth of the Manned Space Flight Center, North American officials recommended him as one who could contribute more than any other NAA officer. Jeffs flew to the Cape and sat in on several meetings until, as Jeffs was to report later to the House Subcommittee on NASA Oversight, “I was told that I was no longer a member of the Board.” The representative of the review board who dismissed Jeffs gave no reason for the dismissal. Thus all members of the board were government employees, a fact that was to cause NASA considerable criticism from Congress.
Debus asked all KSC and contractor employees for complete cooperation with the review board. He called their attention to the Apollo Mission Failure Contingency Plan of 13 May 1966 that prohibited all government and contractor employees from discussing technical aspects of the accident with anyone other than a member of the board. All press information would go through the Public Affairs Office. In scheduled public addresses, speakers might discuss other aspects of the space program but “should courteously but absolutely refuse to speculate at this time on anything connected with the Apollo 204 investigation or with factors that might be related, directly or indirectly, to the accident.” Debus’s action muted at KSC the wild rumors that had prevailed in east Florida and spread throughout the country after the fire.
Under authorization from the review board, ground crews carefully removed the debris on the crew couches inside the command module on 3 February. They recorded the type and location of the material removed. Then they laid a plywood shelf across the three interlocked seats so that combustion specialists could enter the command module and examine the cabin more thoroughly. On the following day they removed the plywood and the three seats. Two days after that, they suspended a plastic false floor inside the command module so that investigators could continue to examine the command module interior without aggravating the condition of the lower part of the cabin.
Engineers at the Manned Spacecraft Center duplicated conditions of Apollo 204 without crewmen in the capsule. They reconstructed events as studies at KSC brought them to light. The investigation on pad 34 showed that the fire started in or near one of the wire bundles to the left and just in front of Grissom’s seat on the left side of the cabin – a spot visible to Chaffee. The fire was probably invisible for about five or six seconds until Chaffee sounded the alarm. “From then on,” a Time writer stated, “the pattern and the intensity of the test fire followed, almost to a second, the pattern and intensity of the fire aboard Apollo 204.”
The members of the review board sifted every ash in the command module, photographed every angle, checked every wire, and questioned in exhausting detail almost everyone who had the remotest knowledge of events related to the fire. They carefully dismantled and inspected every component in the cockpit.
In submitting its formal report to Administrator Webb on 5 April 1967, the board summarized its findings: “The fire in Apollo 204 was most probably brought about by some minor malfunction or failure of equipment or wire insulation. This failure, which most likely will never be positively identified, initiated a sequence of events that culminated in the conflagration.”
To the KSC Safety Office, the next finding of the Review Board seemed to be the key to the entire report: “Those organizations responsible for the planning, conduct and safety of this test failed to identify it as being hazardous.” Since NASA had not considered the test hazardous, KSC had not instituted those procedures that normally would have accompanied such a test.
The Review Board had other severe criticism:
Deficiencies existed in Command Module design, workmanship and quality control. . . . The Command Module contained many types and classes of combustible material in areas contiguous to possible ignition sources. . . . The rapid spread of fire caused an increase in pressure and temperature which resulted in rupture of the Command Module and creation of a toxic atmosphere. . . . Due to internal pressure, the Command Module inner hatch could not be opened prior to rupture of Command Module. . . . The overall communications system was unsatisfactory. . . . Problems of program management and relationships between Centers and with the contractor have led in some cases to insufficient response to changing program requirements. . . . Emergency fire, rescue and medical teams were not in attendance. . . . The Command Module Environmental Control System design provides a pure oxygen atmosphere. . . . This atmosphere presents severe fire hazards.
A last recommendation went beyond hazards: “Every effort must be made to insure the maximum clarification and understanding of the responsibilities of all the organizations involved, the objective being a fully coordinated and efficient program.”
The review board recommended that NASA continue its program and get to the moon and back before the end of 1969. Safety, however, was to be a prime consideration, outranking the target date. The board urged, finally, that NASA keep the appropriate congressional committees informed on significant problems arising in its programs.
Astronaut Frank Borman, a member of the board, summed up the fact that everyone had taken safety in ground testing for granted. The crewmen, he stated, had the right not to enter the spacecraft if they thought it was unsafe. However, “none of us,” Borman insisted, “gave any serious consideration to a fire in the spacecraft.”
The board members sharply criticized the fact that the astronauts had no quick means of escape and recommended a redesigned hatch that could be opened in two to three seconds instead of a minute and a half. They proposed a number of other changes in the design of both the spacecraft and the pad and recommended revised practices and procedures for emergencies. Many of these, incidentally, KSC already had in its plans for “hazardous” operations.
One of the most amazing facts to come out in the testimony of so many at KSC was the complicated process of communications. A contractor employee would confer with his NASA counterpart, who would in turn get in touch with his supervisor, who would in turn report to someone else in the chain of command. It must have seemed to the review board easier for a man on the pad to get through to the White House than to reach a local authority in time of an emergency.
When the review board began its investigation in February, the Senate Committee on Aeronautical and Space Sciences held a few hearings but confined its queries to major NASA officials. When the Apollo 204 Review Board turned in its report to Administrator Webb, the Senate Committee enlarged the scope of its survey; and the House Committee on Science and Astronautics, more particularly the Subcommittee on NASA Oversight, went into action.
Congress had wider concerns, however, than the mechanics of the fire that had occupied so much of the review board’s time. Both houses, and especially two legislators from Illinois, freshman Senator Charles Percy and Representative Donald Rumsfeld, showed great interest in the composition of the review board, especially its lack of non-government investigators. Members of Congress questioned the board’s omission of any analysis of the possibility of weakness in the managerial structure that might have allowed conditions to approach the point of disaster. Senator Edward Brooke of Massachusetts wondered about the extensive involvement of North American Aviation and its capacity to handle such a huge percentage of the Apollo contracts. To the surprise of both NASA and NAA officials, members of both the Senate and House committees were to take a growing interest in the report of the Phillips review team of December 1965. This probing was to lead to some embarrassing moments for Mueller of NASA and Atwood of North American Aviation. But these aspects of the hearings belong more properly to the NASA Headquarters history.
Questioning of Debus by two members of the House Committee on Science and Astronautics at a hearing in Washington on the evening of 12 April bears directly on the KSC story. Congressman John Wydler of New York asked Debus to clarify his secrecy directive, which Wydler believed had caused some misunderstanding. Debus read his initial directive of 3 February, which asked for total cooperation with the board and squelched other discussion of the disaster; and then his second announcement of 11 April, after the review board had submitted its report, which removed all restraints. Wydler seemed satisfied.
When Congressman James Fulton of Pennsylvania asked Debus a few minutes later if he would like to make a short statement for the record, Debus came out candidly:
As director of the installation I share the responsibility for this tragic accident and I have given it much thought. It is for me very difficult to find out why we did not think deeply enough or were not inventive enough to identify this as a very hazardous test.
I have searched in my past for safety criteria that we developed in the early days of guided missile work and I must say that there are some that are subject to intuitive thinking and forward assessment. Some are made by practical experience and involved not only astronauts but the hundreds of people on the pads. . . .
It is very deplorable but it was the known condition which started from Commander Shepard’s flight. . . . from then on we developed a tradition that. . . . considered the possibility of a fire but we had no concept of the possible viciousness of this fire and its speed.
We never knew that the conflagration would go that fast through the spacecraft so that no rescue would essentially help. This was not known. This is the essential cause of the tragedy. Had we known, we would have prepared with as adequate support as humanly possible for egress.
Congressman Fulton congratulated Debus on his statement. “This is why we have confidence in NASA. We have been with you on many successes. We have been with you on previous failures, not so tragic. . . . The Air Force had five consecutive failures and this committee still backed them and said go ahead.” By looking at matters openly and seeking better procedures, Fulton felt that NASA was making progress.
The House Subcommittee on NASA Oversight, under the chairmanship of Olin Teague of Texas, held hearings at the Kennedy Space Center on 21 April. When the investigation opened, it soon became clear – as the review board had already learned – that any emergency procedures at the space center would be extremely complicated matters involving conferences between NASA and contractor counterparts, and even in certain instances with representatives of the Air Force safety section. Beyond this the most noteworthy event of the hearing was the recommendation of Congressman Daddario that the members commend the brave men on the pad who had tried to save the astronauts.
While the Senate committee in Washington spent a great deal of time on the Phillips report, and embarrassed NASA and NAA officials with questions about the document, the committee finally had to agree with the testimony that “the findings of the Phillips task force had no effect on the accident, did not lead to the accident, and were not related to the accident.” On the positive side, the committee learned from President Atwood that North American Aviation had made substantial changes in its management. The firm had placed William B. Bergen, former president of Martin-Marietta, in charge of its Space Division; obtained the full-time services of Bastian Hello and hired as consultant G. T. Wiley, both former Martin officials; and transferred one of its own officers, P. R. Vogt, from the Rocketdyne Division to the Space Division. Atwood testified that North American would probably make other changes.77 In the end, the Senate committee recommended that NASA move forward to achieve its goal within the prescribed time, but reaffirmed the review board’s insistence that safety take precedence over target dates, and reminded NASA to keep appropriate congressional committees informed of any significant problems that might arise in its program.
Reaction at KSC
During the ensuing months, NASA took many steps to prevent future disasters. It gave top priority to a redesigned hatch, a single-hinged door that swung outward with only one-half pound of force. An astronaut could unlatch the door in three seconds. The hatch had a push-pull unlatching handle, a window for visibility in flight, a plunger handle inside the command module to unlatch a segment of the protective cover, a pull loop that permitted someone outside to unlatch the protective cover, and a counterbalance that would hold the door open. NASA revised flight schedules. An unmanned Saturn V would go up in late 1967, but the manned flight of the backup crew for the Grissom team – Schirra, Eisele, and Cunningham – would not be ready before the following May or June. In the choice of materials for space suits, NASA settled on a new flame-proof material called “Beta Cloth” instead of nylon. Within the spacecraft, technicians covered exposed wires and plumbing to preclude inadvertent contact, redesigned wire bundles and harness routings, and increased fire protection.
Initially, NASA administrators said they would stay with oxygen as the atmosphere in the spacecraft. But after a year and a half of testing, NASA was to settle on a formula of 60% oxygen and 40% nitrogen. NASA provided a spacecraft mockup at KSC for training the rescue and the operational teams. At complex 34 technicians put a fan in the white room to ventilate any possible smoke. They added water hoses and fire extinguishers and an escape slide wire. Astronauts and workers could ride down this wire during emergencies, reaching the ground from a height of over 60 meters in seconds.
NASA safety officers were instructed to report directly to the center director. At Kennedy this procedure had been the practice for some time. A Headquarters decision also extended the responsibilities of the Flight Safety Office at Kennedy. Test conductors and all others intimately involved with the development of the spacecraft and its performance sent every change in procedure to the Flight Safety Office for approval.
The fire had a significant impact on KSC’s relations with the spacecraft contractors. When KSC had absorbed Houston’s Florida Operations team in December 1964, the launch center was supposed to have assumed direction of the spacecraft contractors at the Cape. The North American and Grumman teams at KSC, however, had continued to look to their home offices, and indirectly to Houston, for guidance. This ended in the aftermath of LC-34’s tragedy. With the support of NASA Headquarters, KSC took firm control of all spacecraft activities at the launch center.
The Boeing-TIE Contract
To strengthen program management further, NASA entered into a contract with the Boeing Company to assist and support the NASA Apollo organization in the performance of specific technical integration and evaluation functions. NASA retained responsibility for final technical decisions. This Boeing-TIE contract, as it came to be called at KSC, proved the most controversial of all post-fire precautions. Many in middle or lower echelons at KSC criticized it. They looked upon it as a public relations scheme to convince Congress of NASA’s sincere effort to promote safety.
Even NASA Headquarters found it difficult to explain to a congressional subcommittee either the expenditure of $73 million in one year on the contract, or that it had hired a firm to inspect work which that firm itself performed. As a matter of fact one segment of the Boeing firm – that working under the TIE contract – had to check on another, the one that worked on the first stage of Saturn V. Mueller explained to the committee that “the Boeing selection for the TIE contract. . . . was based upon the fact that this was an extension of the work [Boeing personnel] were already doing in terms of integrating the Saturn V launch vehicle.”
When a member of the committee staff called Mueller’s attention to the fact that Boeing had problems with its own specific share of the total effort, Mueller’s defense of the contract rested on the old adage that “nothing succeeds like success.” He felt that if the total program succeeded, the nation would no longer question specific aspects and expenditures.
Boeing sent 771 people to KSC, one-sixth of the total it brought onto NASA installations under the TIE contract. In such a speedy expansion, the quality of performance was spotty. The “TIE-ers” were to find it difficult to get data from other contractors, as well as from NASA personnel. The men at KSC felt they had the personnel to do themselves what the TIE-ers were attempting to do.
The TIE statement of work at KSC carried a technical description of twelve distinct task areas: program integration, engineering evaluation, program control, interface and configuration management, safety, test, design certification reviews, flight readiness reviews, logistics, mission analysis, Apollo Space System Engineering Team, and program assurance.
Many KSC personnel felt that the TIE contract was too much like the General Electric contract they had fought a few years before. In this they forgot that the earlier contract had been a permanent one, which would have given GE access to its competitors’ files, and thus involved a conflict of interest. The Boeing-TIE contract had a specific purpose and a time limit. NASA made the arrangement on an annual basis. Further, those who criticized the number of Boeing personnel forgot that one could not assess the size of the problem until he investigated it.
The TIE personnel located and defined delays in the progress of equipment to the Kennedy Space Center. They spotted deficiencies in equipment. They discovered erroneous color coding of lines, for instance, that might have caused a disaster. The insulation of pipes had obscured the color and men had improperly tagged the sources of propellants and gases. When tests at KSC proved changes of equipment necessary, the TIE personnel expedited these changes. They set down time schedules for necessary adjustments. They eliminated extraneous material from the interface control documents. But it remains difficult to assess the exact contribution of the TIE contract.
Far more important than the efforts of the 771 Boeing-TIE personnel, or any specific recommendation of the review board (except perhaps that calling for a new hatch design), the most significant difference at Kennedy Space Center was a larger awareness of how easily things could go wrong. For a long time no test or launch would be thought of as a foregone success.
Most important of all, in spite of the disaster, the President, the Congress, the nation, and NASA itself determined that the moon landing program would go on with the hope of coming as close to President Kennedy’s target date as possible.
APOLLO 204 FIRE
(Apollo Accident Report). Aviation Week and Space Technology. 6 February 1967, pp. 29-36; 13 February 1967, pp. 33-36; and 20 February 1967, pp. 22-23. Discusses the ways NASA was attempting to maintain its Apollo landing schedule despite the Apollo 204 accident. Also covers congressional monitoring of the accident investigation and the inquiry itself. Not a conclusive discussion, since the investigation had not yet ended as of 20 February, but it gives something of the flavor and immediacy of the situation in NASA and the country in the wake of the tragedy.
Bergaust, Erik. Murder on Pad 34. New York: G.P. Putnam’s Sons, 1968. A highly-critical account of the investigation of the Apollo 204 accident in January 1967 that killed astronauts Gus Grissom, Roger Chaffee, and Edward White. Bergaust takes issue with NASA’s design approach that allowed for the use of a pure oxygen atmosphere in the Apollo command module. It is largely a journalistic rehash of criticism of NASA coming from Congress and the media, with very little new commentary or analysis and no new factual information. Bergaust concludes that the human and fiscal sacrifices made in Project Apollo have been in vain, since the Soviet Union (seen as the reason for Apollo) may not be going to the Moon at all.
Biddle, Wayne. “Two Faces of Catastrophe.” Air and Space/Smithsonian. 5 (August/September 1990): 46-49. Discusses the different ways in which NASA handled the Apollo 204 fire in 1967 and the Challenger disaster in 1986. Biddle concludes that the comparison shows NASA had become more fragile and lost direction following the Moon landing.
Boyes, W. Killed Twice Buried Once: A Story about the Catastrophic Apollo Fire. Rockville, MD: Chesapeake Bay Press, 1986. This “novelized” account of the Apollo 204 fire is, the author claims, “based on the actual events which surrounded” the disaster, but as it contains many fictionalized names and events, it must be consulted with extreme care and only in conjunction with “factual” discussions–or at least ones whose sources are attributed.
“The Capsule Fire Flares Up Again.” Life. 17 September 1971, pp. 24-29. 8 B&W photos. Story of the lawsuit brought against North American by Betty Grissom and an engineer’s story of the Apollo 204 disaster.
Gray, Mike. Angle of Attack: Harrison Storms and the Race to the Moon. New York: W.W. Norton and Co., 1992. This is a lively journalistic account of the career of Harrison Storms, president of the Aerospace Division of North American Aviation that built the Apollo capsule. Because of the Apollo 204 fire that killed three astronauts in January 1967, Storms and North American Aviation got sucked into a controversy over accountability and responsibility. In the aftermath Storms was removed from responsibility for the project. The most important aspect of this book is its discussion of the Apollo fire and responsibility for it from the perspective of industry. It lays the blame at NASA’s feet and argues that Storms and North American were mere scapegoats. It, unfortunately, has no notes and the observations offered cannot be verified.
Kennan, Erlend A., and Harvey, Edmund H., Jr. Mission to the Moon: A Critical Examination of NASA and the Space Program. New York: William Morrow and Co., 1969. This book features a detailed examination of the facts of the Apollo 204 fire in January 1967 that killed three astronauts. It does not provide a balanced account of the lunar landing program or NASA. Instead it is filled with critical asides. For example, the authors conclude: “The real reasons for the [Apollo] tragedy–were a lack of perspective and flexibility within NASA management at all key levels; inept, competing, or nonexistent channels of communication throughout the organization’s many facilities; lazy, sloppy, and unduly profit-motivated contractor performance, myopic congressional indulgence (often referred to as ‘moon-doggling’), irresponsible public relations–to the point where NASA actually believed its own inflated propaganda; and finally, a remarkable aloofness from and disdain for the legitimate interests of the taxpaying American public.” Unfortunately, the treatment is long on hyperbole and short on reasoned analysis; the New York Timesreviewer said that the book “adds little that is new on any of the problems or possible solu- tions….But perhaps the book’s sense of outrage is in itself an adequate reason for the book’s existence.”
“The Ten Desperate Minutes.” Life. 21 April 1967, pp. 113-114. Riveting reconstruction of the events in the ten minutes following the outbreak of fire onboard Apollo 204. Based on eyewitness accounts by pad personnel.
United States House, Committee on Science and Aeronautics. Apollo and Apollo Applications: Staff Study for the Subcommittee on NASA Oversight of the Committee on Science and Astronautics, U.S. House of Representatives, Ninetieth Congress, Second Session. Washington, DC: Government Printing Office, 1968. A brief analysis of the state of the Apollo program in the wake of the Apollo 204 fire followed by four appendices containing documents and abstracts supporting the conclusions of the staff study, which included the judgement: “It appears that NASA and the key industrial contractors are recovering momentum following the Apollo 204 accident and are utilizing the information derived effectively to improve the safety and efficiency of equipment and operations” but that a “number of difficult engineering problems remain to be solved….”
United States House, Committee on Science and Astronautics. Apollo Program Pace and Progress; Staff Study for the Subcommittee on NASA Oversight, Ninetieth Congress, First Session. Washington, DC: Govt. Print. Off., 1967. This thick committee print provides a “summary of the status, completed in December 1966, of the Apollo lunar landing program prior to the tragic” Apollo 204 fire. The introduction and program evaluation occupy only 13 pages, but they are followed by over 1,000 pages of correspondence and transcripts of staff conferences with industrial contractors and NASA center managers in Houston, at Kennedy and Marshall. A summary at the beginning announces it as “the finding of this study that the NASA- industry team is employing its resources effectively in solution of those technical problems which currently pace the program.”
Effects Of The Apollo 204 Accident On Schedule And Cost Of The Apollo Program
The Apollo 204 accident and its investigation resulted in substantial changes in the program with resultant impacts on cost and schedules. The principal schedule changes and the cost impact of the accident on the program follow.
The initial Apollo manned flight with the modified Block II spacecraft is scheduled for launch by an uprated Saturn I vehicle during the third or fourth quarter of calendar 1968, some 17 or 18 months after the scheduled launch of Apollo 204 in February 1967. The first unmanned qualification flight of the Saturn V launch vehicle carrying a Block I spacecraft was rescheduled from early 1967 to late 1967 when a highly successful system performance was realized. This flight is to be followed by a third Saturn V unmanned flight in 1968. If the Saturn V launch vehicle is manrated as a result of these flights and the first manned Block II spacecraft mission meets its objectives, subsequent Apollo flights involving command module and lunar module operations in earth orbit in preparation for the lunar landing would be transferred to the Saturn V vehicle rather than utilizing dual uprated Saturn I launches for these practice missions as previously contemplated. However, dual uprated Saturn I missions could be flown as backup missions in the event of Saturn V vehicle qualification delays. A Saturn V vehicle success schedule now projects six manned launches in 1968 and 1969 with the possibility of accomplishing a lunar landing before 1970.
The impact of the Apollo 204 accident has been to reduce the probability of such a landing, not eliminate it. If required for the lunar landing objective, the last six of the original complement of 15 Saturn V vehicles would be launched after 1969.
Apollo Program Cost
Time is a major factor influencing the cost of the Apollo program. In 1966 NASA advised the committee that the total estimated cost of the Apollo program was $22.718 billion assuming that all 12 uprated Saturn I and 15 Saturn V launch vehicles were required for the lunar landing. The comparable estimate provided by NASA during the May 9, 1967 hearing is $23.190 billion, an increase of $472 million. The increase is largely due to the effect of stretching out the Apollo/Saturn V launch schedule. However, early achievement of the lunar landing objective would permit the allocation of unused Apollo hardware and an appropriate share of operational expenses to the Apollo applications program with an offsetting reduction in the cost of the Apollo program.
There was no immediate impact of the accident on the NASA fiscal year 1967 financial plan or the fiscal year 1968 budget request because of offsetting factors such as the suspension of flight schedules and changes in spacecraft production planning, which permitted adjustments within the total NASA budget framework for these years. The overall impact of the Apollo 204 accident, therefore, will appear in future years as is evidenced by the increase in the total runout cost estimate for the Apollo program.
NASA Response To Findings, Determinations, And Recommendations Of Apollo 204 Review Board
In addition to the extensive system, subsystem, and component studies on the Apollo spacecraft made by the Apollo 204 Review Board, NASA undertook a detailed analysis of the entire Apollo program and its management. This included a comprehensive review of each deficiency noted by the Board and its supporting panels to identify and initiate corrective action in those areas noted. In addition to identifying and taking actions to improve crew safety, this review, because of its extraordinary depth and analysis, should result in substantial improvements to many other aspects of the Apollo program.
Many changes have been made in the Apollo program because of the accident and are discussed in parts 6, 7, and 8 of the hearings. The astronauts have had and will continue to have a direct hand in all planning and changes for the Apollo command module and no manned flights have been or will be attempted in the Apollo program until the astronauts, in the light of their newly acquired technical information, are completely satisfied with all aspects of the Apollo system.
Sunstantial changes in the management of the Apollo program have been made both in the agency and in the prime contractor’s effort.
Some of the more important procedure and hardware changes that have been initiated by NASA follow:
All tests taking place in 100 percent pure oxygen environments are now defined as hazardous.
Responsibility for test procedures at the Kennedy Space Center and the Manned Spacecraft Center has been redefined.
An Office of Flight Safety has been established independent of the flight program office at both the headquarters and field centers to rview all aspects of design, manufacturing, test, and flight from a safety standpoint.
Emergency-type training is now required for test support personnel and the launch pad is required to be equipped with appropriate fire fighting and rescue equipment.
Spacecraft and Facility Modifications
All manned flights will be in the Block II spacecraft, the design of which already incorporates many of the changes recommended by the Apollo 204 Review Board.
A significant change has been instituted in the approach to the selection and placement of materials inside the command module. This change, which severely restricts and controls the amount and location of combustible material in the command module, is more significant than any other improvement resulting from the accident.
A new quick-opening hatch to be installed on all Block II spacecraft is being developed.
Provision has been made in the spacecraft for a fire extinguishing capability using jellied water.
An emergency oxygen supply system has been provided for the flight crew in the event they are separated from their suits.
The launch facilities have been modified to accommodate the quick-opening hatch and expedite flight crew exit through the service structure in the event of fire.
One Hundred Percent Pure Oxygen Environment
NASA has defined all tests taking place in 100 percent pure oxygen environment as hazardous. While NASA has reconfirmed by detailed review that the inflight cabin atmosphere, outside the Earth’s atmosphere, should continue to be 100 percent oxygen at 5 p.s.i.a., it has modified the command module systems on the launch pad. Should full scale flammability tests indicate a need to change to an air atmosphere for ground operations, NASA will implement this capability. However, the dual gas cabin atmosphere, while reducing the fire hazard, creates other risks such as the risk of the astronauts getting the “bends” if their cabin pressure is reduced quickly.
NASA Status Report
NASA submitted to the committee on January 8, 1968, a report on the status of actions taken on the Apollo 204 Review Board Report as of December 28, 1967. This document is printed as part 8 of the committee’s hearings on the Apollo accident. This status report shows that NASA has made substantial progress in adopting and implementing the findings, determinations, and recommendations of the Apollo 204 Review Board and its task panel.
The thorough investigation by the Apollo 204 Review Board of the Apollo accident determined that the test conditions at the time of the accident were “extremely hazardous.” However, the test was not recognized as being hazardous by either NASA or the contractor prior to the accident. Consequently, adequate safety precautions were neither established nor observed for this test. The amount and location of combustibles in the command module were not closely restricted and controlled, and there was no way for the crew to egress rapidly from the command module during this type of emergency nor had procedures been established for ground support personnel outside the spacecraft to assist the crew. Proper emergency equipment was not located in the “white room” surrounding the Apollo command module nor were emergency fire and medical rescue teams in attendance.
There appears to be no adequate explanation for the failure to recognize the test being conducted at the time of the accident as hazardous. The only explanation offered the committee is that NASA officials believed they had eliminated all sources of ignition and since to have a fire requires an ignition source, combustible material, and oxygen, NASA believed that necessary and sufficient action had been taken to prevent a fire.
Of course, all ignition sources had not been eliminated.
The Apollo 204 Review Board reported that it took approximately 5 minutes to open all hatches and remove the two outer hatches after the fire was reported; that the first firemen arrived about 8 to 9 minutes after the fire was reported and that the first medical doctors did not arrive until about 12 minutes or more after the fire was reported. Thus there was not expert medical opinion available on opening the hatch to determine the condition of the three astronauts although medical opinion based on autopsy reports concluded that chances for resuscitation decresed rapidly once consciousness was lost and that resuscitation was impossible by the time the hatch was opened.
It is clear from the Board’s report and the testimony before the committee that this kind of accident was completely unexpected; that both NASA and the contractor were completely unprepared for it despite the amount of documentation of fire hazards in pure oxygen environments. The committee can only conclude that NASA’s long history of successes in testing and launching space vehicles with pure oxygen environments at 16.7 p.s.i. and lower pressures led to overconfidence and complacency.
The Apollo 204 accident was a tragic event in the nation’s space program. Because of it there has been a thorough analysi and review of all aspects of the Apollo program. Consequently many changes have been made in the Apollo system design, operations, management, and procedures and NASA expects this will result in an improved spacecraft and booster system. The committee’s review of the accident found nothing which would make the committee question this expectation. It is the committee’s hope that the remainder of the program will be carried out with greater understanding and dedication than if there had been no accident. The total impact of the Apollo 204 accident on the Apollo program is not yet known. In continuing its close surveillance over the Apollo program, your committee will be especially mindful of the impact of the accident on program schedules and cost, and on the effectiveness of the changes in management and operations made by NASA during the past several months.