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The CSB investigated a chlorine release at the DPC Enterprises chlorine repackaging facility near Festus, MO. CSB investigators' root cause findings included: DPC's Quality Assurance management system did not ensure that chlorine transfer hoses met adequate specifications, the transfer hose distributor had no quality assurance program for its product, and DPC's testing and inspection program did not ensure that the process emergency shutdown was functioning correctly. Contributing causes included: an inadequate hose identification system for chlorine transfer hose manufacturers, failure to detect corrosion in the chlorine transfer system, and an inefficient community notification system. The CSB issued safety recommendations based on these root and contributing causes.
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