Disaster Prevention and Management: An International Journal

Bright Sparklers fire and explosions: the lessons learned

Ibrahim M. Shaluf, Fakharulrazi Ahmadun, Saari Mustapha, Aini Mat Said, Rashid Sharif,
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Bright Sparklers fire
and explosions: the
lessons learned
Ibrahim M. Shaluf
Fakharul-razi Ahmadun
Sa'ari Mustapha
Aini Mat Said and
Rashid Sharif
The authors
Ibrahim M. Shaluf is a PhD student, Department
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of Chemical and Environmental Engineering,
Fakharul-razi Ahmadun is Head of Department of
Chemical and Environmental Engineering,
Sa'ari Mustapha is Associate Professor, Department
of Chemical and Environmental Engineering,
Aini Mat Said is a Lecturer at the Faculty of Human
Ecology, Rashid Sharif is Head of the Department of
Biology and Agriculture Engineering, all at the University
Putra Malaysia, Selangor, Malaysia.
Keywords
Fire, Disasters, Malaysia, Accidents
Abstract
The fireworks industry is a dangerous business. Many
disasters occur due to manufacturing and use of
fireworks. It has been recorded that there have been 15
disasters resulting from fireworks worldwide. Malaysia
has experienced such tragedies through a fire and
explosion of Bright Sparklers fireworks factory. This paper
summarizes the sequence of events which led to the
Bright Sparkler disaster and proposes some lessons which
could be learned from the experience.
Electronic access
The current issue and full text archive of this journal is
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Disaster Prevention and Management
Volume 11 . Number 3 . 2002 . pp. 214221
# MCB UP Limited . ISSN 0965-3562
DOI 10.1108/09653560210435812
214
Introduction
Many disasters occur in the world from the
dangerous fireworks industry. The disasters
result during manufacturing of fireworks
products, or using of fireworks. The disasters
leave many casualties and high damage losses.
Recently, on 31 December 2001, at 21:37
GMT a tragedy occurred in the capital of
Peru, Lima due to fireworks; at least 282
people died and 134 were injured in the
disaster (BBC News, 2001).
The United Nation Environmental
Program (UNEP) through the developed
APELL's (Awareness and Preparedness
for Emergency and Local Level) (UNEP-
Apell, 2002) database recorded that since
1973 15 man-made disasters had occurred
worldwide due to fireworks. The fatalities
were estimated to be 779 and there were
873 injured. These disasters were as a result
of fireworks factory explosions or just
disasters which were waiting to happen.
The disasters due to the fireworks industry
have been summarised in Table I.
Malaysia experienced a tragedy due to
manufacturing of fireworks when the Bright
Sparklers fireworks factory exploded in 1991.
Immediately a Royal Commission was
appointed by His Majesty to investigate the
causes and the conditions which led to the
disaster. Therefore, the Bright Sparkler's
tragedy has been investigated in detail (Royal
Commission, 1991).
The findings from the inquiry report show
that the company management breached the
statutory regulations and rules of the country
through the installation of the firework factory
on agricultural land, and operating the factory
without manufacturing license, on many
occasions, importing the raw materials
without an authorization or license, storing of
the explosive materials without license, and
exporting the fireworks products without
license.
The relevant authorities which had direct
contact with the activities of the Bright
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
relevant applicable rules and laws.
Consequently, the errors accumulated in an
incubation period estimated to be 16 years,
 Bright Sparklers fire and explosions: the lessons learned Disaster Prevention and Management
Ibrahim M. Shaluf et al. Volume 11 . Number 3 . 2002 . 214221

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
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1974 19/7 India, Allahabad Explosion of rail transport, fireworks 42

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
Ibrahim M. Shaluf et al.
History of Bright Sparklers (sequence of
events)
Figure 2 shows the sequence of events which
led to the Bright Sparklers disaster.
The incident
The Bright Sparklers fireworks factory
was located at Kampong baru, Sungai
Buloh, Selangor Darul Ehsan in an
agriculture area about 30ft away from
a residential area. The factory buildings
were not constructed according to
specifications (the distance between the
buildings was not considered). The
fireworks' raw materials and the finished
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products were stored at the factory.
The fireworks were assembled by hand
and tested in the factory. The main types
of fireworks manufactured by the factory
were hand-held sparklers, Roman candles,
fountains and rockets.
On 7 May 1991 at about 3.45 p.m.
a new product was being tested close to
chemicals which had been dried. It is
believed that fire sparks and smouldering
casing fragments flew in many directions,
some falling on the chemicals, causing a
fire. Some fragments flew towards the
inside of the canteen. At that time, the
canteen contained thousands of finished
and semi-finished products. The fire
spread, causing an explosion, which
caused the rockets to fly everywhere,
spreading the fire to other places and
buildings. There were finished products
and various types of chemicals being stored
in various buildings within the factory
premises; also, it was indicated that there
were two containers loaded with finished
products ready for shipment. The fire
rapidly spread to other buildings, causing a
series of explosions.
The fire and explosion destroyed the entire
factory. In the tragedy, 23 people lost their
lives, in addition, 103 others sustained
injuries of varying degrees of seriousness.
Among the injured was one who was crippled.
Several properties, including residential and
factory buildings surrounding the factory,
were damaged as a result of the fire and
explosions.
The causes of the tragedy are summarized
in Table II.
216
Disaster Prevention and Management
Volume 11 . Number 3 . 2002 . 214221
Discussion
The fireworks industry is a dangerous
business, where the manufacturing of
firework products is imposing a continuous
source of potential hazards and jeopardizing
the lives of employees and surrounding
residents, unless all safety measurers are
considered. Malaysia has experienced such
type of disasters when the Bright Sparklers
factory exploded in 1991.
The Bright Sparklers' tragedy was a result
of an accumulation of errors in a period
estimated to be 16 years. The errors
accumulated due to the breaching of the
statutory regulations, rules, laws and
procedures by the Sparklers Company's
management. Also the errors accumulated
due to lack of communication between the
Police Petaling jaya and the FIDA, due to lack
of understanding of the relevant laws by the
customs department, lack of following-up by
the inspection body, the department of
machineries and factory, and lack of
enforcement of law by the Police Petaling
jaya. The inspection authority did not benefit
from the Bhopal disaster. The company and
the authority failed to learn from the warnings
such as the fire, fire-explosion accidents and
from the complaints. Consequently, fireworks
manufacturing was banned in the country.
Also the use of fireworks occasionally
during religious celebrations and national
occasions could trigger a disaster waiting to
happen. When the triggering event combines
with the unsafe conditions, a disaster results,
e.g. the Peruvian disaster.
Kuala Lumpur shopping centre is one of
the largest commercial centres, filled with
merchandise susceptible to ignition and
spreading of fire. Therefore, the Peruvian and
other lessons should be learned from this; in
addition, all of the safety measures should be
taken during the use of fireworks on occasions
such as festivals, etc.
Conclusion
. The management of the Sparklers
Company and the authorities failed to
learn from the fire and explosion
accidents and from the complaints
``warnings''.
. The Sparklers Bhd. Sd. Company's
management was the main cause behind
 Bright Sparklers fire and explosions: the lessons learned Disaster Prevention and Management
Ibrahim M. Shaluf et al. Volume 11 . Number 3 . 2002 . 214221

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 . 214221

Figure 2
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218
 Bright Sparklers fire and explosions: the lessons learned
Ibrahim M. Shaluf et al.
Figure 2
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the sparkler tragedy through the violation
of the country rules, regulations and laws
and the standard codes.
. The authorities who have direct contact
with the company's activities failed to
enforce the law and to follow-up the
recommended actions.
. The fireworks continuous hazard source
was eliminated in Malaysia, however, the
fireworks hazards still appear occasionally
during celebrations, and national
occasions.
219
Disaster Prevention and Management
Volume 11 . Number 3 . 2002 . 214221
Lessons learned from Bright
Sparklers disaster and international
experience
. Respect and adherence to the country
regulations, laws are obligatory and of
paramount necessity for the
continuation of any organization's
business legally.
. The application of the standard
regulations and specification during
design, installation, manufacturing,
 Bright Sparklers fire and explosions: the lessons learned
Ibrahim M. Shaluf et al.
Table II Summary of causes of the tragedy
Bright Sparklers
Poor organization structure
Poor company's management
Poor planning
Lack of safety management
Poor communications
Poor documents
The management did not comply with the standards
in the design of the buildings
The management did not comply with the Safe
Working place Act
The company did not comply with the statutory
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
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other than sparklers)
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
required and should be followed in order
to meet the minimum safety
requirements.
. Understanding of the regulations, rules,
and enforcement of the law by the
authorities is necessary to control the
country's organizations.
. The following up of the recommended
actions decisions are required from the
organization's management as well as by
the authorities to remedy any error and
prevent the accumulation of errors inside
the organization.
. The warnings such as the near miss,
incident, accident, complaints,
recommendations, constructive critics,
etc. should be investigated deeply and
seriously by the organization's
management at all levels and the relevant
authorities.
. Safety should always given top priority,
during design, construction, and
operation as well as safety training and
improving of culture level.
Disaster Prevention and Management
Volume 11 . Number 3 . 2002 . 214221
Related authorities Warnings Triggering events (immediate causes)
Lack of knowledge Fire accidents Testing of the new products of fireworks
Lack of Fire-explosion in inadequate places near to chemicals
understanding accidents which were being dried
Lack of decision Recommendations Fragments were flying in different directions
Poor communications from the related Storing of finished and semi-finished products
Poor monitoring authorities in canteen
Inspection deficiency Complaints Explosion of canteen
Lack of following up Rockets flying in different directions
Laxity in enforcement Storing of the chemicals finished product in
of the regulations almost every building caused series of
explosions
. The organization's management
and the related authorities should make
sure that the inter-organizational and
intra-organizational communications
flow in the right channels at the right
time.
. The imported fireworks products should
meet the safety standard, therefore, the
quality of the imported fireworks
products should be monitored carefully,
e.g. the USA has a team of inspectors of
the American Fireworks Standards
Laboratory (AFSL) in China to inspect
the fireworks products quality
(maomagazin, 2002).
. The lessons learned from the
Peruvian disaster should be heeded.
Therefore, the handling, storage,
location, and use of fireworks should be
monitored and controlled properly
during the New Year celebration and
national occasions.
. The imported fireworks products'
relevant legislations should be enforced at
all locations. An amendment or review
220
 Bright Sparklers fire and explosions: the lessons learned
Ibrahim M. Shaluf et al.
also is recommended in light of the
lessons learned from the Peruvian
fireworks tragedy, unless all the safety
aspects were considered.
. The authorities that enforce the legislation,
which relates to fireworks products should
be vigilant at all times. It was pointed out
(The Star, 2002) that the Perak Customs
enforcement division in Penskalan Hulu
seized 300 large boxes of banned red
firecrackers worth RM450,000 at the
North Butterworth Cargo Terminal in
Penang. As far as the disasters related to
fireworks are concerned, if the seized
consignment of fireworks was triggered
and combined with unsafe conditions, this
could lead to a disaster.
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221
Disaster Prevention and Management
Volume 11 . Number 3 . 2002 . 214221
References
BBC News (2001), ``Peru fire toll `could top 300'``,
31 December, available at: http://news.bbc.co.uk/hi/
english/world/americans/newsid.
Kletz, T. (1974), ``Hazard and operability studies'',
Chemical Engineering, Vol. 92 No. 7, pp. 48-68.
Royal Commission (1991), Enquiry of the Fire
and Explosions at the Bright Sparklers Sdn.
Bhd. Factory at Kampong Baru Sungai Buloh,
Selangor Darul Ehsan on 7 May 1991,
Malaysia.
(The) Star (2002), ``Firecrackers worth RM450,000 seized'',
No. 11544, 23 January, PP. 1641/3/2002, Malaysia,
p. 18.
UNEP-APELL (2002), ``Disasters database'', January,
available at: www.unepie.org/pc/apell/disasters/
lists/disasterdate.html
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