Skip to Main Content

An independent federal agency investigating chemical accidents to protect workers, the public, and the environment.

Text Size AA
PRINT PAGE
DPC Enterprises Festus Chlorine Release
FINAL REPORT: Final Investigation Report
Location: Festus, MO
Accident Occurred On: 08/14/2002
Final Report Released On: 05/01/2003
Accident Type: Release
Company Name: DPC Enterprises

statistics

Total # of Recommendations
24
Total # of Open Recommendations
0
Total # of Closed Recommendations
24
Total % of Open 0 vs. Closed 100

investigation information

Image
Accident Description
On August 14, 2002, a chlorine transfer hose ruptured during a rail car unloading operation at the DPC Enterprises chlorine repackaging facility near Festus, Missouri. The hose rupture ultimately led to the release of 48,000 pounds of chlorine, causing three workers and 63 residents to seek medical treatment.
Investigation Status
The final report on this investigation was approved May 1, 2003.


 

Recommendations

Agency for Toxic Substances and Disease Registry (ATSDR)
2002-04-I-MO-17

Work with State and local agencies to address concerns about the long-term health effects of the chlorine release in Festus, Missouri, and communicate your findings to the community.

Status: Closed - No Longer Applicable
Closed - No Longer Applicable (C - NLA) - Due to subsequent events, the recommendation action no longer applies (e.g., the facility was destroyed or the company went out of business).
 

Branham Corporation
2002-04-I-MO-11

Implement a materials verification procedure to improve quality assurance during chlorine transfer hose fabrication and shipment, such that hoses shipped to customers are readily identifiable and meet required specifications.

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Chlorine Institute
2002-04-I-MO-18

Work with the Association of Hose and Accessories Distributors (NAHAD) and chlorine hose manufacturers, such as Crane-Resistoflex, to develop and implement a recommended practice requiring continuous positive identification (e.g., coding, stenciling, stamping) throughout the supply chain, from manufacturing to the end user of the product.

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2002-04-I-MO-19

Develop recommended practices to address moisture in dry chlorine piping systems. Include information on suggested material specifications, prevention and corrective measures, and adverse consequences (particularly for emergency shutdown [ESD] systems).

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2002-04-I-MO-20

Develop recommended practices for testing, inspection, and preventative maintenance of ESD systems for bulk transfer of chlorine.

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2002-04-I-MO-21

Communicate the findings and recommendations of this report to your membership.

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

DPC Enterprises, Festus Site
2002-04-I-MO-1

Revise the mechanical integrity program: Develop and implement a quality assurance management system, such as positive materials identification, to confirm that chlorine transfer hoses (CTH) are of the appropriate materials of construction.

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2002-04-I-MO-2

Revise the mechanical integrity program: Implement procedures and practices to ensure the emergency shutdown (ESD) system operates properly. Include procedures to verify that the ESD valves will close to shut down the flow of chlorine.

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2002-04-I-MO-3

Revise the mechanical integrity program: Revise the preventive maintenance and inspection program for the chlorine transfer system to address moisture-related corrosion. Evaluate and correct any problems associated with corrosion that could potentially lead to chlorine transfer and safety system failure.

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2002-04-I-MO-5

Revise the Emergency Response Plan: Develop procedures to clearly designate the roles and responsibilities of facility emergency response personnel, including post-incident remediation.

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2002-04-I-MO-6

Revise the Emergency Response Plan: Develop and implement a timetable for drills to test emergency response personnel on various levels of response, including a large uncontrolled release that could affect the public. Coordinate these drills with local emergency response authorities. Provide a copy of the revised Emergency Response Plan to the local emergency planning committee, and review the plan with the committee and the local fire department. Work with these authorities to implement an improved community emergency notification system.

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2002-04-I-MO-7

Revise the Emergency Response Plan: Improve accessibility of equipment required for emergency response, considering likely response scenarios.

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2004-04-I-MO-4

Revise the mechanical integrity program: Require periodic inspection of the above critical safety systems by the operations or facility manager.

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

DX Group
2002-04-I-MO-8

In light of the findings of this report, conduct periodic audits of the safety management systems involved in this incident, such as mechanical integrity, emergency response, and material quality assurance. Ensure that the audit recommendations are tracked and implemented. Share findings and recommendations with the work force at your repackaging facilities.

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2002-04-I-MO-9

To improve supervision of day-to-day operations, revise your corporate safety management training program on chlorine repackaging operations. Emphasize safety critical systems, including verification of safety system performance.

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2002-04-I-MO-10

Communicate the findings and recommendations of this report to all DPC facilities.

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Jefferson County Emergency Management Agency (EMA)
2002-04-I-MO-12

Work with DPC to implement a community notification system that will immediately alert neighboring residents and businesses of a chemical release.

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2002-04-I-MO-13

Work with DPC, local emergency planning and response authorities in Jefferson and adjacent counties, the City of Festus, and Crystal City to improve overall response and mitigation time.

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2002-04-I-MO-14

Communicate the findings and recommendations of this report to your membership.

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Missouri Department of Natural Resources (DNR) and other Appropriate Agencies
2002-04-I-MO-16

In collaboration with appropriate agencies, hold a community meeting in Festus, Missouri, to hear concerns raised by local citizens affected by the DPC incident and to respond to issues raised by the community.

Status: Closed - No Longer Applicable
Closed - No Longer Applicable (C - NLA) - Due to subsequent events, the recommendation action no longer applies (e.g., the facility was destroyed or the company went out of business).
 

Missouri State Emergency Response Commission (MERC)
2009-04-I-MO-15

Communicate the findings and recommendations of this report to local emergency planning committees (LEPC), emergency management agencies (EMA), and local fire departments.

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

National Association of Chemical Distributors (NACD)
2009-04-I-MO-24

Communicate the findings and recommendations of this report to your membership.

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

National Association of Hose and Accessories Distributors (NAHAD)
2002-04-I-MO-22

Work with The Chlorine Institute and chlorine hose manufacturers, such as Crane-Resistoflex, to develop and implement a recommended practice requiring continuous positive identification (e.g.,coding, stenciling, stamping) throughout the supply chain, from manufacturing to the end user of the product.

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2009-04-I-MO-23

Communicate the findings and recommendations of this report to your membership.

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

 
 

Related Video

Emergency Preparedness: Findings from CSB Accident Investigations
6/9/2009 4:00:00 AM
Lessons from ten years of CSB investigations on preparing for chemical disasters. read more

Download QuickTime Video

Related News

DPC2
CSB Board Votes 5-0 to Approve Report on DPC Chlorine Release, Calls for Industry-Wide System for Hose Identification
5/1/2003
(Festus, MO - May 1, 2003) Saying that better equipment maintenance and quality assurance programs could have prevented last year's atmospheric release of chlorine from DPC Enterprises in Festus, the U.S. Chemical Safety Board today approved its final report and recommendations on the accident and called for industry-wide measures to improve chlorine safety.
read more
DPC1
CSB Safety Advisory Calls for Validation of Chlorine Transfer Hoses
12/4/2002
(Washington, DC - December 4, 2002) Finding that the use of an incorrect hose led to an August 2002 chlorine leak near St. Louis, a new safety advisory issued today by the U.S. Chemical Safety Board (CSB) calls on other chlorine users to verify the materials of construction of their chlorine transfer hoses. The advisory grows out of an August 14, 2002, chlorine release at DPC Enterprises in Festus, Missouri. In that incident, a transfer hose failed catastrophically during the unloading of a chlorine rail car. Due to the malfunction of an automatic shutdown system, the leak continued unabated for several hours, eventually causing the release of about 48,000 pounds of toxic chlorine gas. Sixty-three people, including workers and nearby residents, sought hospital treatment as the result of the leak.
read more
U.S. Chemical Safety Board Launches Full Investigation of St. Louis-Area Chlorine Gas Release
8/21/2002
U.S. Chemical Safety Board Launches Full Investigation of St. Louis-Area Chlorine Gas Release (Washington, DC - August 21, 2002) The U.S. Chemical Safety & Hazard Investigation Board (CSB) has announced it will conduct a full-scale investigation into the root causes of the three-hour chlorine gas leak at a DPC Enterprises plant in Festus, MO, about 35 miles south of St. Louis. The decision to launch a detailed investigation follows a preliminary assessment conducted by two CSB investigators who
read more
 
 
© csb.gov. All rights reserved