|Oregon Case Report: 03OR020R
Revised March, 2006
On August 1, 2003, a 16-year-old youth working as a camp counselor was
fatally injured when a cannon he was attempting to fire exploded and burst
into pieces. This cannon had been used during evening flag ceremonies
at the camp for about three years.
On the evening of the incident, the victim set up the cannon as instructed
and attempted to fire it during the flag ceremony, but the wind twice
extinguished the touch stick used to fire the cannon. After the second
attempt failed, the ceremony proceeded without the cannon, and everyone
retired for the evening meal. The victim and another youth working as
a counselor remained at the site to see why the cannon did not fire. They
added a small amount of black powder to the touchhole and again attempted
to fire the cannon. This time the cannon fired, and the explosion caused
the cannon’s breech to burst into pieces. One fragment struck the
victim in the head, fatally injuring him.
Photo 1. Black-powder salute (no projectile).
Note flame from touch hole and muzzle.
- Develop written procedures to ensure the cannon is charged and fired
by trained and knowledgeable persons, within the manufacturer’s
operational specifications, and with specific misfire procedures.
- Adult counselors should conduct the firing of black-powder cannons
used at youth camps.
- Youth should not be employed in positions that include the use or
handling of explosive materials.
- Use only solid steel or seamless steel-lined cast-iron cannons to
fire black-powder charges.
- Do not obstruct the bore when firing for ceremonial salutes.
- Use the appropriate grade and quantity of black powder as designated
for the cannon.
- Inspect the gun tube regularly to detect signs of stress.
- Periodically review processes to ensure continuing adherence to safe
On the evening of this fatal incident, the cannon was taken from its
indoor storage location to its firing position, and the victim and another
youth camp counselor prepared to fire the cannon at the flag ceremony
as they had in the past. The adult black-powder instructor, responsible
for supervising the appropriate use of the cannon, was on the field but
not immediately supervising the procedure.
Photo 2. Remnants of cannon.
The two camp counselors poured a charge of black powder down the cannon’s
muzzle from two 35 mm film canisters. The black powder used was usually
a cannon grade, but at times camp staff would use finer, faster-burning
grades intended for black-powder muskets and rifles if cannon-grade powder
was not available. On the evening of this incident, a finer-grade powder
(FFFg) was used to charge the cannon.
The two counselors then filled two film canisters with sand and placed
them into the bore of the cannon along with a wad of toilet paper and
a discarded plastic bag off the ground. Without the wadding, the cannon
was known to produce only a puff of smoke rather than a loud report. Sometimes
a potato or carrot, or other convenient materials were used as wadding.
Next, the counselors placed a small amount of FFFg black powder as a
priming charge over the cannon’s touchhole. Some of this extra black
powder probably fell down the vent and into the cannon’s breech.
Experience had shown that black powder over the touchhole was more effective
than a fuse to ensure the cannon fired at the appropriate time during
the flag ceremony. On the evening of the incident, the victim was using
a 4-foot long stick to light the priming charge over the touchhole. When
the two early attempts with burning twine on the end of the stick failed,
the victim reportedly placed an additional charge of FFFg black powder
over the cannon’s touchhole and also wrapped toilet paper around
the end of the stick for a better flame. This also failed to ignite the
powder, but repeatedly pushing the end of the stick closer to the touchhole
finally ignited the charge causing the cannon to burst. A large portion
of the breech struck the victim in the forehead, and he fell unconscious
to the ground. The other youth was spun around by the force of the blast,
but was uninjured. The victim’s injuries were obviously serious
and a request was made to immediately transport him by air ambulance to
a medical facility. He died in a hospital, 4 days later.
The youth camp has operated a black-powder program for years, providing
instruction in the safe use of black-powder rifles and muskets. The program
operates with a ratio of one adult instructor per youth to ensure safety
while on the firing range. A camp volunteer with experience in firing
black-powder weapons developed the original procedure used to fire the
cannon. The original procedure was not written down, but reportedly included
using only cannon-grade black powder.
The camp’s national organization has written standards for black-powder
programs that do not address using cannons. A training video for the cannon
at the camp was prepared, but was not consistently used, and in many details
did not demonstrate standard safety procedures. The camp did not develop
written procedures for successive youth counselors and therefore procedures
were subject to subtle changes over time.
The cannon involved in this incident had been purchased from a local
dealer, who was well known for his support of the youth organization running
the camp. The cannon, a scaled down replica of a historical British naval
artillery piece, was shipped, along with many others like it, into the
United States from England in the 1960’s. The cannon had been imported
as a solid casting and then had been bored, and a touchhole added, by
a subsequent owner in the United States. The dealer acquired and sold
the piece as a cannon prepared to fire black-powder charges. According
to the employer, there was no literature accompanying the cannon at the
time of sale, and a minimal amount of verbal instructions on how to load,
fire, or care for the weapon.
The cause of the cannon failure could not be conclusively established.
However investigators have considered several possibilities:
- Metal fatigue exacerbated by corrosion in the cannon’s bore
may have reduced its material strength to the point that it was no longer
able to contain the pressure of firing.
- The method of loading resulted in an overload charge that developed
too much pressure for the cannon to withstand.
- The sand-filled film canisters used to occlude the bore may not have
been placed directly against the powder charge, leaving an air gap between
the powder charge and the projectile. This condition has been known
to generate pressures well in excess of those developed by correct loading
Cause of Death
Traumatic injury to the brain.
Recommendation #1: Develop written procedures to ensure the cannon is
charged and fired by trained and knowledgeable persons, within the manufacturer’s
specifications and intended use, and with specific operating procedures,
Discussion: The employer purchased the
cannon and then used internal resources from its black-powder program
to develop safe operating procedures. These procedures were not written
down, and changed over time when communicated to successive counselors.
The employer was apparently not aware of these changes. Written procedures
should address proper use, firing/charging, storage, and how to manage
misfires. Cannons purchased without accompanying literature from the manufacturer,
documenting firing and maintenance procedures, should not be fired.
Additional sources of representative safety procedures for black-powder
cannons, developed from historical records and practical experience of
shooting organizations for antique cannons, are listed in the reference
section of this report.
Recommendation #2: Adult counselors should conduct the firing of black-powder
cannons used at youth camps.
Discussion: Instead of using an unobstructed
charge of cannon-grade (Fg) black powder, the counselors used a charge
of FFFg powder, and obstructed the cannon bore with two sand-filled 35mm
film canisters. Either of these alterations to the established procedure
creates conditions that can cause increased pressures in the cannon upon
firing. Instead of a “salute” charge the procedure resulted
in a “service” charge that fired a projectile. An experienced
adult instructor with knowledge in safe black-powder firing procedures
would have been able to recognize the hazard of the altered firing method
and would have initiated a more formalized misfire protocol.
On this occasion, it is not known if the film canisters were tamped down
securely against the black-powder charge. Witnesses reported the victim
had some trouble in ramming down the first canister. According to safety
rules published by the American Artillery Association, all projectiles
should pass easily through the bore and be firmly seated against the powder
charge. The difficulty in seating the first film canister may indicate
an air pocket existed between the powder charge and the film canisters.
According to cannon experts consulted as part of this investigation, occlusion
of the barrel with the projectile not firmly seated against the powder
charge can result in an explosive blast outward instead of moving the
projectile down the bore toward the muzzle. Some reviewers speculate that
this appears to be what happened in this case, based on evidence from
photographs and the damage to the cannon, sustained entirely in the area
behind its trunnions. (See photo 4) To avoid an
air pocket, a ramrod with two markings should be used: one showing the
position completely against the back of the bore with no load, and a second
showing the position with a properly seated projectile against the powder
charge. The ramrod used at the camp had no markings to verify the depth
of the load.
Similarly, the adult program manager, not youth counselors, should handle
misfires. A cannon misfire must be approached cautiously with a specific
misfire procedure. The American Artillery Association recommends a six-step
procedure to safely discharge the cannon or remove the charge following
a misfire. Details of misfire procedures along with safe loading and firing
procedures can be found at:
Recommendation #3: Youth should not be employed in positions that include
the use or handling of explosive materials.
Discussion: Federal child labor regulations
for agriculture have identified the handling or using of a blasting agent,
including black powder, as a particularly hazardous activity for youth
under age 16 (29 CFR 570.71). Youth under age 18 may not be employed in
plants or establishments manufacturing or storing explosives or articles
containing explosive components (29 CFR 570.51). We recommend that the
nonagricultural and agricultural regulations be harmonized, recognizing
that exposure to explosive materials is particularly hazardous and the
differences between these work environments do not warrant different protective
orders. It is our recommendation that youth under age 18 should not be
employed in positions that include the use or handling of explosive materials,
including ammunition, black powder, blasting caps, dynamite, high explosives,
fireworks, primers and primer cord, smokeless powder, and other goods
and materials designated as explosives by the United States Interstate
Recommendation #4: Use only solid steel or seamless steel-lined cast-iron
cannons to fire black-powder charges.
Discussion: The dealer referred to the
cannon as being made of “grey steel,” an older term used to
describe what is today commonly known as “cast iron.” A metallurgical
engineer consulted as part of this investigation reported that current
manufacturing standards for ceremonial salute cannons require a solid-steel
body or cast iron with a seamless steel insert. Cannons made from poured
or casted processes, the engineer reported, are prone to failure with
time and use.
Solid cast cannons should always be checked for containing solid seamless
steel bores. If they do not have the seamless steel bore, they should
not be used to fire any kind of high explosive.
Recommendation #5: Do not obstruct the bore when firing for ceremonial
Discussion: There are two kinds of firings:
ceremonial salutes and service loads. A ceremonial salute does not include
firing a projectile. The black-powder charge may be doubled as long as
the cannon’s bore is not occluded. A service load refers to a black-powder
charge used in a cannon for the purpose of firing a projectile. Always
follow manufacturer’s recommendations when designing procedures
for setting the amount of black powder used to fire a cannon.
Recommendation #6: Use the appropriate grade and quantity of black powder
as designated for the cannon.
Discussion: Black powder comes in different
grades and ranges. The finer-grained grades of black powder have an increased
surface area compared to coarser grain. Finer grains burn more rapidly
and are more explosive. Usually the main charge should be of the coarsest
granular powder designed for the type of firing (ceremonial/salutes or
service loads). One should consult the manufacturer of the cannon for
specific firing instructions.
The standard safety procedure that designates preparing the powder charge
by wrapping it in heavy aluminum foil had been abandoned at the camp a
year before, because it made cleaning difficult. National safety standards
establish a maximum charge of 656 grains of grade F powder, or about 1½
film canisters. The camp’s firing procedure had been designed for
a salute charge, with powder alone, and a training video shows three film
canisters of grade FFFg powder used for a charge. Some 900 grains was
used regularly. Particularly with the introduction of a means to occlude
the cannon’s bore, the cannon was overcharged. Additionally, a more
explosive grade of black powder was being used. Long use with extra explosive
stress is likely to have weakened the structural integrity of the cannon.
Recommendation #7: Inspect the gun tube regularly to detect signs of stress.
Discussion: Cannons should be magnafluxed
periodically to determine suitability for continued use. Regular assessments
assure the cannon’s structural integrity is being maintained. A
cannon should also be magnafluxed between changes in program directors
to ensure integrity as the new director assumes responsibility for the
A cannon should be stored where it will not be damaged between uses.
After every firing, a cannon should be cleaned according to the manufacturer’s
recommendations. Black powder is hygroscopic (moisture attracting), and
moisture can degrade and weaken the metal with rust. Recommended maintenance
involves washing the bore from muzzle to breech using hot soapy water
followed by a thorough rinse and then allowed to thoroughly dry. The camp
reportedly stored the cannon inside between firings, but it was not cleansed
after each use, but weekly.
Recommendation #8: Periodically review processes to ensure adherence to
safe work practices.
Discussion: Although the employer follows
nationally developed standards for conducting periodic reviews of its
at-risk activities, locally implemented programs, like cannon usage, were
not included in a periodic review and performance evaluation. The employer
had developed an unwritten procedure for safely charging/firing and managing
misfires with the cannon at its local youth camp, but youth counselors,
without review or oversight, gradually modified the verbal procedures
they received. At another youth camp managed by this employer, an adult
volunteer counselor has been using his personal cannon without incident
for several years. The staff at this camp, however, did not communicate
with the other camp’s cannoneer, who had extensive experience with
cannon use and safety procedures.
- The Civil War News, Artillery Safety, http://www.civilwarnews.com/artillerysafety.htm
- Reenactment Safety Regulations for Tannenbaum Historic Park and Greensboro
- California Historical Artillery Society: Safety Rules and Procedures
for Muzzle Loading Artillery, http://www.warhorse.org/saferule.doc (link updated 09/10/2008)
- Sample Rules for Black Powder use in Battle Reenactments, http://www.luckhardt.com/ecwsa106.html
- Cannon Shooting Instructions & Warranty Information, http://www.traditionsfirearms.com/files/Cannon_manual.pdf (page no longer working correctly 3/26/2013)
|Photo 3. This photo shows a solid steel cannon
in use at another of this employer’s youth camps. This cannon
is equipped with a ‘slap hammer” for firing. Problems
encountered with other firing methods, i.e., touchstick, fuse, loose
powder, etc. are eliminated. The person firing the cannon typically
stands 4-5 feet from the cannon and pulls a lanyard to set off a small
cap-like primer charge in the cannon’s touchhole.
Photo 4. Section of failed
cannon breech behind trunnions.
Oregon FACE Program
The Center for Research on Occupational and Environmental Toxicology
at Oregon Health & Science University performs Fatality Assessment
and Control Evaluation (FACE) investigations through a cooperative agreement
with the National Institute for Occupational Safety and Health (NIOSH),
Division of Safety Research (DSR). The goal of these evaluations is to
prevent fatal work injuries in the future by studying the working environment,
the worker, the task the worker was performing, the tools the worker was
using, the energy exchange resulting in fatal injury, and the role of
management in controlling how
To contact Oregon
State FACE program personnel regarding State-based FACE reports, please
use information listed on the Contact Sheet on the NIOSH FACE web site.
Please contact In-house
FACE program personnel regarding In-house FACE reports and to gain
assistance when State-FACE program personnel cannot be reached.
Oregon FACE reports are for information, research, or occupational injury
control only. Safety and health practices may have changed since the investigation
was conducted and the report was completed. Persons needing regulatory
compliance information should consult the appropriate regulatory agency.