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Bright Sparklers fire and explosions: The lessons learned

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DOI: 10.1108/09653560210435812

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 Disaster Prevention and Management: An International Journal
Bright Sparklers fire and explosions: the lessons learned
Ibrahim M. ShalufFakharul-razi AhmadunSa’ari MustaphaAini Mat SaidRashid Sharif
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Ibrahim M. ShalufFakharul-razi AhmadunSa’ari MustaphaAini Mat SaidRashid Sharif, (2002),"Bright Sparklers fire and
explosions: the lessons learned", Disaster Prevention and Management: An International Journal, Vol. 11 Iss 3 pp. 214 - 221
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 Introduction
Bright Sparklers fire Many disasters occur in the world from the
and explosions: the dangerous fireworks industry. The disasters
lessons learned result during manufacturing of fireworks
products, or using of fireworks. The disasters
leave many casualties and high damage losses.
Ibrahim M. Shaluf
Recently, on 31 December 2001, at 21:37
Fakharul-razi Ahmadun GMT a tragedy occurred in the capital of
Sa'ari Mustapha Peru, Lima due to fireworks; at least 282
people died and 134 were injured in the
Aini Mat Said and disaster (BBC News, 2001).
Rashid Sharif The United Nation Environmental
Program (UNEP) through the developed
APELL's (Awareness and Preparedness
for Emergency and Local Level) (UNEP-
The authors Apell, 2002) database recorded that since
1973 15 man-made disasters had occurred
Ibrahim M. Shaluf is a PhD student, Department
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worldwide due to fireworks. The fatalities

of Chemical and Environmental Engineering,
were estimated to be 779 and there were
Fakharul-razi Ahmadun is Head of Department of
873 injured. These disasters were as a result
Chemical and Environmental Engineering,
of fireworks factory explosions or just
Sa'ari Mustapha is Associate Professor, Department
disasters which were waiting to happen.
of Chemical and Environmental Engineering,
The disasters due to the fireworks industry
Aini Mat Said is a Lecturer at the Faculty of Human
have been summarised in Table I.
Ecology, Rashid Sharif is Head of the Department of
Malaysia experienced a tragedy due to
Biology and Agriculture Engineering, all at the University
manufacturing of fireworks when the Bright
Putra Malaysia, Selangor, Malaysia.
Sparklers fireworks factory exploded in 1991.
Immediately a Royal Commission was
Keywords
appointed by His Majesty to investigate the
Fire, Disasters, Malaysia, Accidents causes and the conditions which led to the
disaster. Therefore, the Bright Sparkler's
Abstract tragedy has been investigated in detail (Royal
The fireworks industry is a dangerous business. Many
Commission, 1991).
disasters occur due to manufacturing and use of
The findings from the inquiry report show
fireworks. It has been recorded that there have been 15
that the company management breached the
disasters resulting from fireworks worldwide. Malaysia statutory regulations and rules of the country
has experienced such tragedies through a fire and through the installation of the firework factory
explosion of Bright Sparklers fireworks factory. This paper on agricultural land, and operating the factory
summarizes the sequence of events which led to the without manufacturing license, on many
Bright Sparkler disaster and proposes some lessons which occasions, importing the raw materials
could be learned from the experience. without an authorization or license, storing of
the explosive materials without license, and
exporting the fireworks products without
Electronic access
license.
The current issue and full text archive of this journal is The relevant authorities which had direct
available at contact with the activities of the Bright
http://www.emeraldinsight.com/0965-3562.htm Sparkler's Company partially carried out their
job correctly. They did not enforce the
relevant laws and the following-up of their
decisions and recommendations properly.
This was due to the poor communications
and lack of properly understanding of the
Disaster Prevention and Management
relevant applicable rules and laws.
Volume 11 . Number 3 . 2002 . pp. 214±221
# MCB UP Limited . ISSN 0965-3562 Consequently, the errors accumulated in an
DOI 10.1108/09653560210435812 incubation period estimated to be 16 years,
214
 Bright Sparklers fire and explosions: the lessons learned Disaster Prevention and Management
Ibrahim M. Shaluf et al. Volume 11 . Number 3 . 2002 . 214±221

Table I Disasters due to the fireworks industry

Number of
Year Date Location Accident Deaths Injured

2001 31/12 Lima, Peru Fireworks spark, fire 282 134

1998 24/01 China, Peking Road accident, explosion, fireworks 40 100
1994 4/1 India, Madhyapradish Explosion, fire crackers 30 100
1993 25/11 China, Dulin Explosion, fireworks 26 ±
1993 29/8 China, Nanshankon Explosion, fireworks 27 2
1992 20/6 Libya, Alssawani Explosion at factory, fireworks 17 143
1992 25/1 India, Tharia Explosion, fire, fireworks >25 100
1991 1 India, Lhudiana Market, fireworks >40 ±
1991 12/7 India, Meenampalti Explosion, firework factory 38 ±
1991 4/5 Kuala Lumpur, Malaysia Explosion, fireworks 41 61
1989 19/1 China, Henan Explosion, fireworks 27 22
1988 11/12 Mexico, Mexico city Explosion, fireworks 62 87
1979 12/4 Pakistan, Rawalpindi Explosion, fireworks >30 100
1974 19/7 India, Allahabad Explosion of rail transport, fireworks 42 ±
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1973 29/8 Indonesia, Jakarta Fire, explosion 52 24

Source: UNEP-Apell (2002)

since the inception of the company until the the tragedy based on the findings from the
date of the triggering of the tragedy. In the inquiry report. Finally, the paper proposes
tragedy, 23 people lost their lives, 103 were some lessons which could be learned from
seriously injured and the entire factory was Bright Sparkler's disaster, and international
destroyed. experience.
Although the old proverb said that ``every
dog is allowed one bite'' (Kletz, 1974), which
is not applicable in high risk technology,
Bright Sparklers related governmental
however, the company's management and the
organizations
related authorities failed to learn from all the
warnings which allowed the errors to Figure 1 shows Bright Sparklers, and the
accumulate to produce the fatal bite ± ``the organizations (authorities) which had direct
tragedy''. and/or indirect authority to monitor and
Therefore, a decision was made not to allow
control the activities of the Bright Sparkler's
the installing of any fireworks factory in
Sdn. Bhd. Company.
Malaysia.
The continued source of the potential Figure 1 The Bright Sparklers Sdn Bhd. Company and the authorities
hazards due to fireworks manufacturing has which monitor and control the company
been eliminated in Malaysia, however, the
discrete points of hazards appear
occasionally every year during the new year
celebration, and other occasions. Therefore,
the safety standards, and the quality of the
products, storage, handling, location, and
use of these fireworks should be monitored
and controlled carefully, otherwise the
shadow of the Peruvian tragedy could be
repeated whenever the conditions are
available.
This paper summarizes the history of the
company, the governmental organizations
which were monitoring and controlling the
activities of the Bright Sparklers Company. In
addition, the paper summarizes the causes of
215
 Bright Sparklers fire and explosions: the lessons learned Disaster Prevention and Management
Ibrahim M. Shaluf et al. Volume 11 . Number 3 . 2002 . 214±221

History of Bright Sparklers (sequence of Discussion

events)
The fireworks industry is a dangerous
Figure 2 shows the sequence of events which business, where the manufacturing of
led to the Bright Sparklers disaster. firework products is imposing a continuous
source of potential hazards and jeopardizing
the lives of employees and surrounding
The incident residents, unless all safety measurers are
considered. Malaysia has experienced such
The Bright Sparklers fireworks factory type of disasters when the Bright Sparklers
was located at Kampong baru, Sungai factory exploded in 1991.
Buloh, Selangor Darul Ehsan in an The Bright Sparklers' tragedy was a result
agriculture area about 30ft away from of an accumulation of errors in a period
a residential area. The factory buildings estimated to be 16 years. The errors
were not constructed according to accumulated due to the breaching of the
specifications (the distance between the statutory regulations, rules, laws and
buildings was not considered). The procedures by the Sparklers Company's
fireworks' raw materials and the finished management. Also the errors accumulated
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products were stored at the factory. due to lack of communication between the
The fireworks were assembled by hand Police Petaling jaya and the FIDA, due to lack
and tested in the factory. The main types of understanding of the relevant laws by the
of fireworks manufactured by the factory customs department, lack of following-up by
were hand-held sparklers, Roman candles, the inspection body, the department of
fountains and rockets. machineries and factory, and lack of
On 7 May 1991 at about 3.45 p.m. enforcement of law by the Police Petaling
a new product was being tested close to jaya. The inspection authority did not benefit
chemicals which had been dried. It is from the Bhopal disaster. The company and
believed that fire sparks and smouldering the authority failed to learn from the warnings
casing fragments flew in many directions, such as the fire, fire-explosion accidents and
some falling on the chemicals, causing a from the complaints. Consequently, fireworks
fire. Some fragments flew towards the manufacturing was banned in the country.
inside of the canteen. At that time, the Also the use of fireworks occasionally
canteen contained thousands of finished during religious celebrations and national
and semi-finished products. The fire occasions could trigger a disaster waiting to
spread, causing an explosion, which happen. When the triggering event combines
caused the rockets to fly everywhere, with the unsafe conditions, a disaster results,
spreading the fire to other places and e.g. the Peruvian disaster.
buildings. There were finished products Kuala Lumpur shopping centre is one of
and various types of chemicals being stored the largest commercial centres, filled with
in various buildings within the factory merchandise susceptible to ignition and
premises; also, it was indicated that there spreading of fire. Therefore, the Peruvian and
were two containers loaded with finished other lessons should be learned from this; in
products ready for shipment. The fire addition, all of the safety measures should be
rapidly spread to other buildings, causing a taken during the use of fireworks on occasions
series of explosions. such as festivals, etc.
The fire and explosion destroyed the entire
factory. In the tragedy, 23 people lost their
lives, in addition, 103 others sustained Conclusion
injuries of varying degrees of seriousness.
Among the injured was one who was crippled. . The management of the Sparklers
Several properties, including residential and Company and the authorities failed to
factory buildings surrounding the factory, learn from the fire and explosion
were damaged as a result of the fire and accidents and from the complaints
explosions. ``warnings''.
The causes of the tragedy are summarized . The Sparklers Bhd. Sd. Company's
in Table II. management was the main cause behind
216
 Bright Sparklers fire and explosions: the lessons learned Disaster Prevention and Management
Ibrahim M. Shaluf et al. Volume 11 . Number 3 . 2002 . 214±221

Figure 2 Flow chart summarizes the sequence of events that led to the Bright Sparklers disaster
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217
 Bright Sparklers fire and explosions: the lessons learned Disaster Prevention and Management
Ibrahim M. Shaluf et al. Volume 11 . Number 3 . 2002 . 214±221

Figure 2
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218
 Bright Sparklers fire and explosions: the lessons learned Disaster Prevention and Management
Ibrahim M. Shaluf et al. Volume 11 . Number 3 . 2002 . 214±221

Figure 2
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the sparkler tragedy through the violation Lessons learned from Bright
of the country rules, regulations and laws Sparklers disaster and international
and the standard codes. experience
. The authorities who have direct contact
with the company's activities failed to . Respect and adherence to the country
enforce the law and to follow-up the regulations, laws are obligatory and of
recommended actions. paramount necessity for the
. The fireworks continuous hazard source continuation of any organization's
was eliminated in Malaysia, however, the business legally.
fireworks hazards still appear occasionally . The application of the standard
during celebrations, and national regulations and specification during
occasions. design, installation, manufacturing,
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 Bright Sparklers fire and explosions: the lessons learned Disaster Prevention and Management
Ibrahim M. Shaluf et al. Volume 11 . Number 3 . 2002 . 214±221

Table II Summary of causes of the tragedy

Bright Sparklers Related authorities Warnings Triggering events (immediate causes)
Poor organization structure Lack of knowledge Fire accidents Testing of the new products of fireworks
Poor company's management Lack of Fire-explosion in inadequate places near to chemicals
Poor planning understanding accidents which were being dried
Lack of safety management Lack of decision Recommendations Fragments were flying in different directions
Poor communications Poor communications from the related Storing of finished and semi-finished products
Poor documents Poor monitoring authorities in canteen
The management did not comply with the standards Inspection deficiency Complaints Explosion of canteen
in the design of the buildings Lack of following up Rockets flying in different directions
The management did not comply with the Safe Laxity in enforcement Storing of the chemicals finished product in
Working place Act of the regulations almost every building caused series of
The company did not comply with the statutory explosions
regulation of National Land use
The company did not comply in many times with the
statutory manufacturing regulations (operating the
factory without license and manufacturing products
other than sparklers)
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The company did not comply with the statutory

regulations of Explosive Act 1957 in the importing
of the raw materials, manufacturing, storing of
explosives, removing the products and exporting
of the products
The company did not comply with the statutory
regulations for the storing of explosive materials
Poor testing of new products
Poor quality control inspection
Lack of safety training
Lack of safety culture

operation, testing, maintaining etc. are . The organization's management

required and should be followed in order and the related authorities should make
to meet the minimum safety sure that the inter-organizational and
requirements. intra-organizational communications
. Understanding of the regulations, rules, flow in the right channels at the right
and enforcement of the law by the time.
authorities is necessary to control the . The imported fireworks products should
country's organizations. meet the safety standard, therefore, the
. The following up of the recommended quality of the imported fireworks
actions ± decisions are required from the products should be monitored carefully,
organization's management as well as by e.g. the USA has a team of inspectors of
the authorities to remedy any error and the American Fireworks Standards
prevent the accumulation of errors inside Laboratory (AFSL) in China to inspect
the organization. the fireworks products quality
. The warnings such as the near miss, (maomagazin, 2002).
incident, accident, complaints, . The lessons learned from the
recommendations, constructive critics, Peruvian disaster should be heeded.
etc. should be investigated deeply and Therefore, the handling, storage,
seriously by the organization's location, and use of fireworks should be
management at all levels and the relevant monitored and controlled properly
authorities. during the New Year celebration and
. Safety should always given top priority, national occasions.
during design, construction, and . The imported fireworks products'
operation as well as safety training and relevant legislations should be enforced at
improving of culture level. all locations. An amendment or review
220
 Bright Sparklers fire and explosions: the lessons learned Disaster Prevention and Management
Ibrahim M. Shaluf et al. Volume 11 . Number 3 . 2002 . 214±221

also is recommended in light of the References

lessons learned from the Peruvian
fireworks tragedy, unless all the safety BBC News (2001), ``Peru fire toll `could top 300'``,
aspects were considered. 31 December, available at: http://news.bbc.co.uk/hi/
. The authorities that enforce the legislation, english/world/americans/newsid.
Kletz, T. (1974), ``Hazard and operability studies'',
which relates to fireworks products should
Chemical Engineering, Vol. 92 No. 7, pp. 48-68.
be vigilant at all times. It was pointed out
Royal Commission (1991), Enquiry of the Fire
(The Star, 2002) that the Perak Customs
and Explosions at the Bright Sparklers Sdn.
enforcement division in Penskalan Hulu Bhd. Factory at Kampong Baru Sungai Buloh,
seized 300 large boxes of banned red Selangor Darul Ehsan on 7 May 1991,
firecrackers worth RM450,000 at the Malaysia.
North Butterworth Cargo Terminal in (The) Star (2002), ``Firecrackers worth RM450,000 seized'',
Penang. As far as the disasters related to No. 11544, 23 January, PP. 1641/3/2002, Malaysia,
fireworks are concerned, if the seized p. 18.
consignment of fireworks was triggered UNEP-APELL (2002), ``Disasters database'', January,
and combined with unsafe conditions, this available at: www.unepie.org/pc/apell/disasters/
could lead to a disaster. lists/disasterdate.html
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221
 This article has been cited by:

1. M.S. Aini, A. Fakhru’l-Razi. 2013. Latent errors of socio-technical disasters: A Malaysian case study. Safety Science 51:1,
284-292. [CrossRef]
2. Hayati Mohd Dahan, Noryati Ahmad, Catherine S F Ho. 2010. Crisis Management at Taman Negara National Park, Kuala
Tahan, Pahang, Malaysia. International Journal of Trade, Economics and Finance 1:1, 24-27. [CrossRef]
3. M.S. Aini, A. Fakhru'l‐Razi. 2009. Issues and lessons from fire inquiry tribunals. Disaster Prevention and Management: An
International Journal 18:4, 434-442. [Abstract] [Full Text] [PDF]
4. Ibrahim Mohamed Shaluf, Fakhru'l‐Razi Ahmadun. 2006. Disaster types in Malaysia: an overview. Disaster Prevention and
Management: An International Journal 15:2, 286-298. [Abstract] [Full Text] [PDF]
5. Ibrahim M Shaluf, Fakhru’l-Razi Ahmadun, Abdul Rashid Shariff. 2003. Technological disaster factors. Journal of Loss
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