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CSB Releases Report on 2011 Hawaii Fireworks Explosion

Posted in on Fri, Jan 18, 2013

From CSB –

CSB Report says Honolulu Fireworks Disposal Explosion
that Killed Five Workers Resulted from Unsafe Practices, Lack of National Guidelines, and Lack of Safety Provisions for Federal Contractors

Washington, DC, January 17, 2013 – In a final report set to be considered today, the U.S. Chemical Safety Board (CSB) said 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 draft document, scheduled for a board vote at a public meeting in Washington, DC, today, recommends that federal agencies develop a new government-wide safety and environmental responsibility requirement for contractors, and calls for new regulations on the safe disposal of fireworks, a growing problem across the U.S.

The CSB also planned to release a new safety video entitled “Deadly Contract” with an animation depicting the tragic sequence of events.

See the entire press release and more information at http://www.csb.gov/newsroom/detail.aspx?nid=444

The April 8, 2011,
accident occurred as employees of Donaldson Enterprises, Inc. (DEI) sought
shelter from rain inside a tunnel-like magazine located at Waikele Self Storage
in Waipahu, Hawaii, near Honolulu.  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 that changes in DEI’s fireworks disposal process resulted in the
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.  One worker, who had been standing outside the magazine entrance
door, escaped with injuries.

CSB Chairperson Dr.
Rafael Moure-Eraso said, “Our 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. While fireworks provide entertainment for
millions, the disposal of unused fireworks creates enormous hazards for workers
because, we were surprised to find, there are no guidelines to do the work.”

The investigation
found that a single, large, federal contractor, the VSE Corporation of
Alexandria, Virginia, handles storage, auctions or disposal for large amounts
of government-seized property, such as counterfeit goods, livestock, and in
this case, illegal fireworks.  VSE subcontracted the disposal of three imported
fireworks shipments seized by federal law enforcement agencies that had come
through Honolulu over a three-year period to DEI.  They were labeled for
consumer use, but actually contained far more explosive materials typical of
those used for professionally-produced public displays.

CSB investigator
Amanda Johnson said, “DEI was awarded the subcontract from VSE 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, VSE was unaware that despite DEI’s military ordnance background, the
company had no experience with fireworks disposal.”  The report found
that the U.S. Department of the Treasury’s contracting regulations did not impose
sufficient requirements on VSE for selecting and overseeing subcontractors to
handle hazardous materials.

DEI began the
operation in early summer of 2010 after obtaining an emergency environmental
permit for the work from the state.  With no good practice standards to
follow, DEI improvised a disposal plan and submitted it to VSE, which approved
it—believing DEI was competent to do the work. That plan 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.

Investigator Johnson
said, “Disassembling the fireworks was a major change to the disposal
process.  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.”

On the morning of
April 8, 2011, five DEI employees were taking apart one-inch firework tubes
known as “Sky Festivals” under a tent outside the magazine.  A sixth
worker was cleaning up and organizing items inside. Using various tools the DEI
workers cut the firework tubes and separated out the aerial shells and the
black powder. The CSB calculated that combining such large amounts of these
explosive materials inside boxes increased the explosion hazard by more than
450 times.

The CSB also found a
lack of regulations or industry standards addressing fireworks disposal.
The report found that there are no federal, state, or local regulations or
industry standards establishing safety requirements, providing guidance on
proper ways to dispose of fireworks, or addressing the hazards associated with
the disassembly of fireworks and the accumulation of explosive fireworks
components.

The report notes that
OSHA’s Process Safety Management (PSM) standard applies to fireworks manufacturing,
but not to fireworks disposal work. Had the standard applied, DEI would have
been required to conduct a safety review of the potential hazards involved when
it changed its fireworks disposal process.  The investigation determined,
“DEI would have greatly benefitted from Process Safety Management (PSM)
principles and concepts of inherent safety,” among them, not accumulating large
amounts of highly explosive black powder and aerial shells while awaiting
disposal. A contributing factor, investigators found, was that data about the
highly explosive compounds in the seized fireworks was not made available to
DEI and was not required under the disposal contract, and the companies
involved did not treat the fireworks as having the highest level of hazard.

Before engaging in the
disposal work, DEI did obtain a waste disposal permit from the State of
Hawaii.  Such permits are granted throughout the country to entities
seeking to dispose of seized contraband fireworks because they are considered
an imminent threat to human health and the environment. But a CSB finding
disclosed that the federal Resource Conservation and Recovery Act (RCRA) does
not incorporate PSM-type elements in its hazardous waste permitting process,
which would help assure the disposal process is conducted safely.

The CSB found that the
Federal Acquisition Regulation (FAR), which governs federal agencies’
acquisition of goods and services, does not specifically require a federal
contracting officer to consider safety performance measures and qualifications
when determining the “responsibility” of a potential government
contractor.  Contracting officers would be required to specifically review
companies’ ability to use safe methods for any work involving hazardous
materials, including explosives and fireworks, under the proposal.

The draft report –
subject to the board’s approval – recommends that the Federal Acquisition
Regulatory Council and the Treasury Department incorporate rigorous
safety-related provisions throughout the federal contracting process dealing
with the storage, handling, and disposal of explosive hazardous materials,
including fireworks.

The draft report makes
recommendations to the VSE Corporation, which awarded the subcontract to DEI,
to utilize experts for contractor selection and oversight of future contracts
involving explosive hazardous materials.  The report also recommends that
the National Fire Protection Association (NFPA) develop national best practices
for the safe disposal of waste fireworks that are consistent with environmental
requirements.

In addition, the
report recommends that the U.S. Environmental Protection Agency (EPA) revise
the Resource Conservation and Recovery Act (RCRA) regulations to require a
permitting process with rigorous safety reviews to replace the use of emergency
permits, as is the practice now, for the disposal of explosive hazardous
materials, including fireworks. The draft report also urged the Bureau of
Alcohol, Tobacco, Firearms and Explosives (ATF), which regulates fireworks in the
U.S., to participate with the NFPA in developing guidance on the safe disposal
of fireworks.

Though national
statistics are not available, CSB investigators learned from various officials
across the country that many local agencies have undertaken the task of
disposing of seized fireworks themselves because contracting the work out to
companies that have the requisite permits is too time-consuming and
costly.

Investigator Johnson
said, “As we state in the report, the CSB has learned that the extensive time
and cost necessary for local jurisdictions to ship the fireworks elsewhere has,
unfortunately, resulted in the growing accumulation of illegal consumer and
display fireworks in magazines in states across the country. This poses a
serious hazard because of the lack of national standards and guidelines for
safe disposal of these inventories.”

The report cites a
deadly accident that occurred on July 4, 2012, in which a volunteer was killed
when he and other volunteers were disposing of fireworks that had not
discharged during a fireworks display show in Lansing, Kansas.  One of the
three-inch diameter aerial shells thrown into a burning pit ejected forcefully
and burst near the volunteer. The display operator for the city told the CSB
that as much as ten percent of the fireworks used annually failed to function
properly and have to be discarded. The report noted disposal methods are
inconsistent across the country, including those used by fire departments and
local law enforcement agencies.

The CSB report concludes,
“The wide array of disposal techniques across the country; incidents such as
the one in Lansing, Kansas; and the lack of existing regulations and standards
that provide safety requirements and guidance to those disposing of fireworks,
all support the conclusion that a regulatory gap exists in this country
pertaining to fireworks disposal.  Closing this gap to prevent fatal
incidents requires a combined effort by ATF, EPA, NFPA, state and local
agencies, and the fireworks industry to create standards and guidance that
clearly indicate the dangers of handling and disposing of fireworks, and
discuss how to properly and effectively manage the hazards and safely conduct
this work.”

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