CSB Report says Honolulu Fireworks Disposal Explosion that Killed Five Workers Resulted from nsafe !

ra"ti"es# $a"k of %ational &uidelines# and $a"k of Safety !rovisions for Federal Contra"tors

Washington, DC, January 17, 2013 In a final report set to be consi ere to ay, the !"#" Che$ical #afety %oar &C#%' sai an e(plosion an fire that )ille fi*e +or)ers uring a fire+or)s isposal operation in ,a+aii in 2011 resulte fro$ unsafe isposal practices- insufficient safety re.uire$ents for go*ern$ent contractor selection an o*ersight- an an absence of national gui elines, stan ar s, an regulations for fire+or)s isposal" /he final report, sche ule for a boar *ote at a public $eeting in Washington, DC, to ay, reco$$en s that fe eral agencies e*elop a ne+ go*ern$ent0+i e safety an en*iron$ental responsibility re.uire$ent for contractors, an calls for ne+ regulations on the safe isposal of fire+or)s, a gro+ing proble$ across the !"# /he C#% also planne to release a ne+ safety *i eo entitle 1Dea ly Contract2 +ith an ani$ation epicting the tragic se.uence of e*ents"

/he 3pril 4, 2011, acci ent occurre as e$ployees of Donal son 5nterprises, Inc" &D5I' sought shelter fro$ rain insi e a tunnel0li)e $aga6ine locate at Wai)ele #elf #torage in Waipahu, ,a+aii, near ,onolulu" /he storage facility containe go*ern$ent0confiscate illegally labele fire+or)s, +hich the +or)ers ha been is$antling un er a subcontract to a fe eral pri$e contract" /he C#% eter$ine that changes in D5I7s fire+or)s isposal process resulte in the accu$ulation of a large .uantity of e(plosi*e co$ponents 8ust insi e the $aga6ine entrance, creating the essential ele$ents for a $ass e(plosion" 3 large e(plosion an fire fatally in8ure all fi*e +or)ers insi e the $aga6ine" 9ne +or)er, +ho ha been stan ing outsi e the $aga6ine entrance oor, escape +ith in8uries" C#% Chairperson Dr" :afael ;oure05raso sai , 19ur in*estigation foun that co$pany personnel ha no specific e(pertise in fire+or)s isposal, that the co$pany7s proce ures +ere e(tre$ely unsafe, an that there are no national stan ar s or accepte goo practices for isposing of fire+or)s" While fire+or)s pro*i e entertain$ent for $illions, the isposal of unuse fire+or)s creates enor$ous ha6ar s for +or)ers because, +e +ere surprise to fin , there are no gui elines to o the +or)"2 /he in*estigation foun that a single, large, fe eral contractor, the <#5 Corporation of 3le(an ria, <irginia, han les storage, auctions or isposal for large a$ounts of go*ern$ent0sei6e property, such as counterfeit goo s, li*estoc), an in this case, illegal fire+or)s" <#5 subcontracte the isposal of three i$porte fire+or)s ship$ents sei6e by fe eral la+ enforce$ent agencies that ha co$e through ,onolulu o*er a three0year perio to D5I" /hey +ere labele for consu$er use, but actually containe far $ore e(plosi*e $aterials typical of those use for professionally0pro uce public isplays" C#% in*estigator 3$an a Johnson sai , 1D5I +as a+ar e the subcontract fro$ <#5 because it +as a local co$pany alrea y storing the sei6e fire+or)s in the hillsi e facility, an its proposal +as the lo+est in cost an consi ere the $ost ti$e0efficient" ,o+e*er, <#5 +as una+are that espite D5I7s $ilitary or nance bac)groun , the co$pany ha no e(perience +ith fire+or)s isposal"2 /he report foun that the !"#" Depart$ent of the /reasury7s contracting regulations i not i$pose sufficient re.uire$ents on <#5 for selecting an o*erseeing subcontractors to han le ha6ar ous $aterials" D5I began the operation in early su$$er of 2010 after obtaining an e$ergency en*iron$ental per$it for the +or) fro$ the state" With no goo

practice stan ar s to follo+, D5I i$pro*ise a isposal plan an sub$itte it to <#5, +hich appro*e it=belie*ing D5I +as co$petent to o the +or)" /hat plan calle for soa)ing the fire+or)s in iesel fuel an then burning the$ at a local shooting range" ,o+e*er, so$e fire+or)s +ere not burning, but e(plo ing" /he co$pany conclu e that the iesel +as not sufficiently penetrating the aerial shells an thus altere the proce ure, isasse$bling the in i*i ual fire+or) tubes an cutting slits in the aerial shells so the iesel coul soa) into the shells to re uce the e(plosion ha6ar uring burning" /he process +as further altere to spee up estruction of the ne(t batch of confiscate fire+or)s in early 2011" Wor)ers +ere tol to separate the blac) po+ er fro$ the shells, accu$ulating the$ in separate bo(es an ra$atically increasing the e(plosion ha6ar , the C#% foun " /he in*estigation foun the co$pany i not a e.uately analy6e the potential ha6ar s create by $a)ing these changes to the isposal plan" In*estigator Johnson sai , 1Disasse$bling the fire+or)s +as a $a8or change to the isposal process" >oo process safety practice +oul ha*e calle for a thorough ha6ar analysis as +ell as a co$prehensi*e re*ie+ of the potential safety i$pacts of the propose change"2 9n the $orning of 3pril 4, 2011, fi*e D5I e$ployees +ere ta)ing apart one0inch fire+or) tubes )no+n as 1#)y ?esti*als2 un er a tent outsi e the $aga6ine" 3 si(th +or)er +as cleaning up an organi6ing ite$s insi e" !sing *arious tools the D5I +or)ers cut the fire+or) tubes an separate out the aerial shells an the blac) po+ er" /he C#% calculate that co$bining such large a$ounts of these e(plosi*e $aterials insi e bo(es increase the e(plosion ha6ar by $ore than @A0 ti$es" /he C#% also foun a lac) of regulations or in ustry stan ar s a ressing fire+or)s isposal" /he report foun that there are no fe eral, state, or local regulations or in ustry stan ar s establishing safety re.uire$ents, pro*i ing gui ance on proper +ays to ispose of fire+or)s, or a ressing the ha6ar s associate +ith the isasse$bly of fire+or)s an the accu$ulation of e(plosi*e fire+or)s co$ponents" /he report notes that 9#,37s Brocess #afety ;anage$ent &B#;' stan ar applies to fire+or)s $anufacturing, but not to fire+or)s isposal +or)" ,a the stan ar applie , D5I +oul ha*e been re.uire to con uct a safety re*ie+ of the potential ha6ar s in*ol*e +hen it change its fire+or)s isposal process" /he in*estigation eter$ine , 1D5I +oul ha*e greatly benefitte fro$ Brocess #afety ;anage$ent &B#;' principles an concepts of inherent safety,2 a$ong the$, not accu$ulating large a$ounts of highly

e(plosi*e blac) po+ er an aerial shells +hile a+aiting isposal" 3 contributing factor, in*estigators foun , +as that ata about the highly e(plosi*e co$poun s in the sei6e fire+or)s +as not $a e a*ailable to D5I an +as not re.uire un er the isposal contract, an the co$panies in*ol*e i not treat the fire+or)s as ha*ing the highest le*el of ha6ar " %efore engaging in the isposal +or), D5I i obtain a +aste isposal per$it fro$ the #tate of ,a+aii" #uch per$its are grante throughout the country to entities see)ing to ispose of sei6e contraban fire+or)s because they are consi ere an i$$inent threat to hu$an health an the en*iron$ent" %ut a C#% fin ing isclose that the fe eral :esource Conser*ation an :eco*ery 3ct &:C:3' oes not incorporate B#;0type ele$ents in its ha6ar ous +aste per$itting process, +hich +oul help assure the isposal process is con ucte safely" /he C#% foun that the ?e eral 3c.uisition :egulation &?3:', +hich go*erns fe eral agencies7 ac.uisition of goo s an ser*ices, oes not specifically re.uire a fe eral contracting officer to consi er safety perfor$ance $easures an .ualifications +hen eter$ining the 1responsibility2 of a potential go*ern$ent contractor" Contracting officers +oul be re.uire to specifically re*ie+ co$panies7 ability to use safe $etho s for any +or) in*ol*ing ha6ar ous $aterials, inclu ing e(plosi*es an fire+or)s, un er the proposal" /he C#% foun that the ?e eral 3c.uisition :egulation &?3:', +hich go*erns fe eral agencies7 ac.uisition of goo s an ser*ices, oes not specifically re.uire a fe eral contracting officer to consi er safety perfor$ance $easures an .ualifications +hen eter$ining the 1responsibility2 of a potential go*ern$ent contractor" Contracting officers +oul be re.uire to specifically re*ie+ co$panies7 ability to use safe $etho s for any +or) in*ol*ing ha6ar ous $aterials, inclu ing e(plosi*es an fire+or)s, un er the proposal" /he raft report sub8ect to the boar 7s appro*al reco$$en s that the ?e eral 3c.uisition :egulatory Council an the /reasury Depart$ent incorporate rigorous safety0relate pro*isions throughout the fe eral contracting process ealing +ith the storage, han ling, an isposal of e(plosi*e ha6ar ous $aterials, inclu ing fire+or)s" /he raft report $a)es reco$$en ations to the <#5 Corporation, +hich a+ar e the subcontract to D5I, to utili6e e(perts for contractor selection an o*ersight of future contracts in*ol*ing e(plosi*e ha6ar ous $aterials" /he report also reco$$en s that the Cational ?ire Brotection 3ssociation &C?B3'

e*elop national best practices for the safe isposal of +aste fire+or)s that are consistent +ith en*iron$ental re.uire$ents" In a ition, the report reco$$en s that the !"#" 5n*iron$ental Brotection 3gency &5B3' re*ise the :esource Conser*ation an :eco*ery 3ct &:C:3' regulations to re.uire a per$itting process +ith rigorous safety re*ie+s to replace the use of e$ergency per$its, as is the practice no+, for the isposal of e(plosi*e ha6ar ous $aterials, inclu ing fire+or)s" /he raft report also urge the %ureau of 3lcohol, /obacco, ?irear$s an 5(plosi*es &3/?', +hich regulates fire+or)s in the !"#", to participate +ith the C?B3 in e*eloping gui ance on the safe isposal of fire+or)s" /hough national statistics are not a*ailable, C#% in*estigators learne fro$ *arious officials across the country that $any local agencies ha*e un erta)en the tas) of isposing of sei6e fire+or)s the$sel*es because contracting the +or) out to co$panies that ha*e the re.uisite per$its is too ti$e0consu$ing an costly" In*estigator Johnson sai , 13s +e state in the report, the C#% has learne that the e(tensi*e ti$e an cost necessary for local 8uris ictions to ship the fire+or)s else+here has, unfortunately, resulte in the gro+ing accu$ulation of illegal consu$er an isplay fire+or)s in $aga6ines in states across the country" /his poses a serious ha6ar because of the lac) of national stan ar s an gui elines for safe isposal of these in*entories"2 /he report cites a ea ly acci ent that occurre on July @, 2012, in +hich a *olunteer +as )ille +hen he an other *olunteers +ere isposing of fire+or)s that ha not ischarge uring a fire+or)s isplay sho+ in Dansing, Eansas" 9ne of the three0inch ia$eter aerial shells thro+n into a burning pit e8ecte forcefully an burst near the *olunteer" /he isplay operator for the city tol the C#% that as $uch as ten percent of the fire+or)s use annually faile to function properly an ha*e to be iscar e " /he report note isposal $etho s are inconsistent across the country, inclu ing those use by fire epart$ents an local la+ enforce$ent agencies" /he C#% report conclu es, 1/he +i e array of isposal techni.ues across the country- inci ents such as the one in Dansing, Eansas- an the lac) of e(isting regulations an stan ar s that pro*i e safety re.uire$ents an gui ance to those isposing of fire+or)s, all support the conclusion that a regulatory gap e(ists in this country pertaining to fire+or)s isposal" Closing this gap to pre*ent fatal inci ents re.uires a co$bine effort by 3/?, 5B3, C?B3, state an local agencies, an the fire+or)s in ustry to create stan ar s an gui ance that clearly in icate the angers of han ling an isposing of

fire+or)s, an iscuss ho+ to properly an effecti*ely $anage the ha6ar s an safely con uct this +or)"2

/he C#% is an in epen ent fe eral agency responsible for in*estigating serious che$ical acci ents" /he agencyFs boar $e$bers are appointe by the presi ent an confir$e by the #enate" C#% in*estigations loo) into all aspects of che$ical acci ents, inclu ing physical causes such as e.uip$ent failure as +ell as ina e.uacies in regulations, in ustry stan ar s, an safety $anage$ent syste$s" /he %oar oes not issue citations or fines but oes $a)e safety reco$$en ations to plants in ustry organi6ations, labor groups, an regulatory agencies such as 9#,3 an 5B3" <isit our +ebsite, +++"csb"go*"