The Accident

The Investigation

The Findings

Following the fire, NASA immediately formed a Review Board chaired by Dr. Floyd L. Thompson and charged with the responsibility to review the evidence and recommend changes to reduce the hazards inherent in the program. They first met on January 28, 1967 and twice daily thereafter to review proposed plans and determine requirements for testing and analysis of the data and to provide basic direction. Witnesses were interviewed and film and other evidence reviewed. 

Command Module 012 ⁽¹⁾, to be forever known as Apollo 1, was taken apart at the launch complex until it was determined that tests had progressed to a point where the Command Module could be removed without disturbing the evidence. On February 17, 1967 CM 012 was removed to the Pyrotechnic Installation Building. Command Module 014, originally scheduled to be flown as Apollo 7, had been shipped to KSC on February 1 to establish exact location and condition of all components prior to the accident. CM 012 was painstakingly taken apart component by component and studied closely with all components showing evidence of abnormal fire effects examined both internally and externally. Disassembly was completed two months after the fire.

Twenty-One Panels were each assigned a specific task: ⁽²⁾

Panel 1 Spacecraft and Ground Support Configuration

This included physical configuration of the spacecraft and ground support equipment, immediately prior to, and during, the fire, including equipment configuration, switch positions, and non-flight items in the cockpit. 

Panel 2 Test Environments

Task Panel 2 planned and implemented a review of all tests for histories pertinent to the investigation. Attention was focused primarily upon oxygen test histories of the crew compartment systems, and arcing and shorting problems experienced during those tests. All environments were reviewed for rationale used in original deviation, substantiation by ground and flight vehicle tests, and margins imposed when implemented into component level tests. The other environments were examined as possibly being germane to the cause of the accident. These reviews included the vibration, heating, and humidity environments.

Panel 3 Sequence of Events

Task Panel 3 analyzed data obtained prior to and during the fire accident including digital, analog, voice communications, and photography. It was tasked to display significant events as they occurred with a precise time tag. 

Panel 4 Disassembly Activities

Task Panel 4 developed plans and procedures for progressive disassembly of the Apollo 012 spacecraft for purposes of inspection and failure analysis. Disassembly was configured to proceed on a step-by-step basis, in a manner to obtain the maximum amount of information. Contents of testing plans were considered. Disassembly plans included both the cockpit and the area outside the pressure hull. 

Task Panel 5 conducted inspections, chemical analysis of the spacecraft parts and rubble to establish point of fire origin, direction and rate of propagation, temperature gradients and extremes. It also determined the nature of the fire, the type of materials consumed, and the degree of combustion. 

Task Panel 6 assembled and reviewed records on the Spacecraft and associated systems, in order to determine the applicability of these records to the Apollo 204 accident. In addition, historical narratives were prepared to reflect the relationship and flow of significant review and acceptance points, highlight documentation pertinent thereto, and to present a brief history of the prelaunch operation performed on Spacecraft 012 at Kennedy Space Center. 

Task Panel 7 documented test procedures employed during the day of the incident. Deviations between planned procedures and those actually used were indicated. It determined potential changes which might alleviate fire hazard conditions or provide for improved reaction or corrective conditions. 

Task Panel 8 assembled and summarized data and analyses related to the flammability of spacecraft materials. Results of programs other than Apollo were considered. It recommended requirements for additional testing and reviewed Apollo test conditions for adequacy. Recommendations were made for materials or configuration changes to alleviate fire hazard. Analyses were performed, as appropriate, to determine such information as overall energy balance and correlations with temperature and pressure building. 

Task Panel 9 conducted critical design reviews of systems or subsystems that were potential ignition sources within the cockpit or which might have provided a combustible condition in either normal or failed conditions. This panel considered glycol plumbing configuration, electrical wiring and its protection, as well as other potential ignition sources such as motors, relays, and corona discharges. Other areas of review included egress augmentation and basic cabin atmosphere concept (one versus two-gas system). 

Task Panel 10 inspected the spacecraft for structural failures resulting from the fire. It analyzed these failures from various standpoints including local pressure, temperature levels, and direction of gas flow. 

Task Panel 11 was assigned the responsibility of providing a summary of medical facts together with appropriate medical analysis which would be of interest to the investigation. Examples given included the cause of death, pathological evidence of overpressure, and any other areas that might be of technical value in determining the cause of the accident or in establishing corrective action. 

Task Panel 12 was assigned the responsibility for determining who to interview, arranging for competent interviewers, and recording the data. The Panel also analyzed the pertinent sequence of events as reported by the bulk of the witnesses, together with a summary of that testimony which is contradictory to the main data. 

Panel 13 reviewed and evaluated the emergency provisions in existence at the time of the accident. This included investigations of emergency procedures in published documents, internal and external spacecraft emergency equipment, and emergency training of the flight crew and checkout test team personnel. It also reviewed existing methods used to identify hazards and insure adequate documentation. 

Panel 14 reviewed for adequacy, security procedures in existence at the time of the accident. This review included access control, personnel sign-in requirements, buddy systems and background investigation requirements. The Panel made recommendations to the Apollo 204 Review Board for changes to existing practices. 

This series consists of the Board Administrative Procedures and a summary report of Task Panel 15 of the Apollo 204 Review Board. This Panel established and documented administrative procedures of the Board. This included activity such as procedures for control of spacecraft work, logging and filing of exhibits, maintenance of the Board activities log, scheduling of meetings, preparation of agendas for Board meetings, arrangements for secretarial services and reproduction of material. 

This Panel coordinated tests desired by other groups into an overall, integrated test plan. Test results were collected, reviewed and edited so as to be included in the Final Report of the Apollo 204 Review Board. This Panel was dissolved February 23, 1967, and merged with Panel 18, Integration Analysis. 

This Panel was responsible for organizing the Final Report of the Board, delegating responsibility to other panels, reviewing and editing submitted material and the final preparation of the report. 

This Panel coordinated all phases of hardware inspection, disassembly, test and analysis requirements, and presented periodic status reports and summaries to the Board. It also was responsible for the correlation, validation and determination of each significant finding and presented periodic status reports and summaries of test results to the Board. 

Task Panel 19 was responsible for reviewing all operations performed during the investigation to assure that all personnel safety requirements were adequately maintained. 

This Panel reviewed in-flight fire emergency procedures and other provisions relative to their adequacy as well as whether emergency procedures existed for all appropriate activities. This included recommendations for changes in existing procedures and other provisions and for the creation of new emergency provisions if deemed necessary. 

This Panel was responsible for the planning and execution of necessary Service Module activity beginning at the time of Board approval for Command Module Demate.