scope:

Abstract:

The attached report is a compilation of all credible, unintentional hypergolic fluid related spills, fires, and explosions from the Apollo Program, the Space Shuttle Program, Titan Program, and a few other programs. Spill sites include the following government facilities: KSC, JSC, WSTF, VAFB, CCAFS, EAFB, Little Rock AFB, and McConnell AFB.

The root causes and consequences of the incidents contained in this document vary drastically; however, certain themes can be deduced and utilized for future hypergolic propellant handling. Some of those common themes are summarized below:

1. Improper configuration control and complacency can lead to being falsely comfortable with a system Communication breakdown can escalate an incident to a level where injuries occur and/or hardware is damaged.

2. Improper propulsion system and ground support system designs can destine a system for failure.

3. Improper training of technicians, engineers, and safety personnel can put lives in danger.

4. Improper PPE, spill protection, and staging of fire extinguishing equipment can result in unnecessary injuries or hardware damage if an incident occurs.

5. Improper procedural oversight, development, and adherence to the procedure can be detrimental and quickly lead to an undesirable incident.

6. Improper local cleanliness or compatibility can result in fires or explosions.

The items listed above are only a short list of the issues that should be recognized prior to handling of hypergolic fluids or processing of vehicles containing hypergolic propellants. The summary of incidents in this report is intended to cover many more issues than those listed above that have been found during nearly the entire spectrum of hypergolic propellant and/or vehicle processing.