Moonport: A History of Apollo Launch Facilities and Operations|
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.54 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."55 Debus's action muted at KSC the wild rumors that had prevailed in east Florida and spread throughout the country after the fire.56
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.57
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."58
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.59
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."** 60
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."61 Since NASA had not considered the test hazardous, KSC had not instituted those procedures that normally would have accompanied such a test.62
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.63A 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."64
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."65
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.66
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.67
* The NASA members were: the chairman, Dr. Floyd L. Thompson, Dir., Langley Research Center; Astronaut Frank Borman, Manned Spacecraft Center; Dr. Maxime A. Faget, Dir., Engineering and Development, MSC; E. Barton Geer, Assoc. Chief, Flight Vehicles and Systems Div., Langley; George C. White, Jr., Dir. of Reliability and Quality, Apollo Program Off.; and John J. Williams, Dir., Spacecraft Operations, Kennedy. The non-NASA members were Dr. Robert W. Van Dolah, Research Dir., Explosive Research Center, Bureau of Mines, Dept. of the Interior; and Col. Charles F. Strange, Chief of Missiles and Space Safety Div., Off. of the Air Force Inspector General, Norton AFB, CA. Report of Apollo 204 Review Board, p. 5. The only non-government person on the original board, Dr. Frank Long of Cornell Univ., a member of the President's Scientific Advisory Committee, soon resigned because of the press of other activities and was replaced by Van Dolah. Aviation Week and Space Technology, 13 Feb. 1967, p. 33.
** The review board ignored and a congressional committee later vehemently rejected the hypothesis of Dr. John McCarthy, NAA Division Director of Research, Engineering, and Test, that Grissom accidentally scuffed the insulation of a wire in moving about the spacecraft. (Investigation into Apollo 204 Accident, 1 : 202, 263.) In the same congressional investigation, Col. Frank Borman, the first astronaut to enter the burnt-out spacecraft, testified: "We found no evidence to support the thesis that Gus, or any of the crew members kicked the wire that ignited the flammables." This theory that a scuffed wire caused the spark that led to the fire still has wide currency at Kennedy Space Center. Men differ, however, on the cause of the scuff.