A CASE STUDY
Bray Park -- Brisbane
-- Australia
Fatal Fireworks Explosion
2000 -- Queensland Department of Mines and Energy reports of a serious
fireworks incident on 20 May 2000, resulting in a fatality and a number of spectators
being critically or seriously injured.
The incident occurred when a roman
candle type firework (ground display fireworks) apparently detonated on ignition inside a
steel supporting tube. Fragments of the steel tube were projected into the spectator area
with tragic consequences.
-- The accident, which happened in Australia last year, was caused by the
explosion of three roman candles which were in steel tubes. The explosion shattered the
tubes sending high-speed steel fragments into the crowd. Allen
Webb of HSE's Explosives Inspectorate says: "It should always be assumed that
fireworks can misfire, and, in the worst case, explode. The problem with support tubes, as
demonstrated by this tragic incident, is that they can confine the firework and,
therefore, increase the severity of a misfire."
Fireworks tragedy raises safety
concerns
Transcript from a radio broadcast.
2000 -- In Queensland investigations are continuing into a fireworks accident in
which an 11-year-old girl died and many other people were injured. The incident happened
on Friday night in a suburb north of Brisbane. As John Taylor reports, the tragedy has
raised concerns about the safety of fireworks displays in Queensland.
JOHN TAYLOR: It should have been a happy occasion. Hundreds of people spending a Saturday
night watching a fireworks show at the Holy Spirit Primary School fete on Brisbane's
outskirts. Instead it ended up like a war zone when a steel mortar shell exploded.
TOM BRAME: There was one person deceased and two people were very seriously injured and
about another seven people have received minor injuries and have been treated at different
hospitals around the city.
JOHN TAYLOR: Police Inspector, Tom Brame. The crowd was more than 50 metres away from the
display but, when the explosion occurred, shrapnel flew as far as 200 metres.
UNIDENTIFIED: So I jumped up and ran to her, and her head had been opened up. And I just
sat down and sort of held her head together until the ambulance came.
JOHN TAYLOR: Before the explosion, a safety inspector had checked the display to ensure it
was legal and licensed. An investigation involving police and Mines and Energy explosives
experts is now under way and will hand down a report to a coronial inquest.
The man who sold fireworks to the operator responsible for the weekend display says safety
guidelines appear to have been ignored. Chris Bennett is from Acme Fireworks.
CHRIS BENNETT: It was put in thick steel mortar tubes which I mean I even told these guys
last week don't use steel mortar tubes.
JOHN TAYLOR: Queensland's major fireworks operators are rallying in Brisbane today to call
for changes to the law. Clive Featherby from KC Fireworks says the industry is in crisis.
Mr Featherby says there are thousands of operators who have only completed a three-day
training course which he says isn't enough.
CLIVE FEATHERBY: We've got a couple of thousand fireworks operators running around with
two inspectors in the south-east Queensland region trying to keep tabs on the lot. And
they haven't got a hope in hell of keeping tabs on all that lot.
JOHN TAYLOR: Was this an accident waiting to happen?
CLIVE FEATHERBY: We've all, the major players in the fireworks industry have been
contacting the Mines Department on a very regular basis for the last 18 months, and we've
been writing everything else, saying they should rescind all these three-day licences and
the other licences that have been issued on short-term notice. And we've all been ignored
and unfortunately, this is what happened.
JOHN TAYLOR: The State Mines and Energy Minister, Tony McGrady, has announced an immediate
interim ban on the use of metal equipment in fireworks displays. He also wants operators
with information about the weekend explosion to contact police.
TONY McGRADY: The Queensland legislation is regarded by many people as being the toughest
in the Commonwealth. All the conditions which we impose are based on Australian standards
and there's current debate taking place now about further measures and we've involved the
industry with this.
But what I'm saying is that people who are running to the media now, some of them have
vested interests and I don't believe I should involve myself in a public debates with
these people until after the Coroner has handed down his decision.
Bray Park -- Brisbane
School fireworks display
One dead seven injured
-- Friends of an 11-year-old are today coming to terms with her tragic death
at a school fireworks display.
The accident also left seven others
injured including an amputee from the person who was running the fireworks.
It's believed the accident happened
when a steel mortar tube which held a roman candle firework exploded sending metal
fragments flying.
A witness to the tragedy says he saw
the fireworks set up on a tripod which was wobbling from side to side.
Brisbane tragedy prompts fireworks review
Transcript 22/5/2000
KERRY O'BRIEN: Celebrations and pyrotechnics have
always gone hand in hand and for schools around the nation, firework nights have become an
important part of the fund-raising tradition.
But celebration turned to tragedy over the weekend
at a primary school fete in Brisbane's northern suburbs.
An 11-year-old girl was killed and seven others
injured after a blast sent metal fragments flying into a crowd gathered to watch a
fireworks display.
Questions are now being asked about the ease with
which people can obtain a licence to operate pyrotechnics.
Concerns have also been raised about the use of
metal tubes to house fireworks.
Today, members of the pyrotechnic industry in
Queensland formed their first ever representative body to try to raise standards in the
profession.
Tracey Bowden reports.
CROWD: Five, four, three, two, one -- .
TRACEY BOWDEN: Spectacular occasions like this are
what fireworks are made for.
A slightly scaled-down version was supposed to be
the highlight of the Holy Spirit Primary School fete at Bray Park in Brisbane's northern
suburbs, but things went terribly wrong.
NEWSREEL: Witnesses say there was a boom and a flash
of white light.
TRACEY BOWDEN: 11-year-old Dominique Baxendell died
in the accident.
Four people remain in hospital, one patient
dangerously ill.
CHRIS BENNETT, ACME FIREWORKS: A two-inch Roman
candle was placed in a steel mortar tube to secure it and the candle malfunctioned and the
steel mortar tube blew apart and the shrapnel caused the injuries.
TRACEY BOWDEN: Chris Bennett has owned Acme
Fireworks for four years. He sold Graham Stratford the fireworks to be used at the fete.
Chris insists Graham had the appropriate licence for what he said he was planning, a
ground level fireworks display.
How did you feel about their level of experience?
CHRIS BENNETT: Well, they weren't like really
experienced operators, but um, you know, they didn't seem to be very experienced
operators.
TRACEY BOWDEN: Did that bother you at all?
Um, no, well, it does all the time, yes. I mean,
they didn't have a copy of the regulations or the standards, so I gave them a copy of
that, as well.
TRACEY BOWDEN: Did that ring alarm bells when they
didn't have a copy of that?
CHRIS BENNETT: Yeah, it did concern us a little bit,
yeah.
ROBERT STEVENSON, ACE FIREWORKS: He certainly had
aerial shells in his bag and he isn't licensed -- definitely -- for that aerial shell
fireworks.
TRACEY BOWDEN: Robert Stevenson owns Ace Fireworks.
We're told he trained Graham Stratford and asked that an inspector from the Department of
Mines be present at the fireworks display.
ROBERT STEVENSON: Because I knew that Graham
Stratford was inexperienced and the other chap helping him didn't have a licence at all
and I knew what they were letting off. It certainly was dangerous in a small area like
that.
TRACEY BOWDEN: What is still unclear is whether
appropriate safety procedures were followed on the night.
The Australian standards regarding the use of
explosives includes: Burial and mortars in the ground to an appropriate depth, placement
of sandbags around mortars to an appropriate height, and placement of mortars in metal or
wooden racks, or placement of mortars behind a barrier or wall shown by witness tests to
be resistant to fragments generated by explosion.
CHRIS BENNETT: This is a plastic mortar tube, really
what's preferred to be used.
TRACEY BOWDEN: And the firework is inside it?
CHRIS BENNETT: That's right.
TRACEY BOWDEN: Now, what did Graham buy?
CHRIS BENNETT: He used the steel mortar tube. And
the firework malfunctioned and it shattered and threw steel everywhere.
TRACEY BOWDEN: What difference would it have made if
it had been a plastic tube?
CHRIS BENNETT: I think it would have greatly reduced
the hazard if a plastic mortar tube was used.
TRACEY BOWDEN: The accident has prompted the
Queensland Government to place a ban on the use of metal fittings and accessories with
fireworks, but it's also prompted claims that it's simply too easy to get a licence and
join this lucrative industry.
RICHARD LOWE, SPECTACULAR FIREWORKS: Well, for the
current licences that are in place, I think it's two days of theory, one day of practice,
which I don't think is a full day of practice anyway, and basically that's it, you've got
your licence.
You pay your money -- whereas when I went for my
licence it was minimum, well it was mandatory, the 12 months training with a licensed
pyrotechnician TRACEY BOWDEN: As police investigations continue the state Minister for
Mines and Energy Tony McGrady won't speculate about possible changes to legislation
governing fireworks.
TONY McGRADY, QLD MINES & ENERGY MINISTER: I
don't believe there's any benefit at all in having this public debate now. We're asking
people to come forward, give their evidence and let the coroner come down with his
decision.
Let me say this to the people of Queensland, that
whatever the coroner comes down with, our Government will accept it lock, stock and
barrel.
TRACEY BOWDEN: Meanwhile, after talks with the
minister, the fire workers industry, for the first time in its history, has formed a
representative group with hastily-appointed spokesperson, Sue Riedel.
SUE RIEDEL, INDUSTRY SPOKESPERSON: I would like to
see stricter regulations on licensing, also, on people actually forming firework display
companies. There is no regulation on this at this stage.
TRACEY BOWDEN: If you could have your time again, do
you wish you'd done anything differently or not?
CHRIS BENNETT: Well, I have looked over that and we
do test everything we import. We pretty much do as much as we can.
I honestly think if I went over it again I would
have done exactly the same thing. You sort of try and think of other ways you could have
stopped it, but yeah.
KERRY O'BRIEN: Well, I guess the message is there
for all of us about the risks of fireworks, but what a terrible cost was paid for it.
Investigation --
Report
1 Dead -- 12 Injured
-- The Incident: An explosion occurred during a fireworks display held
at a fete at the Holy Spirit Primary School, Sparkes Road, Bray Park at 19:47 hours on
Saturday 20 May 2000. Three 2" Roman candles exploded and the steel tubes holding
these Roman candles fragmented causing one fatality and resulting in seven people
receiving serious injuries. An 11-year-old grade 7 student at the Holy Spirit Primary
School, received fatal injuries. People receiving serious injuries included the following:
A 36 year old received extensive loss of frontal lobe of forehead and brain,
loss of one eye, deep laceration on the left side of her face from brow to jaw and other
injuries; A 38 year old received a traumatic amputation of lower right leg; A
12 year old received a partial amputation of right foot; A 10 year old received deep
lacerations to upper thigh adjacent groin area; A 16 year old received minor
lacerations to left arm, bruising to chest, and hole in arm from shrapnel; A 14 year old
received a cut to right foot requiring stitching; and A 43 year old received perforated
right eardrum. Scope: The Explosives Inspectorate was given
directions by the Coroner to conduct an investigation into the explosives incident. This
investigation was separate from and in addition to the Police investigation. The scope of
the investigation was to determine the nature and cause of the incident and to recommend
ways to prevent a similar explosives incident from happening again. In addition, other
issues to be addressed included a review of training activities, competency of the
fireworks industry, use of metal hardware in connection with fireworks displays, the
adequacy of resources for the Explosives Inspectorate and appropriate insurance for
fireworks displays. An investigation team was formed to investigate the explosives
incident. Details of the Event: The explosion occurred when
the fireworks display had been underway for approximately one minute and fifty seconds.
Before the explosion occurred, a man had lit the fuse of one 2" 8 shot white
tail Roman candle in tube A as shown below and then lit a second 2" 8 shot white tail
Roman candle 3.6 metres away. The first comet of the 2" 8 shot white tail Roman
candle in tube A functioned normally. Three seconds later the explosion occurred. The
explosion was described by a witness as `extremely loud and intense and created a powerful
shock wave'. Nature and Cause: The Roman candles in twin tube
steel fireworks stands involved in the explosion at the scene are shown below. The
three 2" Roman candles in tubes A, B and C exploded. These Roman candles were the two
2" 8 shot white tail Roman candles in the twin tube steel fireworks stand (tubes A
and B) and one 2" 5 shot gold tail Roman candle (tube C) in a twin tube steel
fireworks stand 900mm away from the other Roman candles. Each firework stand
consisted of a base plate with two steel tubes 500mm long, 76mm outside diameter and 3.6mm
wall thickness welded to the base plate. The Roman candles were a close fit inside
the steel tubes.
Page 2
Investigation Report: Bray Park Fireworks Tragedy 20 May, 2000 A 2" 8
shot White Tail Roman Candle, B2" 8 shot White Tail Roman Candle, C2" 5
shot Gold Tail Roman Candle, D1" 8 shot Cracker Tail Roman Candle, Figure ES 1:
Configuration of Roman candle fireworks in twin tube steel fireworks stands. The
energy released from the three exploding Roman candles fragmented the three steel tubes in
which they were standing. Some of these steel fragments caused serious bodily injury
and one fragment from tube B identified as Police Exhibit No: 119 struck Dominique Maree
Baxendell. Fragments of various sizes were found at various distances up to approximately
175 meters from the blast centre. Fragments were found in the fireworks display area,
spectator-viewing locations on the school oval, outside the barricaded-off safety zone
area of the display, and the adjoining neighbourhood. Forty-two pieces of steel fragment
were recovered. The investigation has concluded that, in the operation of the 2" 8
shot white tail Roman candle in tube A, the first comet had functioned normally. A three
second delay between the firing of the first and second comets being fired was expected.
The second comet was expected to be expelled from the Roman candle when the explosion
occurred. This Roman candle exploded due to the comet exploding. The comet exploded within
a very short delay after ignition in close proximity to its at rest position in the Roman
candle. The exploding comet caused the remaining unburnt comets and black powder in the
Roman candle to explode en masse. The cause of the comet exploding was due to a physical
feature in the comet, namely the porous and permeable nature of that comet. The porous and
permeable nature of the comet allowed the burning rate of the comet, which is normally a
controlled rate of burn like a cigarette type burn, to accelerate through the porous and
permeable areas leading to an explosion. The exploding Roman candle caused the surrounding
metal tube to expand and fragment, producing high energy steel fragments. The velocity of
the steel fragments from tube A has been estimated to be as high as 400 metres per second
(1440 km/hr). Tube A expanded and impinged or struck the adjacent steel tube (tube B)
approx. 15mm away containing a second Roman candle, causing the tube to be dented inwards.
The dent compressed the contents of the second 2" 8 shot white tail Roman candle,
causing that Roman candle to
Page 3
Investigation Report Bray Park Fireworks Tragedy
20 May, 2000 Page 3 explode en masse, producing steel fragments similar in form and
mass to the first steel tube fragments. The velocity of the steel fragments from tube B
was estimated to be as high as 500 metres per second (1800 km/hr). Both steel tubes in the
fireworks stand had totally fragmented leaving only the base plate remaining. This 12mm
thick steel base plate had been dished about 6mm deep beneath tube A. A fragment or
fragments from the first twin tube steel fireworks stand struck a second twin tube steel
fireworks stand 900mm away containing the 2" 5 shot gold tail Roman candle in tube C.
The point of fragment impact was approximately 200mm from the top of tube C. The 2" 5
shot gold tail Roman candle also exploded en masse. The explosion caused the tube to
partially rupture producing several small fragments and one large fragment, with a steel
collar being a part of this large fragment. Tube D was damaged but was not fragmented.
Trials and Investigation For the investigation under the Explosives Act 1999, the
investigation included management and evaluation of the evidence (video, testamentary and
physical evidence). Interviews were conducted with people connected with the fireworks and
the display. A trial methodology was developed and a trials program was undertaken to
establish nature and cause. This included physical and chemical testing of fireworks,
components and fragments, field trials, performance tests of fireworks, sensitivity
testing, testing fragment behaviour, communication trails, testing features from the life
cycle of fireworks, behaviour of comets and non-destructive testing. Once all information
was obtained on the fireworks and evidence, a trials program was developed and undertaken
using the information gained from what may occur during the life cycle of the Roman
candles to determine why the Roman candles exploded. The key areas of the trials program
included field trials to replicate the explosion observed at the Holy Spirit Primary
School oval. Sometimes simulation techniques were used in the trials to replicate the
explosion. A number of methods were developed to make a Roman candle explode from an
introduced feature. Once a method was established, Roman candles with this feature were
placed into steel firework stands and exploded. The fragmentation was evaluated. The
fragments and the effect on the base plate were very similar to that observed from the
steel stands at the explosives incident. Communication trials using a donor acceptor test
in a twin tube steel firework stand was undertaken. The donor firework, with the
introduced feature to make the Roman candle explode, was placed in tube A of the twin tube
steel firework stand. The Roman candle was from a particular batch of white tail Roman
candles, which in an unmodified state, would not malfunctioning to explosion. A similar
but unmodified Roman candle was also placed in the adjacent tube B of the firework stand.
The donor Roman candle in tube A was ignited. The results of these tests showed that the
Roman candle in the adjacent tube B would also explode as a result of the Roman candle in
tube A exploding. The Roman candle in tube B exploded regardless of the batch of Roman
candles used. Again, the fragments and the effect on the base plate were very similar to
that observed from the steel stands at the explosives incident.
Page 4
Investigation Report Bray Park Fireworks Tragedy
20 May, 2000 Page 4 Trials were then undertaken to evaluate communication of the
explosion from the twin tube firework stand holding the two 2" 8 shot white tail
Roman candle with the firework stand holding the 2" 5 shot gold tail Roman candle
900mm away. Explosives were used to simulate the impact of metal fragments on the steel
tube holding the 2" 5 shot gold tail Roman candle. Trials were undertaken using this
simulation technique of impact from metal fragments due to the low probability of hit at a
certain location on the tube. The results were similar to that observed from the steel
stand containing the 2" 5 shot gold tail Roman candle at the explosives incident. The
trial showed that the 2" 5 shot gold tail Roman candle exploded as a result of impact
from metal fragments. Comets from the batch of 2" 8 shot white tail Roman candles
that exploded were tested. These comets were found to explode under normal ignition while
not contained within the Roman candle. Microscopic examination of the comet showed that
there was a porous and permeable feature within the comet that could lead to the comet
exploding. The features found in these comets were not found in other batches of Roman
candles examined. Trials simulating this feature showed that comets from batches of Roman
candles, which did not exhibit explosive behaviour, exploded on ignition in unconfined
conditions. The trials program was successful in determining the nature and cause of the
explosion of three Roman candles at the Holy Spirit Primary School on 20 May, 2000 and the
subsequent fragmentation of the steel tubes holding those Roman candles. The metallurgical
study by Dr Yeomans found that the failure of the three tubes as a result of the explosion
occurred by a process of ductile fracture accompanied by a high level of absorbed energy
and gross plastic deformation. It is also Dr Yeomans' view that the method and quality of
fabrication of the fireworks stands did not contribute to this failure. The tubes burst
and failed as a result of mechanical overload as a direct consequence of the explosion. Dr
Yeomans also conducted a study on the fragments of the steel tubes from the trials program
and concluded that "the fireworks stands manufactured for the Department of Natural
Resources and Mines' trials program are a fair representation, if not and almost exact
facsimile, of the fireworks stands in use at the time of the fireworks incident at the
Holy Spirit Primary School, Bray Park". Accordingly it can be taken that their
behavior in the trials program is an accurate representation of the failure mechanisms
that operated in the original fireworks stands used at Bray Park. People connected with
the fireworks display or the fireworks themselves were interviewed as a part of the
investigation process. The continuity of the fireworks lifecycle was followed and no known
abnormal events were established to have occurred with the fireworks prior to the display.
Other users of this batch of 2" 8 shot white tail Roman candles were contacted and
three operators reported malfunctions with the 2" 8 shot white tail Roman candles
used before 20 May, 2000. Inspectorate Involvement Inspector Jim Fowler, Inspector of
Explosives, Southern Region was on duty at the Holy Spirit Primary School at the time of
the explosives incident. Inspector Fowler was present at the request of the Chief
Inspector of Explosives, Mr Robert Sheridan following information provided by Mr Robert
Stevenson of ACE Fireworks to the Explosives Inspectorate about Mr Stratford. Inspector
Fowler had carried out inspections on the set-ups of both the ACE Fireworks and the
Stratford fireworks displays. Inspector Fowler stopped Mr Stratford from setting up and
using the aerial fireworks he had prepared for use at the display, as indicated on his
set-up plan and "Firing Orders". Mr Stratford was licensed to use ground display
fireworks
Page 5
Investigation Report Bray Park Fireworks Tragedy
20 May, 2000 Page 5 only and not aerial fireworks. Inspector Fowler had secured but not
formally seized the fireworks for which Mr Stratford was not licensed. Inspector Fowler
had planned to take a statement from Mr Stratford and take possession of the aerial
fireworks after Mr Stratford's display was completed. Inspector Fowler's involvement was
investigated by Inspector John Howe Inspector of Mines (Mechanical), Northern Regional
Office, Mount Isa. His report to the Chief Inspector of Explosives dated 12 July 2000
found that Inspector Fowler had fulfilled the duties expected from an Inspector of
Explosives and had acted in an effective and professional manner in this matter as
required by the Chief Inspector of ExplosivesAccident History. The investigation has found
in June 2001 that 2" Roman candles have been malfunctioning in the United States of
America and Canada. There have been two known explosives incidents at Yeppoon, near
Rockhampton, in January 1999 and at Mount Isa in November 1999 where 2" Roman candles
exploded. In both these incidents wooden stands and not steel tubes were used to support
the Roman candles. Following the investigation of the Yeppoon incident, the Explosives
Inspectorate issued a Safety Alert, which was distributed to all Queensland licensed
fireworks operators and interstate explosives regulatory agencies. An extensive literature
search was conducted on fireworks accidents during the investigation. The Evidence. ACME
Fireworks and ACE Fireworks supplied the fireworks Mr Stratford planned to use at the
display. The 2" Roman candles and the aerial fireworks were supplied by ACME
Fireworks. Photographs have been taken and plans and drawings have been produced by the
Police and the Department of Natural Resources and Mines Investigation Team regarding the
evidence and any matters arising with the investigation. Studies Post Blast Analysis
Two post-blast studies have been undertaken, one a post blast study co-ordinated through
Unisearch, the business arm of the University of New South Wales through the Australian
Defence Force Academy and another study by Dr David Kennedy of Orica Explosives. The
theoretical studies closely matched the observed results of fragmentation resulting from
the 2" Roman candles exploding at Bray Park and also results obtained from the trials
program. The Unisearch study concluded thatthe computer modelling, supported by a
metallurgy and chemical modelling study and data provided by the client, predicts that a
Roman candle has sufficient energy, if it explodes for whatever reason, to rupture a thin
walled tube and produce fragments. The model closely matches that observed for the actual
event. It was also predicted that the comet contribution to the overall pressure dominates
over the black powder lifting charges.
Page 6
Investigation Report Bray Park Fireworks Tragedy
20 May, 2000 Page 6 Prevention The main considerations in determining the preventative
measures that might be implemented to prevent a similar outcome from a fireworks display
in the future: #"the adequacy of current fireworks legislation and codes of practice
#"the competency of fireworks operators #"the compliance of operators with the
legislation #"the Explosives Inspectorate's performance of its role #"the
management of fireworks displays #"the quality of fireworks, and #"the risks
associated with a fireworks display. The review into the preventative measures has
identified a number of control measures for the risk management of fireworks displays. A
number of recommendations have been made based upon these control measures. Training and
Competencies A review of the approved training courses and an assessment of the
competencies of the fireworks industry through a survey of licensed fireworks operators
was undertaken. The quality of training was an issue at the time of the accident and
directions were given to include evaluation of training into the investigation. It is
considered that the quality of the training courses played no direct role in the
explosives incident. However the knowledge and skills of the operators, and the continued
maintenance of those knowledge and skills, and the education of event organisers and the
public, are considered to be important areas in explosives and fireworks safety. Market
ResearchAn independent market research study was undertaken to investigate safety
standards and issues in relation to the fireworks industry. The market research project
was designed to gain an understanding of the culture of the fireworks industry,
particularly in relation to safety in the workplace. It was also designed to determine
customer and community expectations and awareness of hazards and satisfaction levels
regarding services provided by the fireworks industry and the Explosives Inspectorate.
Research activities included two focus groups with fireworks operators, a survey of 120
fireworks operators, a survey of 25 event co-ordinators and a survey of 187 members of the
Queensland public. The market research provided valuable information from these groups of
people.
Page 7
Investigation Report Bray Park Fireworks Tragedy
20 May, 2000 Page 7 ES 2 Key Findings The key findings from the investigation into the
nature and cause of the explosive incident are: 1. There was no evidence found to support
the fact that the incident was other than an accident to the extent that it was unforeseen
and not intentional. 2. Comets contained in 2" 8 shot white tail Roman candles from
the batch used at Bray Park had physical features not observed in other batches of 2"
white tail Roman candles. 3. 2" white tail Roman candles with comets of these
different physical features have a high propensity to explode when confined or unconfined
than other comets not exhibiting this feature. 4. Comets consist of a particularly high
energy fireworks composition used in other types of fireworks to create maximum noise
output such as salutes and reports. 5. An exploding comet can cause the entire Roman
candle to explode. 6. When contained within a close fitting steel tube, an exploding Roman
candle can rupture and fragment the tube. 7. The explosion of a Roman candle inside a
close fitting steel tube can cause an adjacent Roman candle in a steel tube to explode. 8.
The explosion of an adjacent Roman candle also can cause the steel tube holding that Roman
candle to rupture and fragment. 9. The trials program conducted at the Helidon Explosives
Reserve has effectively simulated the explosive incident at Bray Park. 10. The malfunction
in the Roman candle in tube A was not an isolated malfunction but similar malfunctions
were observed in other Roman candles from the same batch. 11. Some Roman candles from the
same batch as the Roman candles used at Bray Park, when fired did explode. 12. The extant
Code of Practice, Australian Standard AS 2187, Part 4 is silent on the placement of Roman
candles in steel tubes. 13. The fragment which caused the fatal injury to Dominique
Baxendell (Police Exhibit No. 119) was identified to have been from tube B. 14. 2" 8
shot white tail Roman candles were supplied to Mr Stratford and Mr Crutcher by a licensed
fireworks seller from a batch that had previously been reported to have a fault. 15. Three
2" 8 shot white tail Roman candles, from the same batch as the 2" 8 shot white
tail Roman candles used by Mr Stratford in his display, had malfunctioned in fireworks
displays prior to 20 May, 2000.
Page 8
Investigation Report Bray Park Fireworks Tragedy
20 May, 2000 Page 8 ES 3 CONCLUSIONS The conclusions have been derived from the
investigation into explosive incident and, in particular, conclusions have been derived
from the analysis of the incident and the suggestions for improvement. The conclusions
are: 1. The fireworks incident, which occurred at Bray Park on 20 May, 2000, was an
accident. 2. The incident occurred as a result of a faulty Roman candle exploding. 3. The
placement of the 2" 8 shot white tail Roman candles in the steel fireworks stand
resulted in the fragmentation of the steel tubes of the fireworks stand when the Roman
candle exploded. The exploding Roman candle in the steel tube caused two adjacent Roman
candles in steel tubes to explode, which also fragmented these steel tubes. The
fragmentation of the three steel tubes caused metal fragments to be distributed around the
display site for distances up to approximately 155 meters. The velocities of these
fragments were estimated to be up to 400 metres per second from tube A and up to 500
meters per second from tube B. 4. The confinement of the Roman candle in the steel tube
was a major contributor to the tragic consequences of this incident. 5. The unnecessary
confinement of fireworks leads to increases the adverse effects of malfunctioning
fireworks, thereby increasing the risk to an unacceptable level. 6. >From the
investigation carried out on the batch of 2" 8 shot white tail Roman candles, it was
evident that the Roman candles could malfunction by exploding. 7. Suppliers of fireworks
do not have a recognised and formal quality system in place. Quality management principles
are not being applied to contemporary standards, which are being adopted throughout the
community elsewhere. 8. A review of the Australian Standard AS2187, Part 4, following this
incident has identified a number of deficiencies including ineffective safety distances,
unsafe work practices and areas where key issues are not addressed. There are areas where
the requirements are implicit rather than explicit. There are areas where there is lack of
clarity and ambiguity. 9. The Australian Standard AS2187, Part 4 covers outdoor fireworks
displays. There are other types of firework activities that are not covered by Codes of
Practice, including Australian Standards in the areas of indoor fireworks displays and
special effects activities. 10. The reporting of explosive incidents is to understand what
has gone wrong, how it has gone wrong, and how the situation may be corrected in the
future. Explosives incidents are not being reported to the Explosives Inspectorate to the
extent that they should be reported. 11. The levels of competency of licensed fireworks
operators were not at a desired level. It is recognised that there is a broad range of
competencies within fireworks operators. 12. There was diversity in the quality of
training being offered. 13. There was a lack of appreciation on the part of event
organisers and other associated persons of their obligations in relation to fireworks
displays.
Page 9
Investigation Report Bray Park Fireworks Tragedy
20 May, 2000 Page 9 14. There is a lack of information available to fireworks operators
and other persons associated with fireworks displays. This information includes Material
Safety Data Sheets, Technical Data Sheets and other safety information. Such information
is essential so that these people know the hazards in the performance of the fireworks
they are dealing with. 15. It is very difficult to find information about fireworks
accidents in the literature and elsewhere. The lack of this information is due to two
issues one, accidents and incidents are not being reported and, two, this information,
when reported, is not being collated. It is considered that such collation is essential so
that the information can be related back to the fireworks industry for their on-going
education and awareness. There is insufficient liaison between the regulatory agencies,
the Explosives Inspectorate and the fireworks industry to enable a healthy exchange and
information on accidents and incidents, investigations, risk management and quality
management issues. A very small percentage of fireworks displays are inspected by
Inspectors of Explosives. The study of the Explosive Inspectorate resources and their
planned activities shows that a very small percentage of the fireworks displays can be
inspected. 16. The Explosives Inspectorate, with its available resources, is not able to
carry out its planned inspection schedule in all areas of explosive activities.
Page 10
Investigation Report Bray Park Fireworks Tragedy
20 May, 2000 Page 10 ES 4 RECOMMENDATIONS The recommendations are in pursuit of a
professional fireworks industry to ensure that a fireworks display is safe and the public
is protected from harm. In arriving at these recommendations, cognisance has been taken of
contemporary industry practices from other sectors of the community, and in particular,
the industries using dangerous goods and hazardous substances. The following
recommendations are made to: (a) Prevent a similar outcome from an explosives incident of
the nature of that at Bray Park (b) Minimise the consequences of any fireworks incident,
and (c) Encourage the adoption of contemporary industry practices within the professional
fireworks industry The recommendations are: 1. To prohibit the presence of any metal tube,
holder, mortar, or other metal equipment that can confine a firework at any fireworks
display site. 2. To prohibit unnecessary confinement of any firework. 3. To include,
within the Explosives Legislation, explicit obligations on specific classes of persons,
including the supplier and the operator, for the quality of fireworks. Such obligations
would include the need for an operating and documented quality system and a prohibition on
the use of fireworks unless the fireworks have a current Certificate of Compliance. 4. To
include within the Explosives Legislation specific obligations and responsibilities for
all classes of persons associated with a fireworks display, including operators,
assistants, suppliers, event organisers, property owners and the viewing public. 5. To
include within the Explosives Legislation specific obligations on the supplier and the
user in relation to the provision of Material Safety Data Sheets, Technical Data Sheets
and other safety information. 6. To develop and implement a national standard for the
quality and testing of fireworks, and in the interim, to develop and implement a
Queensland standard. 7. To revise and upgrade the National Code of Practice (Australian
Standard AS2187.4) for outdoor fireworks displays to correct and address identified
deficiencies, and in the interim, to develop and implement a Queensland set of
requirements. 8. To develop and implement National Codes of Practice for the conduct of
indoor fireworks displays and the use of fireworks for special effects purposes. 9. To
encourage and enforce the requirement to notify the Explosives Inspectorate of all
explosive incidents. 10. To restrict the licensing of fireworks operators to persons who
have satisfactorily completed an approved training course and who have gained suitable
industry experience. 11. To develop the criteria for an industry training package and to
ensure the development of that single training package for fireworks operators. Training
courses would then be approved based on their compliance with their package.
Page 11
Investigation Report Bray Park Fireworks Tragedy
20 May, 2000 Page 11 12. To ensure a system is in place to up-skill existing licence
holders to the standards of the new training package and to maintain these competencies in
all licence holders. 13. To establish and implement an on-going education and awareness
package for all stakeholders associated with fireworks displays, e.g. event organisers,
community. 14. To establish an industry liaison committee and to encourage the development
of a representative fireworks industry organisation. The purpose of this committee should
include review of legislation and standards, incident review, risk management and quality
management issues relevant to the fireworks industry. 15. To develop a technical support
network and information sharing mechanism between regulators within Australia and
overseas. 16. That the Explosives Inspectorate develops readily accessible information
sources, including an explosives incident database, and fosters a national explosives
incident database. 17. That the Explosives Inspectorate be appropriately resourced and
equipped to carry out its enforcement and monitoring functions, and in particular, an
increased level of inspection at fireworks displays and to have the capacity to
effectively investigate all reported explosives incidents. All members of the
Investigation Team express their sincere condolences to the victims and the affected
families of this tragic incident and trust the outcomes and recommendations of this
investigation will help to ensure that fireworks displays are safer in the future.
