在今天要考虑的最终报告中，美国化学安全委员会（CSB）说，爆炸和大火在2011年在夏威夷的烟花处置行动中杀死了五名工人，这是由于不安全的处置惯例而导致的。政府承包商选择和监督的安全要求不足；以及缺乏烟花处置的国家准则，标准和法规。
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.
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的调查员阿曼达·约翰逊（Amanda Johnson）表示：“ DEI被授予VSE的分包合同，因为它是一家本地公司，已经在山坡设施中存放了被清除的烟花，其提议是最低的成本，被认为是最耗时的。但是，VSE并没有意识到，尽管Dei具有军械背景，但该公司没有烟花处置的经验。”该报告发现，美国财政部的合同法规没有对VSE征收足够的要求，以选择和监督分包商来处理危险材料。
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.
该公司得出结论d 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.
调查员约翰逊说：“拆卸烟花是处理过程的重大变化。良好的过程安全实践将要求进行彻底的危害分析，并对拟议变更的潜在安全影响进行全面审查。”
2011年4月8日上午，五名DEI员工在杂志外面的帐篷下拆开了一英寸的烟火管，称为“天空节”。第六名工人正在清理并组织物品。DEI工人使用各种工具切割了烟花管，并将空中壳和黑色粉末分开。CSB计算出，将如此大量的这些爆炸性材料组合在盒子内部，将爆炸危险增加了450倍以上。
CSB还发现缺乏针对烟花处置的法规或行业标准。该报告发现，没有建立安全要求的联邦，州或地方法规或行业标准，提供有关处置烟火的正确方法的指南，或解决与烟花汇合以及爆炸性烟火组件的积累相关的危害。
该报告指出，OSHA的流程安全管理（PSM）标准适用于烟花制造，但不适用于烟花处理工作。如果应用标准，DEI将被要求对更改烟花处置过程时涉及的潜在危害进行安全审查。调查确定：“ DEI将从过程安全管理（PSM）的原理和固有安全性的概念中受益匪浅”，其中不积累大量高度爆炸性的黑色粉末和空中壳，同时等待处置。调查人员发现，一个促成因素是，关于被清除的烟花中高度爆炸性化合物的数据没有提供给DEI，并且根据处置合同不需要，并且所涉及的公司没有将烟花视为具有最高危险危险的烟花。。
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.
该报告草案向将分包合同授予DEI的VSE公司提出了建议，以利用专家进行承包商选择和对涉及爆炸性危险材料的未来合同的监督。该报告还建议，国家消防协会（NFPA）开发了国家最佳实践，以安全处理与环境要求一致的废物烟花。
此外,该报告建议,美国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.
尽管没有国家统计数据，但CSB的调查人员从全国各地的官员那里了解到，许多地方机构本身都承担了处置抢夺烟花的任务，因为将工作签约与拥有必要许可证的公司签约过于耗时且昂贵。
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.”
