Abstract: AT ABOUT 6 AM ON MARCH 7, 1986, A CUSTODIAN AT THE GREENE ELEMENTARY SCHOOL DISCOVERED THAT THE BOILER WAS NOT WORKING. HE NOTIFIED THE PRINCIPAL AND A LOCAL ELECTRICAL CONTRACTOR. THE ELECTRICIAN FOUND A DEFECTIVE CONTROL DEVICE. HE TOLD THE PRINCIPAL THAT THE CONTROL MUST BE REPLACED BY A BOILER REPAIR COMPANY, BUT THAT THE BOILER COULD BE OPERATED MANUALLY IN THE INTERIM. THE CUSTODIAN PROCEEDED TO OPERATE THE BOILER MANUALLY, BUT DECIDED TO SHUT DOWN THE BOILER TEMPORARILY, AS HE HAD TO BE AWAY FROM THE SCHOOL FOR A SHORT TIME. WHEN HE RETURNED HE ATTEMPTED TO RESTART THE BOILER. IT EXPLODED, KILLING HIM. IT WAS DISCOVERED THAT HE HAD BYPASSED THE BUILT-IN SAFETY DEVICES BY BLOCKING THEM WITH A PIECE OF CARDBOARD.