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Case Study





        U.S. Chemical Safety and Hazard Investigation Board





         Key Lessons for Preventing Inadvertent Mixing


         During Chemical Unloading Operations



         Chemical Reaction and Release in Atchison, Kansas












                      Members of the U.S. Chemical Safety and Hazard Investigation Board:



                                             Vanessa Allen Sutherland, J.D./M.B.A.
                                                         Chairperson


                                                       Manuel Ehrlich
                                                          Member


                                                        Richard Engler
                                                          Member



                                                   Kristen Kulinowski, Ph.D.
                                                          Member
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