Journal of Loss Prevention in the Process Industries 13 (2000) 439–442

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Causes and lessons of five explosion accidents

Abstract

This paper describes five disastrous explosion accidents that occurred in recent years that had serious consequences for lives and
property. The five explosions were: 1) The explosion at a TNT workshop of a chemical factory, Liaoning province, on February
9, 1991 in which 17 employees died and 107 were injured; 2) The nitro-amine explosive production workshop of a chemical factory
in Hubei province on June 27, 1992, which led to the deaths of 22 employees and 13 injuries; 3) An explosion in storage warehouses
containing dangerous goods in Shenzhen City on August 5, 1993, where 141 were injured; 4) A explosion of a truck loaded with
1.05 million detonators on October 23, 1994 causing 5 deaths and 95 injuries; and 5) An RDX explosive accident in Hunan province
on January 31, 1996 in which 134 people died and 17 were injured. In this paper, the causes of these accidents are described and
the lessons to be learned from these accidents are summarized.
Great changes and significant achievements have taken place and the national economy has been developing at high speed since
China reform and open policy. But as far as safety in production is concerned, catastrophic explosion accidents have occurred in
recent times and some of them have been exceptionally serious. The author has participated in the investigation of many explosion
accidents, which brought about heavy casualties and great economic losses. The bitter experiences have given us many beneficial
lessons written in blood from which we must try to avoid such similar unnecessary accidents. In this paper, the causes of five
disastrous explosion accidents are analyzed and lessons learned from these accidents are summarized. Proposals for safety production
are also put forward.  2000 Published by Elsevier Science Ltd. All rights reserved.

1. Explosion accidents in the explosives and 1.2. Case 2: Explosion accident of the Nitro-amine
chemicals industries explosive production

1.1. Case 1: An explosion accident in nitration of The Nitroamine explosion production workshop of a
toluene to TNT chemical factory, Hubei province, suffered a massive
explosion at 10:00 June 27, 1992; 22 employees were
On February 9, 1991, at 19:30 a massive explosion killed and 13 were injured. The quantity of explosives
occurred in the trinitrotoluene production area of an was estimated to be equivalent to approximately 4 tons
explosive manufacturing plant in Liaoning province. The of TNT. The workshop and the production equipment
explosion source was estimated to be the equivalent of were extensively damaged.
40 tons of TNT, the explosion demolished the pro-
duction line and the workshop, leaving a funnel-shaped 1.3. Case 3: Explosion accident in a warehouse
crater 7 meters deep and 40 meters in girth. All buildings storing ammonium nitrate
within 600 meters from the explosion center were totally
demolished. Those within 1200 meters were significantly The massive explosion accident in a storage ware-
damaged and those within 3000 meters were partially house containing various quantities of dangerous chemi-
damaged. In this accident, 17 employees were killed and cal goods in Shenzhen City occurred at 13:26 on August
107 were injured, 13 of these seriously. 5, 1993. Fifteen people were killed and 141 were injured.
The explosion not only completed destroyed the ware-
house and nearby building, along with all stored goods,
but also ignited a nearby timber mill and a sundry goods
warehouse 200 meters away from the explosion centers.
Two large explosions were identified in the accident, the
* Corresponding author. Tel: +86-6859-4506; fax: +86-6859-4232. initial explosion and a second explosion approximately

0950-4230/00/$ - see front matter  2000 Published by Elsevier Science Ltd. All rights reserved.
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440 Z. Guoshun / Journal of Loss Prevention in the Process Industries 13 (2000) 439–442

one hour later. The result left two big funnel-shaped pits 2.1. Nitrify machine not instrumented with automatic
7 meters deep and 20 meters in diameter caused from safety devices and non-conformity of worker’s
an explosive quantity estimated at 29 tons of ammonium operation with the technological principal
nitrate and 62 tons of ammonium nitrate, respectively.
In Case 1, the explosive materials, a liquid phase of
1.4. Case 4: Explosion accident in transportation of organics and acids have a chemical reaction in the nitrify
commercial detonators machine. Trinitrotoluene, commonly known as TNT, is
produced through a gravity flow step wise nitration of
toluene using nitric and sulfuric acids. The process uses
A truck containing 1.05 million detonators exploded water cooled stirred vessels called nitrators that are con-
at 13:40 on October 23, 1994, during a delivery to a figured for the three step reaction process. Toluene is
customer site in Shandong Province. The resulting fed as the organic feed to the first nitrator with mono-
explosion killed 5 people and a total of 95 people were nitrotoluene (MNT) as the discharge product. The MNT
injured. The resulting explosion created a crater measur- is fed to the second nitrator with dimitrotulene (DNT) as
ing 2 meters in depth and 6 meters in diameter in the the discharge. The DNT is feed for the last stage where a
roadway. The truck chassis was collapsed into a mass third level of nitration is accomplished to the TNT pro-
of metal and buried deep in the resulting crater. The duct.
engine and gearbox were compressed into a small vol- The cause of the accident was attributed to a nitric
ume, and then thrown out within the area between 30
acid valve which was incorrectly set up and led to a
and 88 meters from the source of the explosion. A incorrect reactant flow and off-specification operation
deformed rim of the wheel of the truck was thrown during the 3rd stage of nitration. The operators did not
approximately 100 meters and it damaged the roof of a
notice the incorrect flow of nitric acid and regulate the
house. Houses within the limits of 180 meters had been valve in time. The result of the excess amount of nitric
seriously damaged and crevices were caused in the acid gave rise to the forward movement of the lowest
walls. Houses within the limits of 580 meters were
solidifying point. This made the number 2 nitrator’s
slightly damaged and some glass was smashed. reaction much more violent. The heat of the reaction in
this part ignited the nitration materials. The nitrators
1.5. Case 5: Explosion accident with mixed RDX high were not configured with automatic safety devices which
explosive production would have detected the increases in temperature and
then cooled and/or dumped nitrator to a water bath. The
The explosion accident of the mixed RDX explosion operating worker escaped from the workshop in a hurry
production occurred in Hunan Province at 19:05 on Jan- without activating a manual safety switch which may
uary 31, 1996 resulting in 134 deaths and 117 people have prevented the temperature runaway and ignition.
injured. The explosion amount was equal to 10 tons of This, in turn, created a situation where the organic and
TNT. Buildings at the explosion center and 140 frame acid phases in the nitrator ignited and then exploded.
houses surrounding the center of the explosion were
completely destroyed. Six hundred and five houses were 2.2. Welding in a dangerous place and neglect of
also seriously damaged, and a nearby power supply and safety regulations
feed pipe were destroyed.
The primary causes of the accident in Case 2 were
welding and ignoring regulations. At the time of the
accident, rock nitramon was being produced
2. Causes of the accidents (composition: 85% ammonium nitrate, 11% trinitrotolu-
ene, and 4% wood powder). Because of a mechanical
Though the root causes of the above-mentioned acci- failure in a transport machine, welding was required to
dents varied, the reasons are as follows: (A) operating repair the damage. The trade union Chairman, acting on
personnel had inadequate knowledge of the safety of his own, issued a welding permit directly to the workers
their jobs; (B) an inadequate understanding and respect instead of the leader in charge of the production. This
for the hazards of the materials and processes they oper- was in direct violation of the required Safety Technology
ated; (C) training in normal and emergency operations, Regulation of Dynamite in Dangerous Places. Upon
(D) procedures for safety activities and Enforcement receipt of the permit, the workers began welding one
programs both by the employer and outside regulatory portion of the transport machine without performing the
bodies for rule violations. The severity of each of these required thorough cleaning operation. The contaminated
accidents indicates trends from improper training to transport machine, due to small quantities of Nitramon,
gross employee negligence in the prevention of cata- exploded when the welding temperature ignited the
strophic explosions. material. The initial explosion propagated to other adjac-
 Z. Guoshun / Journal of Loss Prevention in the Process Industries 13 (2000) 439–442 441

ent equipment leading to an explosion of approximately It was found that the detonator boxes had fallen down
4 tons of dynamite in another nearby workshop. from their place of storage in the transporting vehicle.
Apparently, the goods referenced were being sold and
2.3. Warehouse reconstruction and storage violations transported without proper permits or in compliance with
of different goods against regulations regulation by the explosion equipment production fac-
tory and the explosion construction unit, in order to
reduce costs and promote economic benefits. They recti-
The explosion accident described in Case 3 occurred
fied the standard numbers of the detonators examined by
in a chemical dangerous goods warehouse located in the
the Ministry of public Security. The total explosive
industrial district in the City. The original layout and
amount was estimated at 1045 tons of trinitrotoluene and
design of the warehouse district were six separate ware-
approximately 1.05 million industry No. 8 detonators
houses that were constructed and protected for the stor-
located in 140 boxes. The packing and placement of the
age of sundry goods. There was a 20-meter separation
detonators caused a greater contribution to the whole
between each of the six warehouses for emergency
explosion energy and a much more serious accident.
access and for fire fighting vehicle entry.
These warehouses had been upgraded with expanded
2.5. Illegal purchase, transport, and processing of
sections to store additional goods. The final separation
military scrapped explosives
distance due to these changes had been reduced to 2-5
meters, effectively eliminating the fire fighting vehicle
Case 5 was caused by illegal purchasing, transporting,
access. This action was in direct violation of the Con-
and processing of military scrapped explosives with
struction Design Safety Laws for commercial buildings
lower cost and similar equipment for financial gain by
in the district. The more serious problem, however, was
some workers. The RDX explosives, separated from the
that the occupancy of the sundry goods warehouses were
military faulty explosives (composition: 94% RDX, 3%
changed by the owners to dangerous goods storage. This
double (2,2,2-trinitroethanol) formal, 2% poly vinyl
also was a direct violation of the Civil Explosion
acetate, 1% stearic acid), were much higher than TNT
Materials Administrative Regulations of the Peoples
in its sensitivity and power. Not fully understanding the
Republic of China, and the Chemical Dangerous Goods
property of the explosives, the workers took more than
Safety Administrative Regulations of the State Council.
10 tons of the explosives to an underground house and
The revised occupancy included materials such as
processed them there. Furthermore, they tried to grind
strong oxidizers in the form of ammonium super sulfate,
the military explosives with a common grinding
potassium permanganate, ammonium nitrate, potassium
machine. The explosion accident then destroyed the
nitrate and strong reductants such as sodium sulfide,
whole village, killing and injuring many farmers.
flammable matches, and camphor essence. The ware-
houses were also being used to blend mixes of these
hazardous materials. The result of the incompatible stor-
3. Lessons learned and recommendations
age, the lack of fire fighting access, and the mixing of
materials combined to ignite an activity in progress
From the above-mentioned cases, it is clear that
which then escalated to cause exothermic reactions in
causes of these accidents were neither problems of tech-
the stored materials and subsequently explosions. Appar-
nologies and equipment nor problems of the safety rules
ently, inspections had been performed and violations had
and regulations. The persons in charge did not strictly
been identified. Information on rectifying the major fire
enforce the laws, and paid no attention to safety regu-
insurance hidden dangers had already been sent to the
lations. Therefore, lessons must be learned from these
warehouse owners and operators by the local fire fighting
accidents written in blood by examining mistakes on
authorities. The conditions for an explosion accident
safety management, and taking effective measures to
were already in progress.
enforce safety management and supervision in order to
stop similar accidents and ensure safety production. The
2.4. Automobile transportation of dangerous goods author’s recommendations are as follows.
against safety regulations
3.1. Taking effective measures to improve safety
The investigation of the explosion identified in Case technology and the quality of equipment continually
4 led to a conclusion that an initial automobile accident
was not the cause but initiation occurred in the deton- Safety production is an eternal subject to enterprise
ators. The detailed accident investigation found the det- management, and it is very important especially to the
onator storage/transportation box was mounted higher in explosive production enterprises. Safety production not
the truck than that of the limit required by law in the only refers to enforcing management, but also to making
Civil Explosion Equipment Transportation Regulations. use of advanced safety protection technology and
442 Z. Guoshun / Journal of Loss Prevention in the Process Industries 13 (2000) 439–442

improving the quality of equipment. Backward tech- production and transportation. We can not think only of
niques and old equipment have much relationship with the economic benefit although most enterprises conform
the accident in Case 1. The nitrify machine was used to the best benefit rule. Units must learn lessons from
before the 1950’s and had no automatic safety detection, the accidents in Cases 3 and 4 even though there have
warning, or explosion mitigation devices. The accident been no accidents for a long time. Potentially dangerous
occurred before the funds for reconstruction arrived. The factors must be recognized clearly and be corrected
accident also made us realize the importance of a total quickly.
integrated safety production system. Safety and
operabilty improvements must be completed on time, 3.4. Carrying out safety evaluation to dangerous
either by stopping production or by taking special meas- goods production and transportation enterprises
ures to enforce management.
Safety evaluation synthesized the theory and method
3.2. Strengthening the legal safety propaganda and of safety system engineering and analyzed the safety fac-
safety technology education, improving for cadres and tors completely. Many aspects in enterprises; such as
workers and strictly enforcing rules and regulations synthetic safety management, dangerous equipment fac-
tors, and environmental safety conditions have many dif-
The legal system has been greatly improved since Chi- ferences with the evaluation standard. In accordance
na’s reform and open policy. Many regulations and laws with the above views, safety measures can be formulated
have been formulated including the safety production and problems can be resolved to meet the demands of
regulations concerned with economy construction. On the standard safety conditions and improve the safety
one hand, the legal safety system propaganda is not fully quality of the enterprise. Practices have fully proved that
understood by many cadres in charge and forefront safety education is a synthetic management measure and
workers such as welding in dangerous places with an effect was to improve management levels, and to sys-
explosives as in Case 2. On the other hand, laws are not tematize and standardize the safety management of the
strictly executed such as with illegal purchasing, trans- enterprise.
porting, and processing military scrapped explosives in The above-mentioned case could have been rectified
Case 5. Therefore, the legal system propaganda and and avoided if the safety evaluation had been done earl-
quality education must be the first important things. ier. Therefore, every civil explosion enterprise must
Cadres and workers must strengthen their own responsi- carry out safety evaluation strictly according to the
bility and get in to the habit of obeying laws and regu- Safety Evaluation Standard of Civil Explosion Equip-
lations. They also have to increase their safety tech- ment Factories. Aspects such as workshop construction,
nology knowledge and improve their self-protection place arrangement, technology equipment, mechanical
abilities. At the same time, the Ministry of Management and electrical equipment, fixed faculty and quantity
and Supervision must strictly enforce laws and raise their work, working environment and synthetic management
level of safety consciousness. must be evaluated and corrected by following standards.
Potential accidents could be avoided and safety pro-
3.3. Dealing with the relationship between safety and duction could be ensured through these efforts.
benefit to dangerous production and transportation Enterprises which do not carry out safety evaluation
or do not fulfil the safety standard should not be given
Increasing safety funds and strengthening manage- a Production License. This would be an effective way
ment and supervision are inevitable to Dangerous Goods to promote safety evaluation in enterprises.