even at the high temperatures used in this case, are available. Whose job is it to see the need for such lubricants and see that they are used?
14 Learning from Accidents
Figure 1.1 Unicorn or oryx? What we see depends on the way we look (Copyright: Bill Clark)
In an area where flammable liquids or gases are handled seized bolts would normally be cut off rather than burned off. In the present case access was so poor that it was decided to burn them off. Why was access so poor? The normal policy in the company was to build a model of the plant before detailed design is carried out and to review access for maintenance on the model (as well as access for operations, means of escape and many other matters). What went wrong in this case? Was the model review really carried out and were operating and maintenance people present?