On the morning of 14 August 2002, a 1 in. transfer hose used in a rail tank car unloading operation at DPC Enterprises, near Festus, Missouri, catastrophically ruptured and initiated a sequence of events that led to the release of 48,000 pounds of chlorine-a toxic gas-into neighboring areas. The facility repackages bulk dry liquid chlorine into 1 ton containers and 150 pound cylinders for commercial, industrial, and municipal use in the St. Louis metropolitan area. Fortunately, the wind direction on the day of the release limited the effects of the chlorine plume on the surrounding community. However, 63 people sought hospital treatment due to exposure, and hundreds of others were affected by the release (the community was advised to shelter-in-place for 4 h, and traffic was halted on Interstate 55 for 1.5 h). The US Chemical Safety and Hazard Investigation Board (CSB) investigated this incident for the following reasons: Potential catastrophic off-site consequences to the public. Large quantity of chlorine released. Prolonged release duration. Wide use of chlorine within the US and potential for similar incidents at other facilities. This paper presents the lesson-learned from this incident to help prevent similar occurrences. This paper is based on US Chemical Safety and Hazard Investigation Board Report Number 2002-04-I-MO, which was approved by the Board on 1 May 2003. This paper has not been independently approved by the Board and is published for general informational purposes only. Every effort has been made to accurately present the contents of the Board-approved report in this paper. Any material in the paper that did not originate in the Board-approved report is solely the responsibility of the author and does not represent an official finding, conclusion, or position of the Board. A complete copy of the Board investigation report upon which this paper is based is available on the CSB website at http://www.csb.gov "Completed Investigations." Published by Elsevier B.V.