In a gunpowder factory, a very intense combustion with a pressure surge effect occurred within a hopper containing powder. Maintenance work was ongoing: 2 workers were connecting by means of a copper cable the recently-installed metal sentry boxes around the loading hoppers of a cartridge production line (“grounding” of the equipment). The line was shut, but sizeable quantities of powder remained both inside the hoppers (which had not been drained prior to the maintenance intervention) and in nearby plastic cans. The perforation (by an employee using a “standard” electric drill) of the wall of the third sentry box caused the heating that initiated the fire. The employee was killed on the spot due to burns. The fire spread throughout the corridor and to both of the juxtaposed platforms, on which cardboard boxes, lead bags and barrels of powder had been stored. The second employee, who was working in the room adjacent to the powder corridor, was severely burned and succumbed the next day. The third technician was thrown from the first floor and slightly burned; he was off work for a full month. Two fire-fighters also sustained burns. The cartridge-filling shop and machines were partially destroyed.

The operator stated having given a verbal order to empty the powder before starting these works, which however were not written up in a workplace safety report. Regular ongoing safety training was not being performed onsite. The construction measures adopted by the workshop proved ineffectual (missing or incorrect calculations): the roof designed to serve as an unloading surface resisted the pressure surge, which in fact contributed to spreading the fire to nearby powder cans.