Skip to content

Donaldson Enterprises, Inc. Fatal Fireworks Disassembly Explosion and Fire

Overview

On April 8, 2011, at approximately 8:50 am, an explosion and fire occurred at magazine A-21 at Waikele Self Storage in Waipahu, Hawaii, during fireworks disposal-related disassembly work conducted by Donaldson Enterprises, Inc. Five DEI personnel were fatally injured and one project supervisor sustained minor injuries. The CSB found that changes in DEI's fireworks disposal process led to the accumulation of a large quantity of explosive components near the magazine entrance, creating the essential elements for a mass explosion.

Incident Snapshot

Field Value
Facility / Company Donaldson Enterprises, Inc. (DEI)
Location Waipahu, HI
Incident Date 2011-04-08
Investigation Status Final report approved by a 3-0 vote at a public meeting in Washington, DC on January 17, 2013.
Accident Type Explosion and fire
Final Report Release Date 2013-01-17

What Happened

  • On April 8, 2011, at approximately 7:15 am, a team of six DEI personnel arrived at the magazine to begin their disassembly work for the day.
  • They prepared their outside work area by setting up a pop-up tent, table, and chairs on the magazine loading dock located directly in front of the magazine entrance.
  • DEI personnel initially transferred three boxes of whole firework tubes to the outside working area.
  • Two UXO technicians cut the tubes using a PVC cutter or knife, while the project supervisor and the two additional technicians broke the tubes apart and separated the internal explosive components into one of the three cardboard boxes.
  • The team was able to disassemble six to seven boxes of fireworks before 8:30 am when, according to the project supervisor, it began to rain heavily.
  • The team stopped work and used a metal hand truck to move the boxes containing black powder, aerial shells, and partially disassembled tubes, and stack them just inside the magazine entrance.
  • They also brought in the table, camp chairs, and a rolling office chair, leaving the pop-up tent outside on the dock.
  • While the team of personnel remained inside the magazine, the project supervisor left and got his phone from his truck, which was parked in front of the magazine dock.
  • He then walked to the front left corner of the magazine dock to make a phone call.
  • While he was on the phone, a large explosion occurred inside the magazine and a fire ensued.
  • The five individuals located inside the magazine at the time of the incident did not survive.
  • Three DEI employees sustained fatal burn injuries while two succumbed to carbon monoxide poisoning.
  • The project supervisor sustained minor injuries.

Facility and Process Context

  • Waikele Self Storage consists of storage magazines cut into a solid rock hillside and used as tunnel-like ammunition storage bunkers.
  • DEI leased magazine A-21 at Waikele Self Storage in Waipahu, Hawaii, to store unexploded ordnance.
  • DEI was subcontracted to dispose of imported fireworks seized in Honolulu, Hawaii, by federal law enforcement personnel.
  • DEI personnel began cutting open, or disassembling, individual firework tubes by hand on a loading dock just outside the magazine entrance and separating out the individual explosive fireworks components, the black powder and aerial shells.
  • The accumulated explosive powder from the fireworks, referred to as black powder, was stored in a plastic container lined with a plastic garbage bag.
  • In early 2011, DEI altered the fireworks disposal process to increase the destruction rate by maximizing the amount of aerial shells that could be burned at once.
  • At the time of the incident, DEI personnel had abruptly halted their disassembly work due to rain and had taken the materials involved in the process to just inside the magazine entrance.
  • Boxes containing aerial shells, black powder, and partially disassembled firework tubes were stacked inside the magazine near the entrance along with tools, a metal hand truck, and chairs.

Consequences

  • Fatalities: 5
  • Injuries: 1 minor injury
  • Environmental Release: Not reported
  • Facility Damage: The explosion was a deflagration that originated inside the magazine near the entrance. Damage indicators included chipping and scorching of the magazine walls, burned 55-gallon drums, and scorching on the lower portions of the ventilation duct within the magazine near the entrance.
  • Operational Impact: The explosion and fire prevented escape by a majority of the DEI workers who were inside the magazine at the time of the incident. DEI was in the process of disassembling the primary seizure on the day of the incident; it had destroyed approximately 35 percent of this seizure at the time of the incident.

Key Findings

Immediate Causes

  • The fire and explosion were a result of the accumulation of explosive black powder and aerial shells inside the magazine near its only entrance, and multiple ignition sources were present.
  • ATF concluded that the explosion was likely triggered when loose explosive pyrotechnic powder, initially generated as the fireworks were disassembled outside, spilled or leaked from the boxes onto the storage magazine floor and was ignited due to friction or a metal-to-metal spark as DEI employees moved materials around inside the magazine.
  • ATF concluded that the ignition likely propagated to one or more of the boxes of the accumulated explosives located near the magazine entrance, resulting in a large explosion.

Contributing Factors

  • DEI’s modifications to the fireworks disposal process accumulated substantially large quantities of explosive material in boxes, greatly increasing the potential explosion hazard.
  • DEI personnel disposing of the fireworks lacked the training, experience, and knowledge of procedural safeguards for the safe conduct of the fireworks disposal.
  • DEI’s hazard analysis of its fireworks disposal process was insufficient.
  • DEI failed to identify key hazards of handling, disassembling, and storing contraband commercial display fireworks, and did not adequately control the identified and evaluated hazards.
  • The Activity Hazard Analysis did not identify hazards of separating explosive firework components that are sensitive to shock, friction, and static, such as black powder, and accumulating them in large quantities, creating a mass explosion hazard.
  • No safety analysis was done that focused on minimizing the amount of hazardous material that was being accumulated during the disposal process.
  • The analysis did not identify or evaluate hazards stemming from the use of regular plastic garbage bags to store black powder rather than utilizing anti-static bags.
  • Workers wore only ordinary street clothes, including cotton shorts and t-shirts, which are not flame resistant.
  • The magazine had only one means of ingress and egress, yet DEI work practices allowed for explosive and combustible materials to effectively block this exit.
  • No provision for emergency breathing air or fire protection clothing was provided.
  • The CSB found a lack of regulations or industry standards that adequately address safe fireworks disposal.
  • Emergency hazardous waste disposal permits are granted in Hawaii and 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.
  • The Resource Conservation and Recovery Act (RCRA) does not incorporate PSM-type elements in its hazardous waste permitting process, despite the extremely hazardous nature of the materials covered by these permits.
  • The fireworks were suspected to be illegally labeled for consumer use.
  • ATF concluded that the products violated APA 87-1, paragraph 3.5.2.
  • The products exceeded the maximum allowable explosive filler weight of 130 milligrams permitted in consumer fireworks by 27 CFR §555.141(a)(7).
  • The products exceeded the maximum permitted charge weight of 130 milligrams for devices that are intended for sale to the public and produce an audible charge effect (APA 87-1, paragraph 3.7.3).
  • ATF opined that the fireworks were classified as explosives (Class 1.3 or higher) and subject to regulations under 27 CFR Part 555, Commerce in Explosives.

Organizational and Systemic Factors

  • Federal contractor selection regulations did not require VSE procurement personnel to conduct a safety-related review of DEI prior to awarding the company the subcontract.
  • VSE procurement personnel involved in awarding this subcontract had no training and experience related to fireworks disposal.
  • VSE’s procurement office selected DEI as the fireworks disposal subcontractor because DEI was already storing the seized fireworks at the time under a separate subcontract with VSE, and because DEI submitted the lowest-cost and most time-efficient bid.
  • VSE procurement personnel were unaware that DEI had no prior fireworks disposal experience when it awarded the subcontract.
  • VSE procurement personnel conducted a non-technical review of DEI and the competing offeror for the fireworks disposal subcontract that did not address health and safety.
  • VSE did not use personnel with the technical background or expertise to properly select and oversee subcontractors performing work with hazardous materials such as fireworks, nor did it consult with or hire anyone with that expertise.
  • The Department of the Treasury Acquisition Regulation (DTAR) does not impose sufficient requirements for safe practices and subcontractor selection and oversight with respect to the unique hazards associated with handling, storing, and disposing of hazardous materials.
  • The procurement process TEOAF and VSE utilized does not explicitly address safety, and lacks sufficient selection and oversight requirements for the prime contractor VSE and its subcontractors for the unique hazards associated with fireworks disposal.
  • The subcontract awarded to DEI contained a Statement of Work (SOW) and a Subcontractor Property Management Handbook; both were generic, related to the management of general property, and did not address hazards associated with handling or disposing of explosive hazardous materials, including fireworks.
  • The VSE Regional Office personnel lacked necessary expertise or training to understand the risks associated with handling and disposing of explosives, including fireworks.
  • The VSE Risk Management analyst lacked the expertise or relevant training to adequately assess a plan for fireworks disposal.
  • The BAI subcontract did not require the BAI representative to oversee safety.
  • Neither VSE nor BAI used personnel with the necessary backgrounds and expertise to recognize the hazards associated with DEI’s fireworks disposal work.
  • DEI management personnel relied solely on military manuals and on-the-job military EOD training and experience to develop the initial disposal methodology.
  • DEI personnel involved in the fireworks disposal activities under the fireworks disposal subcontract lacked the requisite training and experience needed to safely identify and control the hazards of this type of hazardous work.
  • DEI’s main practice as a company was to conduct UXO identification and clearance activities through remote ignition.
  • The CSB could not identify the existence of training available to civilians covering fireworks disposal.
  • DOH personnel lacked the requisite background to analyze DEI’s proposed disposal methodology, experience, and qualifications when issuing this permit.
  • DOH personnel told the CSB that their focus was on environmental protection, not safety.
  • At some point, Timberline entered into a separate agreement with DEI to store the seizures.
  • For unknown reasons, VSE did not renew their storage contract with Timberline and instead, in late 2008, directly subcontracted with DEI to store the firework seizures.
  • Post-seizure, a CBP Fines, Penalties and Forfeitures Officer at Port of Honolulu oversaw the seized property program and aspects of case processing.

Failed Safeguards or Barrier Breakdowns

  • DEI’s Activity Hazard Analysis did not robustly identify hazards associated with the disassembly process.
  • Safeguards DEI management listed to mitigate identified hazards, such as flame-retardant clothing and non-sparking tools, were not implemented.
  • DEI did not conduct a formal Process Hazard Analysis (PHA) of its fireworks disposal activities.
  • DEI did not conduct a formal Management of Change (MOC) analysis when it modified its disposal process.
  • DEI did not implement the proper PPE and emergency provisions such as breathing air.
  • DEI did not have a plan to dispose of the accumulated black powder.
  • VSE did not question or express concern about DEI’s procedure change.
  • VSE did not question the March 2011 change in methodology.
  • VSE Risk Management approved the Property Destruction Plan without researching DEI’s qualifications, experience, or proposed methodology.
  • The Property Destruction Plan overstated the safeguards in place to ensure that disposal was being done safely.
  • DOH did not discuss diesel soaking or fireworks disassembly in the permit.
  • DOH did not conduct additional analysis to better understand DEI’s disposal plan.
  • ATF regulations do not provide guidance on fireworks disposal or disassembly activities.
  • NFPA has no standard or guidance for the safe disposal of fireworks.
  • No OSHA or HIOSH guidance specifically relates to fireworks disposal.
  • The individual shot cakes were unmarked.
  • The second seizure was being stored in the rear of the magazine at the time of the incident.
  • Damaged containers of AE should not be stored in a magazine with serviceable containers of AE.
  • Unpackaged AE items shall not be stored in magazines containing AE in their original shipping container, but may be stored in separate magazines.
  • Do not permit loose powder, grains, powder dust, or particles of explosive substances from broken AE or explosive substance containers in magazines.

Recommendations

  1. 2011-06-I-HI-R1 | Recipient: Federal Acquisition Regulatory (FAR) Council | Status: Closed-Unacceptable Response/No Response Received | Establish an additional contractor responsibility determination requirement under Subpart 9.104-1 of the Federal Acquisition Regulation (FAR) addressing contractor safety performance. The analysis under this requirement should focus on incident prevention, and environmental and system safety. At a minimum, the language should specifically require the review of a prospective contractor’s environmental and safety programs; safety record and incident history; ability to use safe methods for any work involving hazardous materials (including explosives); and suitable training and qualifications for the personnel involved in the work including prior relevant safety experience.
  2. 2011-06-I-HI-R2 | Recipient: Department of the Treasury Office of the Procurement Executive (OPE) | Status: Closed – Acceptable Action | Establish formal policy requiring that solicitations for contracts dealing with the storage, handling, and disposal of explosive hazardous materials, including fireworks, incorporate rigorous safety-related contractor selection provisions such as those provided in the DoD’s Contractor’s Safety Manual for Ammunition and Explosives, Section C1.5, “Pre-Award Safety Survey”; and contracts dealing with the storage, handling, and disposal of explosive hazardous materials, including fireworks, include a provision requiring that any subcontract (regardless of tier) for the storage, handling, and disposal of explosives (including fireworks) be selected based on rigorous safety-related contractor selection provisions such as those provided in the DoD’s Contractor’s Safety Manual for Ammunition and Explosives, Section C1.5, “Pre-Award Safety Survey.”
  3. 2011-06-I-HI-R3 | Recipient: Department of the Treasury Office of the Procurement Executive (OPE) | Status: Closed – Acceptable Action | Establish a formal policy requiring that contracts and subcontracts dealing with the storage, handling, and disposal of explosive hazardous materials, including fireworks, incorporate rigorous safety-related contractor oversight provisions such as those provided in the DoD’s Contractor’s Safety Manual for Ammunition and Explosives, Section C1.6, “Pre-Operational Safety Survey” and C1.7, “Post-Award Contractor Responsibilities” to provide effective oversight of subcontractors handling and disposing of explosives and hazardous materials.
  4. 2011-06-I-HI-R4 | Recipient: Department of the Treasury – Office of the Procurement Executive (OPE) | Status: Closed – Acceptable Action | When the NFPA guidance developed by the National Fire Protection Association for the safe disposal of fireworks as recommended under recommendation 2011-06-I-HI-R7 is completed, incorporate this document by reference into the formal policies established by 2011-06-I-HI-R2 and 2011-06-I-HI-R3.
  5. 2011-06-I-HI-R5 | Recipient: Treasury Executive Office for Asset Forfeiture (TEOAF) | Status: Closed – Acceptable Action | Require additional provisions within the TEOAF seized property management contract, such as a contract line item number (CLIN), that provide for the prime contractor to use expert(s) to assist the prime contractor’s personnel in the selection and oversight of subcontractors who handle, store, or dispose of explosive hazardous materials, including fireworks, pursuant to the main contract.
  6. 2011-06-I-HI-R6 | Recipient: VSE Corporation | Status: Closed – Acceptable Action | Use experts to assist VSE procurement in selecting vendors to properly handle, store, and dispose of explosive hazardous materials, including fireworks, pursuant to prime contract requirements; and assist VSE personnel in overseeing the work to ensure it is being conducted safely.
  7. 2011-06-I-HI-R7 | Recipient: National Fire Protection Association (NFPA) | Status: Closed – Acceptable Action | Develop a new standard, or incorporate within an existing standard, best practices for the safe disposal of waste fireworks that are consistent with environmental requirements. At a minimum this guidance or standard should discourage the disassembly of waste fireworks as a step in the disposal process; minimize the accumulation of waste explosive materials, and encourage practices that reduce, recycle, reuse, or repurpose fireworks; and incorporate input from ATF, EPA, and other agencies, experts, and available resources on fireworks disposal methodologies.
  8. 2011-06-I-HI-R8 | Recipient: National Fire Protection Association (NFPA) | Status: Closed – Acceptable Action | Once fireworks disposal best practices under recommendation 2011-06-I-HI-R7 is completed, develop and implement an outreach plan to promptly communicate the new NFPA practices to relevant government agencies and private entities that dispose of waste fireworks.
  9. 2011-06-I-HI-R9 | Recipient: U.S. Environmental Protection Agency (EPA) | Status: Closed – Unacceptable Action/No Response Received | Revise the Resource Conservation and Recovery Act (RCRA) Subtitle C regulations to require a permitting process with rigorous safety reviews to replace the use of emergency permits under 40 C.F.R. § 270.61 for the disposal of explosive hazardous materials, including fireworks. At a minimum, the new process should require the use of best available technology, safe disposal methodologies, as well as safety management practices, such as those required by OSHA’s Process Safety Management Standard (PSM), 29 C.F.R. § 1910.119 (e.g., hazard analysis and control, management of change).
  10. 2011-06-I-HI-R11 | Recipient: Environmental Protection Agency (EPA) | Status: Closed – Acceptable Action | Effectively participate in the National Fire Protection Association’s standard development process to develop guidance on the safe and environmentally sound disposal of fireworks, as recommended under recommendation 2011-06-I-HI-R7.
  11. 2011-06-I-HI-R12 | Recipient: Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF) | Status: Closed – Unacceptable Action/No Response Received | Effectively participate in the National Fire Protection Association’s standard development process to develop guidance on the safe disposal of fireworks, as recommended under recommendation 2011-06-I-HI-R7.

Key Engineering Lessons

  • Do not allow disassembly and accumulation of explosive firework components to create a mass explosion hazard near a single exit.
  • Fireworks disposal changes require formal hazard analysis and management of change review before implementation.
  • Hazard controls must address static, friction, shock, and ignition sources when handling black powder and other pyrotechnic components.
  • Storage and work practices should prevent loose powder, grains, dust, or particles from broken explosive containers from accumulating in magazines.
  • Emergency permits and generic property-management procedures are not sufficient substitutes for safety-specific controls for explosive hazardous materials.

Source Notes

  • Priority 1 final report was used as the primary authority for incident facts, causes, and recommendations.
  • Priority 3 recommendation status summaries were used only to update recommendation statuses and later agency actions where they did not conflict with the final report.
  • The final report states the incident occurred at magazine A-21 at Waikele Self Storage in Waipahu, Hawaii, on April 8, 2011, at approximately 8:50 am.
  • The final report identifies five fatalities and one minor injury; the project supervisor survived with minor injuries.
  • The final report and supporting transcript describe the incident as an explosion and fire during fireworks disposal/disassembly activities involving seized fireworks.

Similar Incidents

Incidents sharing the same equipment, root causes, or hazard types.

Same Root Cause

Same Hazard

← View in Knowledge Graph