HoltraChem Manufacturing Company - Executive Summary

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RISK MANAGEMENT PLAN PURSUANT TO 40 CFR 68(G) 
 
HoltraChem Manufacturing Company 
Orrington, Maine 
 
Introduction 
 
 
HoltraChem Manufacturing Company owns and operates a plant in Orrington, Maine, which is subject to U.S. Environmental Protection Agency (EPA) regulations governing Accidental Release Prevention (ARP) Requirements: Risk Management Programs under Section 112(r) of the Clean Air Act (40 CFR Part 68).  This Risk Management Plan (RMP) has been developed in accordance with the requirements specified under 40 CFR Part 68, Subpart G.  The RMP certifies that HoltraChem Manufacturing Company has instituted a Risk Management Program at the Orrington, Maine, facility that is in compliance with U.S. EPA ARP requirements.  
 
The RMP includes an Executive Summary and Data Elements following the format published by U.S. EPA.  This document identifies the applicable corporate policies and risk management systems, including comprehensive accident prevention and emergency response programs.   
In addition, this RMP identifies a set of worst case and alternative release scenarios, the potential off-site consequences of those releases, and the facility's five-year accidental release history.  This RMP certifies that prevention and emergency response programs are in place so as to minimize risks to workers and the potentially affected public.    
 
 
1.0  HOLTRACHEM MANUFACTURING COMPANY RISK MANAGEMENT POLICIES 
 
1.1    Control of Hazardous Materials 
 
HoltraChem Manufacturing Company recognizes its legal and moral responsibilities to manage its business in the most efficient and effective manner to ensure protection and enhancements of our nature environment. HoltraChem, and all of its associates, commit to continuously improving our understanding of plant's processes and products and their interaction with the environment. We will perform our day-to-day activities with continuous awareness of and concerns for the environment. HoltraChem is committed to saving and enhancing the quali 
ty of the waters, lands, and air of our communities and of the state for the benefit of the current as well as future generations 
 
HoltraChem maintains knowledge and understanding of all applicable federal, state, and local environmental laws and regulations and implements programs to assure compliance with them. Where, in the opinion of HoltraChem, the existing laws are not adequate to assure protection of the environment, we will establish our own environmental standards and support efforts to strengthen existing laws and regulations through the application of sound science.  
 
HoltraChem works diligently to prevent all releases to the air, land, and waters, and to minimize the amount and toxicity of wastes generated. This commitment is communicated to our associates, vendors, customers, and the public. HoltraChem strives to continuously improve our commitment to the environment and to the people of the state. 
 
 
 
1.2    Risk Management System 
 
 
HoltraChem Manufacturing Company has develo 
ped a management system to implement and maintain compliance with the Accidental Release Prevention (ARP) and related chemical safety and emergency response programs.  This management system identifies lines of responsibility for the entire program and each of its key elements, as illustrated in Figure 1-1.   
 
 
 
Figure 1-1 Organization Chart 
 
 
 
                                        Accidental Release Prevention Program 
 
                                                       Technical Manager 
                                                        Safety Manager 
 
 
 
Off-Site Hazard Assessment            PSM Program                 Emergency Response Program 
 
Technical Manager                            Safety Manager                          Safety Manager  
                                                        Process Engineer                       Technical Manager 
 
 
 
 
 
 
2.0  PROCESSES AND SUBSTANCES SUBJECT TO 40 CFR PART 68 
 
 
The HoltraChem Manufacturing Company manufactures c 
austic soda, chlorine, chloropicrin, and hydrochloric acid at the Orrington, ME, facility in a single integrated process. The raw materials utilized by the plant include water, salt, and electricity. Several of the chemicals manufactured and stored at the facility are present at or above threshold amounts for regulated substances and are regulated under 40 CFR Part 68. The substances subject to the above regulation, which addresses the potential off-site hazards of accidental releases, are chlorine  (Cl2) and hydrochloric acid (HCl). 
 
The EPA Risk Management Regulation identifies three levels of requirements for industrial processes.  Program 1 can be applied to any process which has not had a "significant" release of a regulated substance over the five year period prior to the June 1999 compliance date and for which the worst-case release does not affect "public receptors" (e.g., residences, parks and recreation areas, commercial/industrial facility, hospitals).  Program 2 applies to  
any process that is ineligible for Program 1 and is not subject to Program 3.  Program 3 applies to all processes, such as those present at the HoltraChem facility, that are subject to the Occupational Safety and Health Administration (OSHA) Process Safety Management Standard (PSM). The HoltraChem Accident Prevention Program elements are adopted directly from the compliance program for the PSM standard, consistent with the Level 3 RMP Program requirements for this HoltraChem facility under 40 CFR Part 68.  Program 3 related information is included in the Data Elements section of the Risk Management Plan. 
 
2.1  Chlorine Production System  
 
Chlorine is produced at the HoltraChem Orrington facility as part of an electrolytic process in which a strong electrical current is passed through a mixture of salt and water (brine). The electric current passes from an anode (+ charge) through the brine mixture, to a cathode (- charge) made of mercury.  The strong electric current splits the salt mo 
lecules into sodium and chlorine atoms.  Chlorine gas is then captured, pressurized and stored  at ambient temperature as a liquefied gas in three receivers (horizontally oriented cylindrical storage tanks).  Each receiver can store up to 300,000 lb of liquefied chlorine, although typically no more than two receivers are in use at any time.   Chlorine is then transferred to 90 ton capacity railcars for shipping. 
 
 
 
 
2.2  Hydrochloric Acid System 
 
 
Hydrochloric acid is produced as part of the same electrolytic process used in the chlorine production system. Sodium atoms created in the electrolytic process are converted through chemical processes to caustic soda and hydrogen.  The hydrogen is then burned with chlorine to form high strength 230Be hydrochloric acid (38% HCL solution in water). The HCl solution is stored at ambient temperature in a tank farm, which is surrounded by a concrete dike.  The HCl is then pumped into tank trucks for shipment. 
 
 
 
 
3.0  HAZARD ASSESSMENT 
 
 
For the p 
urposes of developing and maintaining adequate Risk Management Plans, the EPA has defined in its governing rules and guidance a series of modeling methods and assumptions, which are to be used as administrative guides for planning purposes.  In order to standardize and simplify the many factors that can potentially occur in an accidental release situation, some of these assumptions may not take into account the available preventive measures or mitigation methods that could diminish or even eliminate the implied risks that are suggested by "worst-case" analyses. For that reason, both the results for the standardized "worse-cases" defined by the EPA methods and a set of alternative cases which are believed by HoltraChem to more realistically represent situations that may possibly, but rarely, occur within the lifetime of the facility are also presented. The sections of the Risk Management Plan which discuss both worst-case, and alternative cases, are meant to provide the data necessary t 
o develop and evaluate possible improvements in the overall safety programs of the HoltraChem RMP program.  
 
 
 
3.1.Worst-Case Release for Toxic Substances 
 
The worst-case release scenario, as defined by 40 CFR Part 68, is a sudden release of the maximum amount of a stored regulated substance from a single vessel, regardless of whether several vessels are interconnected.  For toxic gases such as Cl2 stored at ambient temperatures it is assumed that the release occurs over a 10-minute period. Toxic liquids, like HCl, are assumed to spill instantaneously and spread to a depth of 1 cm in an undiked area or to cover a diked area.  The duration of the release is based on the evaporation rate of the toxic liquid and the amount spilled. The regulated substance with the most extensive zone of influence, defined as the distance to specified toxic "endpoints", is considered the worst-case release for each facility.  Only passive mitigation (e.g., dikes, enclosures) and administrative controls 
may be accounted for in the evaluation. 
 
EPA has established "toxic endpoints" for various chemicals based on the American Industrial Hygiene Association (ACGIH) Emergency Response Planning Guideline, Level 2 (ERPG-2), which protects individuals from health-threatening or escape-impairing injury.  The ERPG-2 is defined as: 
 
"the maximum airborne concentration below which it is believed that nearly all individuals could be exposed for up to 1 hr without experiencing or developing irreversible or other serious health effects or symptoms which could impair an individual's ability to take protective action." 
 
Given that the worst-case is a 10-minute release duration with a 10-minute concentration averaging time, the actual hazard zone is typically overestimated by the ERPG-2. Within such a time period there are a number of emergency measures that can reduce or eliminate exposures to levels this high for an interval much shorter than an hour. 
 
Under Section 68.22 (e), the RMP rule identifi 
es "surface roughness" as a parameter to be specified in the hazard assessment. The surface roughness affects the amount of dispersion that occurs within a released plume and influences the distance to toxic endpoint. The surface roughness used in determining the distance to toxic endpoint should be characteristic of the transport path of the plume from the release point to the endpoint distance.  'Urban' surface roughness indicates areas where there are many obstacles, such as industrial buildings or trees.  'Rural' indicates that there are no buildings in the immediate vicinity of a facility and that the terrain is generally flat and unobstructed.  
 
In the immediate vicinity of the HoltraChem Orrington facility, the aerodynamic surface roughness is 'urban' in nature, due to the buildings, tanks and structures at the site.  At greater distances, although the area is heavily vegetated, the surface roughness becomes more 'rural', especially along the river valley.  In order to report th 
e most conservative 'distance to toxic endpoint' estimates in the Risk Management Plan, HoltraChem has elected to model the worst-case release scenario assuming 'rural' surface conditions. However, it should be noted that under actual conditions, plume dispersion would be enhanced by the 'urban' type surfaces located near the facility, and result in shorter distances to toxic endpoint. 
 
The EPA's RMP Off-site Consequence Analysis Guidance (1999 Revised OCAG) was utilized to determine distance to toxic endpoint values for the worst-case release scenarios. The OCAG guidance lists a number of refined dispersion models that are also available for off-site hazard assessment applications for risk management programs.  Both chlorine and hydrochloric acid have molecular weights that are substantially greater than the ambient air.  For this reason, concentrated plumes of these substances resulting from accidental releases often display heavy-gas behavior.  In such a case, near-field dispersion  
is dominated by gravitational slumping of the plume and entrainment of air at the plume-air interface.  One of the models listed in the OCAG  commonly used for heavy-gas releases is SLAB.  SLAB, developed by Lawrence Livermore Laboratory, can be utilized to model scenarios that are not directly addressed in the 1999 Revised OCAG.   For these reasons, the OCAG was used to determine the endpoint distances for the worst case releases, while SLAB was used to determine the endpoint distances for the more complex alternative release scenarios. 
 
In accordance with 40 CFR Part 68, the worst-case modeling is conducted assuming a very stable atmosphere with limited dispersion (F stability and 1.5 m/sec wind speed).  Analysis of four years of meteorological data from the National Weather Service at the Bangor International Airport, ME, indicates that these dispersion conditions occasionally occur in the area.  The most predominant directions of transport are to the north and southeast.  
 
Worst-ca 
se dispersion modeling conducted with EPA's RMP 1999 Revised OCAG indicates that, among the two regulated substances, chlorine would result in the greatest distance to toxic endpoint. The toxic endpoint for Cl2 is 0.0087 mg/L.  Since the resulting planning zone predicted for the "worst-case" Cl2 toxic release potentially affects public receptors, regulated processes at the HoltraChem Orrington facility are subject to Program 3 requirements.  40 CFR Part 68 requires that the substance with the largest distance to toxic endpoint be reported in the Worst-Case Release section of the Risk Management Plan.   Therefore, only the Cl2 release results are included in the Data Elements section. 
 
3.1.1    Worst-Case Release: Chlorine 
 
The worst-case scenario for the Orrington facility consists of a 10-minute gaseous ground-level release of 300,000 lbs of stored Cl2, dispersed under atmospheric conditions of F stability and 1.5 m/sec wind speed.  A gaseous release of this magnitude over such a short t 
ime-span is  physically impossible because the amount of heat energy required to so rapidly vaporize the liquid Cl2 would not be available.  Even if the storage tank were to breach, liquid Cl2 would spill to the ground in a boiling pool.  If a hole were to form in the vapor space of the storage tank, the flashing vapor in the tank would cause the tank to auto-refrigerate, thereby gradually reducing the release rate with time.  The selection of the worst-case release for Cl2 should, therefore, be viewed as a regulatory required program element, rather than a realistic representation of a worst-case release event. 
 
The modeling results indicated that under 'rural' surface conditions the worst-case Cl2 release would result in a distance to toxic endpoint of greater than 25 miles.  The worst-case impact zone encompasses a resident population of approximately 130,000, based on the 1990 Federal Census, and estimated by applying EPA's Landview III program.  Public receptors were identified us 
ing 1:24,000 scale U.S.G.S maps, supplemented with comprehensive maps of the local area (DeLorme Street Atlas USA, Version 5).   The potential worst-case hazard zone includes schools, hospitals, prisons, public recreation areas, and industrial/commercial areas. Several environmental receptors (defined as National or State parks, forests, officially designated wildlife sanctuaries, preserves, refuges, and federal wilderness areas) are also located within the worst-case impact zone.  The closest environmental receptor is the Black Woods.   
 
 
3.2    Alternative Releases of Toxic Substances 
 
Alternative releases are intended to represent release scenarios that have a greater likelihood of occurrence than a worst-case release.  Alternative releases do not necessarily represent the types of releases that the PSM hazards analysis and/or accident history indicate would be most frequent, but rather a release that is somewhat more likely than the worst-case release and that generally still has the  
potential to affect off-site receptors. In accordance with the EPA's OCAG, a single alternative release scenario is reported for each regulated substance.  
 
HoltraChem performed a thorough review of the facility utilizing engineering plans, operational experience, and maintenance records, in order to determine alternative release scenarios that could potentially result in off-site impacts. Each scenario was evaluated and the scenarios most likely to occur and to result in off-site impacts were selected for modeling. In order to determine the most conservative off-site consequence estimates, HoltraChem has chosen to include in the Risk Management Plan the alternative release scenarios that resulted in the greatest toxic endpoint distance for each regulated substance. 
 
In accordance with the RMP rule, alternative releases are modeled under typical (rather than worst-case) dispersion conditions.  The EPA OCAG default dispersion conditions are neutral atmosphere, with dispersion neither en 
hanced nor limited (D stability and 3 m/sec wind speed). A review of climatological data for Bangor, ME, confirmed that these conditions are typical of the area and therefore are suitable for the evaluation of alternative releases. Unlike the worst-case release (for which an instantaneous spill or 10-minute ground-level gas release is assumed), alternative scenarios can account for the actual release configuration, and account for both active and passive mitigation. 
 
Alternative dispersion modeling was conducted using the SLAB dense gas dispersion model.  Because the surface roughness in the immediate vicinity of the Orrington facility is urban in nature, and alternative releases typically result in relatively short endpoint distances, an urban surface roughness value was utilized in the alternative release modeling.  
 
3.2.1     Chlorine 
 
The alternative Cl2 release scenario that would result in the greatest off-site impact involves a break in the Cl2 loading line to the railcar. A break  
of this type would result in two-phase flow (vapor and liquid) as the pressurized Cl2 flashed to the vapor state.  The modeling indicated that Cl2 would be released at a rate of 125 lbs/min.  It is conservatively assumed that the Cl2 would then be dispersed as a heavy gas.  HoltraChem has estimated that it would take an operator approximately 6 minutes to respond and shutdown the flow of Cl2, resulting in a total release of 750 lbs.  This alternative Cl2 release scenario is expected to be more representative of the maximum anticipated release at the facility than the "worst-case".   
 
The SLAB modeling indicates that under urban conditions, the distance to toxic endpoint would be 1.0 miles. The hazard impact zone encompasses an estimated residential population of approximately 900 persons, based on the 1990 Federal Census, and estimated in conjunction with EPA's Landview III database program.  Public receptors in the alternative impact zone include a school, public recreation areas, and 
industrial/commercial areas.  No environmental receptors would be affected. 
 
3.2.2    Hydrochloric Acid  
 
The alternative HCl release scenario that would result in the greatest off-site impact involves overfilling a tank truck. The HCl would be released at a rate of approximately 250 gallons per minute. HoltraChem has estimated that it would take an operator approximately 2 minutes to respond and shutdown the flow of HCl, resulting in a total release of 500 gallons of HCl.  
 
The SLAB modeling indicates that under urban conditions, the distance to toxic endpoint would be 0.3 miles.  The hazard impact zone encompasses an estimated residential population of approximately 30 persons, based on the 1990 Federal Census, and estimated in conjunction with EPA's Landview III database program.  Public receptors in the alternative impact zone include industrial/commercial areas. No environmental receptors would be affected. 
 
 
4.0  ACCIDENT PREVENTION PROGRAM 
 
The processes subject to the Risk Manag 
ement Regulation are also subject to Occupational Safety and Health Administration (OSHA) Process Safety Management (PSM) Standard.  PSM governs the same processes and regulated substances at the site that are subject to 40 CFR Part 68.  The HoltraChem Orrington PSM program includes the following elements: 
 
1. Employee Participation 
HoltraChem Manufacturing Company provides for and encourages employees to participate in all facets of process safety management and accident prevention.  Examples of employee participation range from updating and compiling technical documents and chemical information to participating as a member of a process hazard analysis team.  Employees have access to all information created as part of the accident prevention program.  These policies are documented in an employee participation plan that is maintained at the plant. 
 
2.  Process Safety Information 
The plant keeps a variety of technical documents that are used to help maintain safe operation of the proces 
ses.  These documents address chemical properties and associated hazards, limits for key process parameters, specific chemical inventories, and equipment design basis/configuration information.  The information is kept in large binders that are distributed to several areas of the plant, in the computer-based "tool book" system, and in file cabinets in the learning center.  
 
3.  Process Hazard Analysis (PHA) 
HoltraChem has a comprehensive program to help ensure that hazards associated with the various processes are identified and controlled.  The chlorine and the hydrochloric acid systems are Program 3 processes.  The plant uses the What-If/Checklist analysis technique to perform the evaluation of the regulated systems.  The analyses are conducted using a team of people who have operation and maintenance experience as well as engineering expertise.  This team identifies and evaluates hazards of the process, accident prevention and mitigation measures, and make suggestions for additional 
prevention and/or mitigation measures when the team believes such measures may be necessary.  The recommendations from the PHA teams are tracked to completion. 
 
4.  Standard Operating Procedures 
HoltraChem maintains written procedures that address various modes of process operations, such as (1) unit startup, (2) normal operations, (3) temporary operations, (4) emergency shutdown, (5) normal shutdown, and (6) initial startup of a new process.  These procedures form the basis of the operator training and are periodically reviewed and annually certified as current and accurate.  
 
 
5.  Training 
To complement the written procedures for process operations, HoltraChem has implemented a comprehensive training program for all employees involved in operating a process.  A combination of classroom and on-the-job training and observation is used to ensure the person has developed the necessary skills.  All operators receive refresher training each three years on the complete process to ensure th 
at their skills and knowledge are maintained at an acceptable level.  The training is documented for each operator. 
 
6.  Contractors 
HoltraChem conducts a contractor screening policy before hiring contractors to work in the plant.  The HoltraChem engineering and safety departments periodically review contractor performance to assure that contractors are fulfilling their safety obligations.  A training program covering specific hazards appropriate to the job being done by contractors is conducted by the HoltraChem contact before the contractor can begin work. 
 
7.  Management of Change (MOC) 
A comprehensive system exists to manage changes to all covered processes.  This system requires that changes to items such as process equipment, chemicals, technology, procedures, and other facility changes be properly reviewed and authorized before being implemented.  Affected chemical hazard information, process operating limits, and equipment information, as well as procedures are updated to inc 
orporate these changes.  In addition, operating and maintenance personnel are provided any necessary training on the change.  The progress of implementing each MOC is tracked. 
 
8.  Pre-Startup Safety Reviews (PSSR) 
A pre-startup safety review is integrated into the Management of Change system.  A PSSR involves field verification of the construction and serves a quality assurance function by requiring verification that accident prevention program requirements were properly implemented. 
 
9.  Mechanical Integrity 
HoltraChem has well-established practices and procedures to maintain pressure vessels, piping systems, relief and vent systems, controls, pumps and compressors, and emergency shutdown systems in a safe operating condition.  The basic aspects of this program include: (1) conducting training, (2) developing written procedures, (3) performing inspections and tests, (4) correcting identified deficiencies, and (5) applying quality assurance measures.  In combination, these activities  
form a system that maintains the mechanical integrity of the process. 
 
10.  Safe Work Practices 
HoltraChem has safe work practices in place to help ensure worker and process safety.  Procedures for Hot Work, Confined Space Entry, Lock Out/Tag Out, and control over authorized personnel entry to the work site are in place.  Additional special procedures covering Line Break are performed as required. 
 
 
11.  Incident Investigation 
Investigation of incidents that resulted in, or reasonably could have resulted in, a fire/explosion, toxic gas release, major property damage, environmental loss, or personal injury is performed at the plant.  Near misses are included in the definition of incidents which require investigation.  The investigation team documents its findings, develops recommendations to prevent a recurrence, and forwards these results to plant management for resolution.  Corrective actions taken in response to the investigation team's findings and recommendations are tracked until  
they are completed. 
 
12.  Compliance Audits 
Compliance audits for the accidental release prevention program elements are conducted each three years.  The audit team develops findings that are forwarded to plant management for resolution.  Corrective actions taken in response to the audit team's findings are tracked in the data base until they are completed.  The final resolution of each finding is documented. 
 
 
5.0  FIVE-YEAR ACCIDENT HISTORY 
 
 
In conjunction with the current RMP and PSM programs in place at the Orrington plant, there is a standard management practice that requires immediate internal reporting of unusual events, including those in which any abnormal emission of regulated chemicals is observed or suspected.  The incident information is reviewed by supervisory staff and a determination is made as to whether a reportable quantity on any chemical listed as requiring reports to regulatory authorities is involved.  If so, the appropriate authorities are promptly notified. 
 
 
During the past 5 years (June 1994 to June 1999), there has been one accident involving an ARP regulated substance that qualifies for reporting under 40 CFR Part 68. The accident which occurred on an evening in November 1997,  did not result in any injuries, deaths or property damage, but involved off-site site emergency response, provided by the Orrington Fire Department.  This accident involved collision of a railcar with a chlorine railcar that was in the process of being loaded.  An estimated 1600 lbs of chlorine was released. The release, which was effectively stopped after about ten minutes, was also reported by HoltraChem via telephone to the Maine State Police, Penobscot County Sheriff and the National Response Center.  The subsequent accident investigation determined that operator error was the key factor in the accident.  Steps were immediately taken to review loading and switching procedures and reinforce training of personnel on safety and environmental procedures to preve 
nt similar accidents from occurring in the future. In addition, a remotely actuated valving system was installed to close the chlorine loading line valves in the event of an emergency. 
 
 
6.0  EMERGENCY RESPONSE PROGRAM 
 
 
HoltraChem's Orrington plant has established an Emergency Action Plan that is designed to address foreseeable emergency situations at the facility and provide appropriate hazard and emergency preparedness information to employees, contractors, emergency response personnel, and the community.  In regards to chemical releases, HoltraChem has developed a dedicated command structure and specific procedures that must be adhered to in the event of a chemical emergency.  These procedures define the criteria for identifying, classifying, and notifying the appropriate emergency response staff of potential emergency events.  
 
Plant operations at the Orrington facility can present various types of potential hazards and HoltraChem recognizes the need to have a well trained and pre 
pared work force to safely and effectively deal with any emergency situation.  The HoltraChem Orrington facility insists on continuous training of responsible staff and the exercise of important communication links with the community, in order to maintain an appropriate state of readiness for emergency situations.  HoltraChem Orrington plant staff attend  periodic meetings with local industry and emergency response planning officials and have participated in emergency response training exercises.  HoltraChem staff have a "First Response" capability and are able to administer basic first aid and CPR.  HoltraChem and local emergency response planning officials also rely on the Orrington Fire Department  to offer paramedical assistance and transportation to the health center. 
 
 
 
7.0  PLANNED CHANGES TO IMPROVE SAFETY 
 
 
 
HoltraChem's Orrington plant, under the recent RMP program, as well as its existing PSM and earlier SARA Title III Community Right-to-Know Act compliance programs has orga 
nized its management system to effectively address all hazards and potential risks.  Both the advanced planning aspects of process design, operating procedures, and emergency preparedness, and the operational elements of system maintenance, safe operating practices and ongoing personnel training are necessary to support a continual improvement in facility safety.  These programs are thoroughly documented so that information about the safe handling of chemicals present at the facility is available to all employees, and can be readily interpreted by emergency response team staff and the Incident Commander. This is especially important when questions arise from public safety officials regarding potential risks to the community.  All of these features of the RMP and the integrated risk management program at the Orrington plant lead to operations that are safe today, but will be even safer tomorrow. 
 
HoltraChem Orrington's safety program incorporates continuous improvement through use of au 
dits, inspections, and on-going evaluations of in-plant safety and program effectiveness.  The information gathered is evaluated and improvements that are identified are incorporated into the program.   
 
 
 
HoltraChem Manufacturing Co.     Orrington          RMP Executive Summary June 15, 1999
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