A technician was preparing 250 g of an explosive mixture to produce firecrackers used as alerts by divers. The technician noticed at the end of the mixing process the presence of lumps in the composition and decided to run it through a sieve. In order to streamline the operation, he added a porcelain bead into the composition. Turning on the sieve triggered the blast (due to friction), which ejected the technician 1.5 m; he suffered from noise-induced hearing loss. The door to the shop room was blown 10 m off its hinges, a partition wall and the suspended ceiling both collapsed.

The technician’s decision to initiate an additional work step not included in the protocol was the cause of this accident. The operator recalled to staff the need to strictly apply and not deviate from the protocol.