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Donaldson Enterprises, Inc. Fatal Fireworks Disassembly Explosion and Fire
FINAL REPORT: Donaldson Enterprises Inc
Location: Waipahu, HI
Accident Occurred On: 04/08/2011
Final Report Released On: 01/17/2013
Accident Type: Reactive Incident
Company Name: Donaldson Enterprises

statistics

Total # of Recommendations
12
Total # of Open Recommendations
9
Total # of Closed Recommendations
3
Total % of Open 75 vs. Closed 25

investigation information

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Accident Description
On April 8, an explosion occurred in a fireworks storage facility near Honolulu, Hawaii. According to media reports, the incident occurred in a bunker used to store confiscated fireworks at Donaldson Enterprises, Inc.
Investigation Status
The CSB's final report was approved by a 3-0 vote at a public meeting in Washington, DC on January 17, 2013.


 

Recommendations

Bureau of Alcohol, Tobacco, Firearms, and Explosives (ATF)
2013-2011-06-I-HI-I-HI-12

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.

Status: Open - Acceptable Response or Alternate Response
Open - Acceptable Response or Alternate Response (O - ARAR) - Response from recipient indicates a planned action that would satisfy the objective of the recommendation when implemented.
 

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Department of Treasury - Office of Procurement Executive (OPE)
2013-2011-06-I-HI-I-HI-2

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 Safety Manual for Ammunition and Explosives, Section C1.5, "Pre-Award Safety Survey."

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

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2013-2011-06-I-HI-I-HI-3

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.

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

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2013-2011-06-I-HI-I-HI-4

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.

Status: Open - Acceptable Response or Alternate Response
Open - Acceptable Response or Alternate Response (O - ARAR) - Response from recipient indicates a planned action that would satisfy the objective of the recommendation when implemented.
 

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Environmental Protection Agency (EPA)
2013-2011-06-I-HI-I-HI-9

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 CFR §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 CFR §1910.119 (e.g., hazard analysis and control, management of change).

Status: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

2013-2011-06-I-HI-I-HI-10

Until recommendation 2011-06-I-HI-R9 can be implemented, develop and issue a policy guidance document to provide a regulatory process with rigorous safety reviews to replace the use of emergency permits under 40 CFR §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 CFR §1910.119 (e.g., hazard analysis and control, management of change). Ensure its effective communication to all EPA regional administrators, state environmental agencies, and organizations within the fireworks industry

Status: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

2013-2011-06-I-HI-I-HI-11

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. Status

Status: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

Federal Acquisition Regulatory (FAR) Council
2013-2011-06-I-HI-I-HI-1

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.

Status: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

National Fire Protection Association (NFPA)
2013-2011-06-I-HI-I-HI-7

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.

Status: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

2013-2011-06-I-HI-I-HI-8

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

Status: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

Treasury Executive Office for Asset Forfeiture (TEOF)
2013-2011-06-I-HI-I-HI-5

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.

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

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VSE Corporation
2013-2011-06-I-HI-I-HI-6

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. Status:

Status: Open - Unacceptable Response
Open - Unacceptable Response (O - UR) - Recipient responds by expressing disagreement with the need outlined in the recommendation. The Board believes, however, that there is enough supporting evidence to ask the recipient to reconsider.
 

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