Source: NASA Historical Reference Collection, NASA History Office, NASA. Headquarters, Washington, DC.

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.

For further information email histinfo@hq.nasa.gov
Updated September 10, 2015