Accident: DPC Enterprises Festus Chlorine Release
Location: Location: Festus, MO
Accident Occurred On: 08/14/2002 | Final Report Released On: 05/01/2003
Accident Type: Release
Investigation Status: The final report on this investigation was approved May 1, 2003.
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.
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.
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.
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.
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).
Develop recommended practices for testing, inspection, and preventative maintenance of ESD systems for bulk transfer of chlorine.
Communicate the findings and recommendations of this report to your membership.
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.
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.
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.
Revise the Emergency Response Plan: Develop procedures to clearly designate the roles and responsibilities of facility emergency response personnel, including post-incident remediation.
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.
Revise the Emergency Response Plan: Improve accessibility of equipment required for emergency response, considering likely response scenarios.
Revise the mechanical integrity program: Require periodic inspection of the above critical safety systems by the operations or facility manager.
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.
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.
Communicate the findings and recommendations of this report to all DPC facilities.
Work with DPC to implement a community notification system that will immediately alert neighboring residents and businesses of a chemical release.
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.
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.
Communicate the findings and recommendations of this report to local emergency planning committees (LEPC), emergency management agencies (EMA), and local fire departments.
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.