Titan II Accident McConnell AFB, Kansas 1978 Part 2
Part One of this story here.
At 1400 hours, a team of nine additional PTS personnel arrived with RFHCOs and air packs: TSgt John Mock Jr., SSgt Robert Sanders, A1C Scot Jaeger, Michael Greenwell, Middland Jackson, Rodney Larson, Terry Watke, and Gregory Anderson, and SrA James Romig. Mock, Jackson, and Anderson tried to penetrate through the launch control center air intake but were unsuccessful. They then forced their way through the access portal entrapment area. Between the hear from the oxidizer vapor reacting with the materials in the access portal and the physical exertion of using a small crowbar to break through the entrapment area, the team had to resurface for new air packs. Mock, Jackson, and Greenwell made their way down the access portal stairwell with barely any light to see by. The oxidizer vapors were so dense that the flourescent lights, normally more than sufficient illumination, cast hardly any usable light. They finally reached the blast lock area and were able to feel their way to the launch control center where they found Thomas's body. They carried him to the access portal elevator, which was inoperative. A fifth member then joined the rotation of teams as they operated in pairs to carry Thomas up the 55 steps of the access portal, one flight at a time. At approximately 1600, two hours after they arrived on the scene, Thomas's body was on the surface and transported to the base hospital.
Two fatalities resulted from the accident, and 25 personnel were slightly injured. Thomas was declared dead on arrival at the hospital. The autopsy revealed that he had died from acute pulmonary edema due to inhalation of high concentration of oxidizer vapor. Subsequent investigation showed that Thomas had apparently tried to stem the flow of oxidizer from the tank with his glove. The high velocity stream of fluid penetrated the glove/cuff interface, instantaneously filling his suit with a dense cloud of vapors.
Hepstall was transported to Wesley Hospital, Winfield, Kansas. On September 3rd 1978 he died due to lung and renal failure resulting from inhalation of concentrated oxidizer vapors. This was apparently due to either direct entrance via a 7-inch gash in the left leg of his RFHCO or due to vapor inhalation while attempting to give Thomas mouth-to-mouth resuscitation..
Malinger was transported to the William Newton Memorial Hospital, Winfield, Kansas, and then to USAF Medical Center, Scott AFB, Illinois, on August 25th 1978. Malinger developed severe complications but eventually made a gradual recovery, although he suffered permanent damage to his vocal cords and lungs and paralysis in his left arm. The accident left him 100 percent disabled.
The final report of the investigation into the accident was issued by Col Ben Scallorn on October 10th 1978. The primary cause was failure to follow recommended procedures. The actual cause of the accident was the lodging of a Teflon O right from the bottom of the oxidizer filter unit in the poppet valve mechanism, jamming it open. When Hepstall and Malinger began to disconnect the oxidizer transfer line, they had quickly unscrewed the quick-disconnect rather than follow the technical order specification that the quick-disconnect should be slowly unscrewed and if any leak was seen, screw the disconnect back to the fully connected position so that the tank could be unloaded and the quick-disconnect replaced. The filter unit had been removed during the propellant download several weeks earlier, and the lower O right was inadvertently left in place. Technical orders called for the replacement of the filter prior to oxidizer upload, but this was not done. The flow of oxidizer during the upload dislodged the right into the flowing stream. Adherence to applicable technical orders would have prevented this primary cause from occurring.
Thomas died due to an unforeseen flaw in the design of the RFHCO. The attachment points for the gloves and boots were not designed to withstand direct impingement of a high-pressure stream of oxidizer or fuel. The subsequent failure of the left glove/cuff on Thomas's suit allowed direct penetration of the suit environment by liquid oxidizer. A detailed inspection of the suit and later tests with the helmet visors showed that the suits offered only marginal protection to prolonged exposure to liquid oxidizer.
Three significant equipment changes were made as a result of the investigation. The RFHCOs were modified with a visor made out of high-impact material much more resistant to clouding during prolonged exposure to liquid oxidizer. The glove and boot/cuff interface was redesigned to protect against liquid propellant impingement failures. The RTMN upgrade, identified in 1976 but slow to be implemented, was accelerated as a direct result of this accident. A major flaw in the system was removed: no longer could a constantly keyed microphone render the net useless.
On September 5th 1980, Headquarters SAC approved $4.17 million for the repair of the launch complex. In October 1980, the General Accounting Office awarded the Project PACER DOWN contract to Mayfair Construction Company. Mayfair was to rebuild the structure of the silo while Martin Mariette Company installed the missile and launch equipment. Work was delayed further by the inability to coordinate a work schedule that permitted both Mayfair and Martin Marietta personnel to work at the site. These issues were resolved, and on April 28th 1981, Headquarters SAC approved a joint-occupancy schedule with work to begin August 1st 1981, nearly three years after the accident with a proposed completion date of January 8th 1982.
On October 2nd 1981, the Defense Department announced plans to retire the Titan II system. A stop-work order for Project PACER DOWN was issued by Headquarters SAC on November 5th 1981. Contract termination negotiations with Mayfair Construction Company and Martin Marietta Company were completed and by December 1981 Project PACER DOWN was terminated. Launch Complex 533-7 was disposed of in the same manner as the rest of the 381st SMW sites during the Titan II deactivation program.
Part One of this story here.