The accident occurred at 11.30 o’clock in one of the cabins (cabin 9) in department 130 ” Gunpowder
production.” to factory 4, of “Arsenal”. At the time of the accident there have been two workers at the site.
One of them has been sieving a flaring composition with a mechanical sieve while the other one has been
out of this cabin. In violation of “instructions for safety and health at work in the department 130”, which
does not allow mechanical friction or electrical impacts on explosives and “instructions on labor safety in
the preparation of sieving composition” which does not allow friction and hitting of explosives, the worker
in the cabin has caused mechanical impact by hand (abrasion by hand) on the composition in the
mechanical sieve. His action has led to the explosion of the composition in the sieve and subsequent
explosion of a flaring composition located on the table in the entrance of the cabin. The other worker has
heard the explosion. Only the worker operating in the cabin has been injured. He has been taken to the
hospital immediately, but despite the efforts of doctors he has died.
The immediate cause of the accident is allowing mechanical impact on the composition. By this action the
worker ignored the danger of explosion.The underlying cause of the major accident is violation of the
discipline.
The immediate cause of the accident is allowing mechanical impact on the composition. By this action the
worker ignored the danger of explosion.The underlying cause of the major accident is violation of the
discipline.
First aid has been rendered to the victim and he has been evacuated to the hospital by the factory’s medical
team. The area around the cabin has been cleaved and factory’s own security has been installed. The power
and water supply and the local heating have been switched off. The areahas been cleared. An extraordinary
instruction to all workers in the factory has been conducted. A new project for the reconstruction of the
cabin has been approved. This project includes modified flowsheet for the production of flash composition
with further mechanization of operations and reduced.
Measures to prevent reocurrence: After the accident, the following measures had been established: The
training of the personnel had been reviewed and improved. Improvements of the safety management
system had been made. Measures to mitigate consequences: The instructions in the standard technical
operating procedure have been revised to make them clearer and more comprehensible.
