"This incident began with the failure of a chlorine transfer hose (CTH) connecting a tank car to the facility repackaging process. The U.S. Chemical Safety and Hazard Investigation Board (CSB) determined that the ruptured hose was constructed of stainless-steel braid rather than Hastelloy C, a metal alloy (CSB, 2002). The CSB investigation determined the following root causes: The DPC quality assurance (QA) management system did not have adequate provisions to ensure that chlorine transfer hoses met required specifications prior to installation and use; Branham Corporation, the CTH fabricator/distributor, did not have a QA management system to ensure that fabricated hose complied with customer specifications or that its own certification of materials specifications were correct; and The DPC testing and inspection program did not include procedures to ensure that the process emergency shutdown system would operate as designed." Key issues include: mechanical integrity, emergency management, and chlorine transfer hose supply.
Report No. 2002-04-I-MO
U.S. Chemical Safety and Hazard Investigation Board: http://www.csb.gov/