CSB: Unsafe practices led to Honolulu fireworks blast that killed five workers
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 Board 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.
Sheltering from the rain - in the wrong place
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.
No expertise in fireworks disposal
|Click here to watch the new CSB animated safety video, "Deadly Contract," which depicts the tragic sequence of events leading to the five worker fatalities.|
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.
Lowest bid won the contract
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.”
No regs for fireworks disposal
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.
CSB wants government to step in
The report 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 CSB made 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.
Inconsistent disposal methods across U.S.
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.”