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					     ILLINOIS DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION 
                  DIVISION OF PROFESSIONAL REGULATION 
                 STATE BOARD OF PROFESSIONAL ENGINEERS 
Minutes:                   State Board of Professional Engineers 
Date:                      May 10, 2007 
Time:                      10:04 A.M. Adjourned 3:49 P.M. 
Location:                  Springfield Office, room 376 

Board Members Present: 
John C. Dillaplain, Chairman 
Richard Suhadolc, Vice­Chairman 
John P. Hoffstatter, Member 
Edward Gaffigan, Member
Philip M. Corlew, Member
Charles R. Rayot, Member 
John M. McKinney, Member 


Board Members Absent: 
Arlyn E. Albrecht, Member 
Benjamin D. Miller, Member 

The Board Members present constituted a quorum of the Board. 

Guests Present: 

Staff Present: 
M. David Brim, Design Licensing Manager 

          Topic                          Discussion                                        Action 
  I.  Announcements,              A. Welcome New Members                         Meeting was called to order at 
      Correspondence                                                             10:04 a.m. 
A. Welcome New Members            The Board welcomed its new Members: Philip 
                                  Corlew and Charles Rayot. 

                                  The following additions to the Agenda were 
                                  requested: 
                                  New Business: 
                                      A.  Letter from applicant. 
                                      B.  Rules change for CPEES 
                                  Old Business: 
                                      C.    Surveying Engineering 

II. Approval of Minutes           The Minutes for the following meetings were 
                                  discussed: 

                                  January 18, 2007 – Open 
                                                                                 Motion was made, seconded 
                                                                                 (Hoffstatter/Suhadolc) and 
                                                                                 passed to accept the January 18, 
                                                                                 2007 Open Minutes as written. 

                                  January 18, 2007 – Closed 
                                                                                 Motion was made, seconded 
                                                                                 (Hoffstatter/Suhadolc) and



                                                 Page 1 of 4 
     ILLINOIS DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION 
                  DIVISION OF PROFESSIONAL REGULATION 
                 STATE BOARD OF PROFESSIONAL ENGINEERS 
                                                                                        passed to accept the January 18, 
                                                                                        2007 Closed Minutes as written. 
                                February 22, 2007 ­ Open 
                                                                                        Motion was made, seconded 
                                                                                        (Hoffstatter/Suhadolc) and 
                                                                                        passed to accept the February 22, 
                                                                                        2007 Open Minutes as written. 

                                Philip Corlew stated that he abstained from voting 
                                as he was not a member of the Board at the time of 
                                the meetings. 

III. Design Review Complaint    Design Review Complaint 
Committee/Subcommittee          Committee/Subcommittee Reports: 
Reports                         John Dillaplain reported: 
                                The discussion centered around the Zone Meeting 
                                and the Annual NCEES meeting. 
                                    o  2 candidates  for treasurer 
                                    o  Governance committee – asking 
                                         permission to establish an office in 
                                         Washington DC 
                                    o  Computer Based Testing – W. Gene 
                                         Corley appointing task force. 
                                    o  CE – complaints about adequacy of 
                                         programs. 
                                Reports from Boards: 
                                Structural Engineers – no audit of latest renewal 
                                Architects: 
                                     o  New ARE begins phasing in, in 2008.  9 
                                          sections to 7 sections for the exams.  The 
                                          computer based testing requires 24 hour 
                                          access – some were scheduled for 2 am 
                                          tests because of lack of computers. 
                                     o  They now have a full complement of 
                                          Board members, excluding the Public 
                                          member, still vacant. 

                                Cases in Investigations: 
                                Architect – 124 
                                PE – 24 
                                LS – 31 
                                SE – 17 
                                Total – 198 

                                Cases in Prosecutions: 
                                Arch – 57 
                                PE – 21 
                                LS – 32 
                                SE – 10 
                                Design Firm – 22 
                                Total 142 

                                The PEs had 5 cases to review.  Closed 2, sent 2 
                                back to Investigations, referred one to Architects.




                                                Page 2 of 4 
     ILLINOIS DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION 
                  DIVISION OF PROFESSIONAL REGULATION 
                 STATE BOARD OF PROFESSIONAL ENGINEERS 
                             John Dillaplain reported that he had met with 
                             Darryl Woolf regarding the article in the ISPE 
                             magazine.  The statistics of the investigations and 
                             prosecutions are published in the minutes, which 
                             are available on the Department’s website and the 
                             ISPE can publish both that and the information 
                             from the monthly disciplinary reports that the 
                             Department has available on its website. 

                             Phillip Corlew noted that resources all around are 
                             limited. 


IV. Old Business 
  A.  Fire Protection Act    A.  Fire Protection Act Review 
      Review 
                             Kim Robinson from the ISPE stated that the 
                             proposed amended Rules for the Fire Protection 
                             Act have not been adopted.  In ISPE’s opinion the 
                             Fire Marshal’s office is resubmitting the original 
                             Rules that were objected to last year. 

                             John McKinney stated that the Fire Marshal’s 
                             office took liability out of the Act and requested 
                             that this issue be kept on the agenda. 

                             John McKinney submitted a copy of the Case 
                             Study on Universal Form Clamp, Inc. reported by 
                             the US Chemical Safety and Hazard Investigation 
                             Board. 
                                                                                    Motion was made, seconded 
                                                                                    (Suhadolc/McKinney) and 
                                                                                    passed to include a copy of the 
                                                                                    case study in the minutes.


                             The Board discussed the revisions to the PE Act 
                             that had been submitted by the Board to the 
                             Department.  Kim Robinson stated that the 
                             Department had withdrawn all of the revisions to 
                             the Act except the change in TOEFL/TSE. 

                             John McKinney asked that the Director respond in 
                             writing regarding the change in the submission by 
                             the Board. 

B.  IDOT/ISPE Electronic     B.  IDOT/ISPE Electronic Signature Initiative 
Signature Initiative         No new information has been submitted from 
                             either IDOT or ISPE.  The Board requested that 
                             this be taken off the agenda until either IDOT or 
                             the ISPE request to re­open the issue. 
                             . 

C.  Surveying Engineering    C.  Surveying Engineering Programs 
Programs                     The Board discussed the previous 



                                             Page 3 of 4 
      ILLINOIS DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION 
                   DIVISION OF PROFESSIONAL REGULATION 
                  STATE BOARD OF PROFESSIONAL ENGINEERS 
                                   recommendations and the letters to be sent to 
                                   Ferris State University and the ABET accreditation 
                                   department. 
                                                                                         Motion was made, seconded 
                                                                                         (Suhadolc/Corlew) and passed 
                                                                                         that: Have Abet review our 
                                                                                         letters of Denial and request that 
                                                                                         they reply within 60 days. 

                                   As a corollary to the Surveying Engineering 
                                   accreditation by ABET, John Dillaplain asked that 
                                   Edward Gaffigan and Philip Corlew work together 
                                   to review the ABET accreditation on Surveying 
                                   Engineering programs 

V. New Business 
    A.   Letter from applicant.    A.   Letter from applicant. 

                                   Members of the Board had received a letter from 
                                   an applicant regarding his deferral and requesting 
                                   information.  M. David Brim stated that the Board 
                                   members should not answer the letter; it was his 
                                   job as the Department liaison to answer.  He 
                                   collected all the copies of the letter. 


    B.   Rules change for          B.   Rules change for CPEES 
    CPEES 
                                   M. David Brim requested permission of the Board 
                                   to submit changes to the Rules regarding the 
                                   Center for Professional Engineering Education 
                                   Services (CPEES).                                     Motion was made, seconded 
                                                                                         (Hoffstatter/Corlew) and passed 
                                                                                         that: M. David Brim should 
                                                                                         create and submit changes to the 
                                                                                         Rules regarding the Center for 
                                                                                         Professional Engineering 
                                                                                         Education Services (CPEES). 

VI. Application Review                                                                   The Board reviewed and made 
                                                                                         recommendations for 225 
                                                                                         applicants for licensure by 
                                                                                         examination, restoration, and 
                                                                                         endorsement. 

VII.  Signatures                   A.  Action Sheets                                     The Board signed action sheets 
                                   B.  Travel Vouchers                                    through 07­1399 through 07­ 
                                                                                         1623 

VIII.  Adjournment                                                                       Motion made, seconded 
                                                                                         (Suhadolc/Rayot) and passed to 
                                                                                         adjourn.  Meeting adjourned at 
                                                                                         3:49 p.m.




                                                   Page 4 of 4 
CASE STUDY
Mixing and Heating a Flammable Liquid in
an Open Top Tank

One killed, two injured                                        Investigation No. 2006-08-I-IL
                                                                                  April 2007



                                                             Introduction

                                                             This inciçle ~volved the
                                                             ignitio 0  apor cloud
                                                             ~~~ated by mixing and heating
                                                           ~~flammable liquid in an open
                                                       N     top tank without adequate safety
                                                             controls. One contractor was
                                                             killed and two employees were
                                                             injured, one seriously. The
                                                             facility suffered a significant
                                                             business interruption.
                                       Clamp, Inc.
                                       BeUwood, Illinois
                                         June 14, 2006
                ‘0’

Key Issues:                                                   INSIDE
 • Flammable Liquid Process Design
                                                              Incident Description
 • Engineering Controls                                       Company Operations

  • Plan Review and Code Enforcement                          Incident Analysis
                                                              Lessons Learned
  • Emergency Preparedness
Universal Form Clamp Case Study                                                                            April 2007

                                                              He immediately notified a senior operator who
1.0 Incident Description                                      helped him shut down the operation. They both
                                                              exited the building and advised workers in
This Case Study describes the ignition of a vapor
                                                              adjoining areas to leave.
cloud’ generated by mixing and heating a
flammable liquid2 in an open top tank without                 As the vapor cloud spread throughout the mixing
adequate safety controls. The tank was located in
                                                              area and surrounding workspaces, other~êmployees
the chemical mixing area of the Universal Form                exited the building (Figure 2).
Clamp (UFC) facility in Bellwood, Illinois, a
suburb of Chicago.
On the morning of June 14, 2006, an operator was
mixing and heating a flammable mixture of heptane
and mineral spirits3 in a 2,200-gallon open top tank
equipped with steam coils. The finished product,
“Super Clean and Tilt,” is a proprietary mixture,
which is applied to cured concrete surfaces to
prevent bonding with wet concrete.
As the operator was adding an ingredient to the
batch, he observed a “dense fog” accumulating on
the floor below the tank (Figure 1).

                                                                                       Ramp Area
                                                                       Tank Farm




                                                                                            c-i,
                                                              Figure 2. Vapor clou      op~gation

                                                                               (~.
                                                              Within            minutes after the operator first
                                                                            vapor cloud, most employees who
                                                                            ~in the area had evacuated. A
                                                                          delivery driver passed some of these
                                                                 iployees as he walked into the building and into
                                                              the spreading vapor cloud.4 The cloud ignited
                                                              within seconds of him entering. The driver died
                                                              several days later from the bums he received.
Figure 1. Vapor spilling from top of        •n~-t’~nk
                                                              The pressure created by the ignition blew the doors
                                                              open to an adjacent area, injuring a temporary
~      cloud contained vapor            ,   but is referred   employee. This employee suffered second-degree
        “vp I d”                                              burns and was hospitalized for three days.5
2 OSHA defines a “~~b e liquid” as any liquid

having a flash , \~ow100°F. (37.8° C.), except any            The Bellwood Fire Department battled a fire
mixture having        ponents with flashpoints of 100° F.     confined to a bagged resin storage area for about
(37.8° C.) or higher, the total of which make up 99
percent or more of the total volume of the mixture. (29
CFR Part 1910.106(a)(19))                                      Witnesses told CSB investigators that others attempted
  The mixture contained approximately 6,000 pounds of         to warn the driver of the vapor cloud, but he was talking
heptane and 3,000 pounds of mineral spirits. The mixture      on his cellularphone as he entered the building and did
was a flammable liquid. Heptane has a flash point of 250      not hear them.
F (-4° C.), and the flash point for this grade of mineral       A third employee suffered a minor injury to his arm
spirits ranges from 104° F. (40° C.) to 1100 F. (43° C.).     when he tripped and fell while evacuating.
Universal Form Clamp Case Study                                                                          April 2007

• both exhaust fan drive belts were broken before               4.0 Incident Analysis
  the incident, and

• it was not designed to capture and remove a high
  volume of vapors from an open top tank.                       4.1     Failure Scenario

3.4.2 Area Ventilation                                          The CSB investigators identified the following most
                                                                likely failure scenario.
The area ventilation system included one supply
                                                                • On the morning of the incident, the operator
and two exhaust fans mounted at ceiling level.
There were no floor level exhaust registers (floor                began heating the batch of Super Clean and Tilt~
                                                                  in the mixing tank.
sweeps) to remove heavy vapors that accumulated
on the floor.9
                                                                • The temperature controller malfunctioned,
                                                                  allowing the steam valve to remain open and
Because the exhaust registers were located at
                                                                  heat the mixture to its boiling point.
ceiling level, and were a significant distance from
the top of the tank,1° the system was incapable of
removing tank vapors. Thus, when the mixture                    • The boiling mixture produced a heavy,
boiled, the vapor overflowed the tank and spread                  flammable vapor.
along the floor throughout the chemical mixing and
surrounding areas.                                              • The ventilation systems failed to remove the
                                                                  vapor and it overflowed the top of the tank,
                                                                  accumulating along the floor ofthe chemical
3.5     Eliminating Ignition Sources                              mixing area.

                                                                • The vapor cloud spread into ad     ent areas
The Hazardous (Classified) Locations (29 CFR
                                                                  where it was ignited by o ~v        ral possible
1910.307) standard covers the requirements for
                                                                  ignition sources.
electric equipment and wiring safety in locations
where flammables and combustibles are used.
                                                                4.2               and
                                                                        Proje~~sign
The mixing room was designed to meet the
                                                                         c\o~%sfriJction
requirements of 19 10.307, but the adjacent area
where the vapor cloud migrated and likely ignited,
was not. If the design for this process had included
the proper safety controls (i.e., local exhaust
                                                        (      ~
                                                                          p
                                                                            a professional chemist with concrete
                                                            °,~che1nical roduction experience to manage the
ventilation, a high temperature alarm, and/or a        £  ~   ‘design, construction, and operation ofthe chemical
                                                               mixing area. Shortly after his arrival he hired two
backup steam shutoff), the vapors would not hare \~)‘....
overflowed the tank and migrated into the                      engineers through a temporary service to work on
areas where multiple ignition sources                          the construction planning. They reported directly to
                                                               him, and it was their responsibility to draft the plans
                                                                for the building permit application.

                                                                 Despite the credentials of the managing chemist and
                                                                 the two engineers, the process was not designed and
                                                                 constructed in accordance with fire safety codes and
                                                                 OSHA regulations. In addition, mechanical design
~29 CFR 1910.Y~~and       NFPA 30 Flammable and
                                                                 plans that should have illustrated ventilation and
Combustible Liquids Code (1984 and 2003) require
floor-level ventilation for flammable liquid mixing     ~~t~safety            systems were not stamped or reviewed
operations
tO The nearest exhaust register was approximately 52 feet
away.
~ There were a number of unprotected circuits and
motors, including a fork truck, operating at the time of
the incident.                                                                                                         5
Universal Form Clamp Case Study                                                                             April 2007

4.5.2 Process Safety Management of                                    A mechanical integrity program could have
                                                                      identified the problems with the mixing tank
      Highly Hazardous Chemicals (29
                                                                      temperature controller and alerted UFC to the
      CFR 191 0.119)                                                  need to repair it

The Process Safety Management (PSM) standard                      • 1910.119(n) Emergency Planning and Response
provides a structured program for a systematic                        this section requires a plant-wide emergency
approach to chemical process safety and the                         action plan that meets the requirements of
prevention of catastrophic incidents. It applies to                 OSHA 1910.38 Emergency Action~P1ans. FC    U
facilities that use certain highly hazardous                        did not have such a plan.
chemicals and flammable gases and liquids above a
specified quantity. The quantity ofthe mixture
involved in this incident triggered the compliance                4.5.3 Emergency Action Plans (29 CFR
requirements of the PSM              ~  However, at                     1910.38)
the time of the incident, UFC had not implemented
a program to comply with this standard.                           This standard outlines the requirement for, and
                                                                  contents of, an emergency action plan (EAP). EAPs
The PSM standard requires adherence to 14                         are mandatory only when another OSHA standard
elements of safety management. The elements                       requires it.
relevant to the findings of this investigation are:
                                                                  The OSHA standards that are applicable to the
•   1910.119(e) Process HazardAnalysis (PHA) a        —           flammable mixing operation at UFC, and which
    PHA is an organized and systematic effort to                  require an EAP are
    identify and evaluate the hazards associated with
    a specific process. OSHA requires facilities to               • 29CFR 1910.Il9Process Safety Management
    perform an initial PHA on every covered                         of Highly Hazardous Chemicals
    process, and revalidate it at least every 5 years to
    ensure it remains relevant.                                   • l9lOCFRl9lO.l2OHaz           Waste
                                                                                                       a
                                                                    Operations and Em ergen’~J?esponse, nd
    A PHA performed by a competent team would
    have identified and evaluated the hazards                     •                        Extinguishers.
                                                                       1910.157 Por a9~”F~ire
    associated with the flammable mixing operation.
    It likely would have identified the lack of critical          Despite i~ hasis on flammable and combustible
    safety devices such as local exhaust ventilation,                         OSHA 1910.106 Flammable and
                                                                  liqi4~safet~,
    a high temperature alarm, and/or a backup steam                           Liquids does not require an EAP.’6
                                                                  t~i~’thJs)ible
    shutoff system that would have greatly reduced
    the likelihood of this incident.                                 a minimum, an EAP must contain procedures to
                                                           ‘s..   address
•   1910.119(j) Mechanical Integrity this se
                                         —

    requires a written program to maintain:                       • fire and emergency reporting,
    going integrity of critical process
    such as piping and valves,            ~re                     • emergency evacuation and identifying exit
    controllers, and emt                     vstems. It             routes,
    requires regular                          and
    testing procedi             LOW accepted and                  • non-evacuated employees who remain behind to
    generally                    engineering practices.             operate critical plant equipment,

                                                                  • head count for all employees after evacuation,


‘~At the time of the incident, the mixture was                     6OSHA 1910.106, based on NFPA 30(1969), does not
approximately 9000 pounds. However, the batch recipe              require an EAP. However, NFPA 30 (2003) does require
called for additional ingredients that would have                 an EAP, and requires the EAP to include procedures and
exceeded the 10,000 pound PSM threshold for                       schedules for conducting drills. See NFPA 30 (2003),
flammable liquids.                                                Section 7.12.4.                                       7
Universal Form Clamp Case Study                                                                      April 2007

• employees performing rescue and medical                   4.5.5 Portable Fire Extinguishers (29
  duties, and                                                     CFR 1910.157)
• employees needing more information about the              This standard requires employers who provide
  plan or to support their duties under the plan.           portable fire extinguishers to provide initial and
                                                            follow up training to employees expected to use
1910.38 also requires the employer to train
                                                            them. If, however, an employer does not intend
employees on the plan requirements and install an
                                                            employees to use the portable extinguishers, and
employee alarm system in accordance with 29 CFR             instead requires employees to evacuate, the
1910.165. It does not contain a requirement for
                                                            employer must comply with the EAP requirements
employee evacuation drills.’7
                                                            of 1910.38.
If UFC had implemented the EAP and employee
                                                            Although portable fire extinguishers were mounted
alarm system required by this standard, it is likely
                                                            on the walls throughout facility, UFC had not
that all employees would have been safely
                                                            conducted required employee training, and did not
evacuated from the facility and the fatally injured         have an EAP or an employee alarm system in place.
delivery driver would have been prevented from
                                                            While the lack of fire extinguisher training did not
entering the building.
                                                            contribute to the causes of this incident, the death
                                                            and injuries may have been prevented ifthe facility
4.5.4 Hazardous Waste Operations                            would have had an EAP and an employee alarm
      and Emergency Response (29                            system.
      CFR 191 0.120)
                                                            4.5.6          Hazardous (Classified)
The Hazardous Waste Operations and Emergency                               Locations (29 CFR
Response standard (HAZWOPER) applies to                                    1910.307)—See..~ection 3.5
facilities where there is a threat of a hazardous
substance release. It outlines two choices for an
employer. The employer can                                  5.0 Lessons Le~1ned
• require its employees to respond to releases, but
  must implement the rigorous emergency
  response requirements in the standard, or                 5.1     Pi~ectDesign and
                                                                    ~VIanagement
• it can require all affected employees to evacuate
  to a safe distance and rely on an outside response
  agency (e.g., the local fire or Hazmat                          designed and constructed a flammable liquid
  department).                                              heating and mixing operation using an open top
                                                            tank without adequate safety controls in place.
Employers who evacuate their                                Facility managers did not follow regulatory
an outside agency respond to                                requirements or good engineering practices. A
emergencies are exempt from                                 mechanical failure caused the mixture to overheat,
provided they develop an                                    which produced a flammable vapor cloud that
that complies with 29 C \~1’0~8.                                    and killed one and injured two.




                                                            L
UFC did not l~i’ve~~\   ergency action plan, and            A design professional i.e., a competent engineer,
                                                                                   —


had not traine~,employees on actions to take in             or person knowledgeable in the applicable
response to a hazardous substance release.                  building codes, regulations and consensus
                                                            standards should manage the design and
                                                                       —


                                                            construction of a facility that usesflammable
                                                            liquids.
~ The OSHA website “eTools Home” Evacuation Plans
and Procedures says “...it’s a good idea to hold practice
[evacuation] drills as often as necessary to keep
employees prepared.”                                                                                               8
   Universal Form Clamp Case Study                         April 2007

   5.2     Building Permit Code
           Review
   The Village of Bellwood municipal rules required
   UFC to comply with BOCA and NFPA codes and
   standards. However, during its permit application
   review the Village did not ensure such compliance,
   and did not require UFC to utilize a registered
   design professional.

  An experienced code reviewerknowledgeable in
  flammable and combustible liquid safety should
   thoroughly reviewfacility design plans submitted
   to the Village.

  Alternatively, in lieu of conducting a
   comprehensive code review, which may be
   impracticalfor a small municipality, the Village
   may require permit applications involving
  flammable and combustible liquids to include
   design and construction plans prepared by, and
   bearing the stamp of, a registered design
  professionaL

   In either case, the Village should inspect the
   completedproject to verify conformance with
   approvedplans.


~—5~3      Emergency Actions and
           Alarms
   UFC had no emergency action plan, employees had
   not received any emergency action training or
   conducted an evacuation drill, and the facility was
   not equipped with an employee alarm system.
   Seconds before the vapor cloud ignited, the faty
   injured contract driver walked through the lp~~’~
   dock area into the vapor cloud as it i~nit~d~ji’
   addition, the employeewho was sen         l~urned
   was unaware that he needed to     Q~     e, even
   though others working near          left because they
   saw or smelled the vapo      u

   Facilities ha?tdtj49tummable and combustible
   liquids shoulNpplement an Emergency Action
   Plan andpractice evacuation drills at least
   annually, but morefrequently if necessary to keep
   employees prepared.




                                                                        9
Universal Form Clamp Case Study                                                                               April 2007




~
    whose mission is to ensure the safety of workers, the public, and the environment by investigating and
    preventing chemical incidents. The CSB is a scientific investigative organization; it is not an enforcement
    or regulatory body. Established by the Clean Air Act Amendments of 1990, the CSB is responsible for
    determining the root and contributing causes of accidents, issuing safety recommendations, studying
    chemical safety issues, and evaluating the effectiveness of other government agencies involved in
    chemical safety,
    No part of the conclusions, findings, or recommendations of the CSB relating to any chemical accident
    may be admitted as evidence or used in any action or suit for damages. See 42 U.S.C. § 741 2(r)(6)(G).
    The CSB makes public its actions and decisions through investigation reports, summary reports, safety
    bulletins, safety recommendations, Case studies, incident digests, special technical publications, and
    statistical reviews. More information about the CSB is available at www.csb.gov.




                                  CS8 publications can be downloaded at
                                                or
                                  w~vw.csb.gov obtained by contacting:
                                       U.S. Chemical Safety and Hazard
                                              Investigation Board
                              Office of Congressional, Public, and Board Affairs
                                         2175 K Street NW, Suite 400
                                        Washington, DC 20037-1848
                                                (202)261-7600                                  ç~., ~


                                          CSB investigation Reports are formal,
                                          detailed reports on significant chemical
                                     accidents and include key findings, root causes,
                                        and safety recommendations. CSB Hazard
                                     Investigations are broader studies of significant
                                       chemical hazards. CSB Safety Bulletins are
                                     short, general-interest publications that provide
                                             new or noteworthy information on
                                        preventing chemical accidents. CSB Case
                              ~       Studies are short reports on specific accidents
                                     and include a discussion of relevant prevention
                       ‘Q                practices. ALl reports may contain safety
                ~,   çç\                recommendations when appropriate. CSB
                                         Investigation Digests are plain-language
                                            summaries of Investigation Reports.




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