The Risk Management Tool Box Blog

Deadly Contract - New CSB Video

Graham Marshall - Sunday, February 24, 2013

The U.S. Chemical Safety Board (CSB) has recently released a new safety video entitled “Deadly Contract” which highlights how an explosion and fire that killed five workers during a fireworks disposal operation in Hawaii in 2011 resulted from unsafe disposal practices; insufficient safety requirements for government contractor selection and oversight; and an absence of national guidelines, standards, and regulations for fireworks disposal.

The CSB is also calling for new regulations on the safe disposal of government-confiscated illegally labeled fireworks - a growing problem across the U.S.

The  accident occurred in April 2011, as employees of Donaldson Enterprises, Inc. (DEI) worked in a tunnel-like magazine located in Waipahu, Hawaii.

The storage facility contained government-confiscated illegally labeled fireworks, which the workers had been dismantling under a subcontract to a federal prime contract.

The CSB determined there was an accumulation of a large quantity of explosive components just inside the magazine entrance, creating the essential elements for a mass explosion.

A large explosion and fire fatally injured all five workers inside the magazine.

Another worker, who had been standing outside the magazine entrance door, escaped with injuries.

The CSB investigation found that company personnel had no specific expertise in fireworks disposal, that the company’s procedures were extremely unsafe, and that there are no national standards or accepted good practices for disposing of fireworks.

DEI was awarded the subcontract from a Federal Agency because it was a local company already storing the seized fireworks in the hillside facility, and its proposal was the lowest in cost and considered the most time-efficient.

However, despite DEI’s military ordnance background, the company had no experience with fireworks disposal.

DEI improvised a disposal plan that called for soaking the fireworks in diesel fuel and then burning them at a local shooting range

However, some fireworks were not burning, but exploding.

The company concluded that the diesel was not sufficiently penetrating the aerial shells and thus altered the procedure, disassembling the individual firework tubes and cutting slits in the aerial shells so the diesel could soak into the shells to reduce the explosion hazard during burning.

The process was further altered to speed up destruction of the next batch of confiscated fireworks in early 2011.

Workers were told to separate the black powder from the shells, accumulating them in separate boxes and dramatically increasing the explosion hazard, the CSB found.

The investigation found the company did not adequately analyze the potential hazards created by making these changes to the disposal plan.

Good process safety practice would have called for a thorough hazard analysis as well as a comprehensive review of the potential safety impacts of the proposed change.

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