 of cabin fire. (18)
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. (19)
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. (20)
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. " (21)
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 