Hōʻike: He aha ka mea i hana i ka lā i make ai nā limahana ʻelua ma West Haven, Virginia

ʻO ka pā kula ʻo VA Connecticut Health Care System ma West Haven e like me ka nānā ʻana mai ke alanui West Springs ma Iulai 20, 2021. Westport - Ua ʻike ʻia ka hoʻokolokolo Federal ma Nowemapa 13, 2020, he flange hao maʻalahi i loko o kahi laina mokumahu kahiko i loko o kahi hale Veterans Affairs Medical Center koke. ʻoki ʻia i ʻehā ʻāpana, hoʻokuʻu i ka mahu kiʻekiʻe a make ʻelua mau kānaka make. ʻO ka hoʻokolokolo ʻana o ka VA i ka ulia i hōʻike ʻia i nā hanana o ke kakahiaka, e wehewehe ana i ke ʻano o Joseph O'Donnell, kahi mea hana ʻaelike i hoʻolimalima e hoʻoponopono i ka leak i loko o ka pipeline, i komo i ka haʻahaʻa o ka Hale 22 ma hope o ka hoʻoponopono ʻana, i ukali ʻia e Euel Sims Jr., ka paipu paipu. luna, a ʻO ka hemahema o nā lako a me nā hana palekana i alakaʻi i ko lākou make. Akā ua ʻōlelo ka hōʻike i nā mea e pili ana i ka hanana 2020 e pili ana i ka paipu kahiko a ʻaʻole i hoʻokō i nā kūlana waiwai o kēia manawa, nā kīwī i hoʻokomo pono ʻia a me nā paipu e alakaʻi ana i ka wai stagnant, a ʻōlelo ʻia ʻaʻole e hahai i nā kaʻina hana e mālama ai i nā kāne. ʻO ka puka komo o ke alanui West Springs o ke kahua kula ʻo VA Connecticut Health Care System West Haven, i kiʻi ʻia ma Iulai 20, 2021. ʻO ka hopena, i ka wā i wehe ai nā kāne i nā paipu, ua lele ka mahu ma ka paipu 6-iniha, a ua nui ke kaomi ʻana i ka flange. wili ʻia i lalo o ka pahu kuʻi kū i ʻehā mau ʻāpana, puhi i ka mahu i loko o ka lumi. Hōʻike. ʻO ka hōʻike hoʻokolokolo VA, i hoʻokuʻu ʻia i ka lā 15 ʻApelila, ua loaʻa mai e ka New Haven Registry ma o kahi noi Freedom of Information. Ua hoʻoponopono ʻia nā inoa limahana a pau. ʻO ka hanana i alakaʻi i ka loiloi o West Haven Virginia i hāʻule ʻole, ka hopena i ʻeiwa mau leka OSHA a kāhea aku i ka Congress e kūkulu hou i ke kikowaena olakino. Wahi a ka hōʻike, ua hoʻomaka ke kaulahao o nā hanana i ʻOkakopa a i ʻole Nowemapa 2020, i ka wā i hōʻike ʻia ai ka palekana o Virginia no kahi leak i loko o kahi lumi mālama ma ka Hale 22, kokoke i ka hopena o ke ala nui ma ke komo ʻana o Campbell Avenue. Ua koi ʻia ka ʻoihana paipu e hoʻokaʻawale i ka mahu mai ka hale i mea e hōʻemi ai i ka asbestos. Ma ka lā 13 o Nowemapa, ua hoʻopau ka noho ʻana o Danbury a me ka mea hana ʻaelike Mulvaney Mechanical ʻo Mulvaney Mechanical ʻo O'Donnell i ka hoʻoponopono ʻana i ka leak ma ka hola 7:45 amI ka hola 8:00, ua haʻi aku ʻo Sims, he kanaka Navy Seabees a he kamaʻāina ʻo Milford, i kona luna e manaʻo ana e hoʻihoʻi i ka mahu. Ua hele na kanaka ekolu i ke alanui a hiki i ka hale, aka, ua noiia ka luna nana o Sims e wehe i keena kaawale ma ka Hale 22, wahi a ka hoike. Ua hoikeia mai ua hele aku o O'Donnell a me Sims i ka lumi mīkini ma lalo o ka hale 22 e hoohuli i ka pahu mahu. Ma kahi o ka hola 8:10, ua ʻōlelo ka hōʻike, "Ua lohe ka luna hoʻokele waiwai i ke kani nui a ʻike ʻo ia i kahi kahe o ka mahu e puka mai ana mai ke alapiʻi e alakaʻi ana i ka lumi mīkini. Ua hoʻopaʻa ʻia ka nalowale o ke kaomi mahu ... . ." Ua pani ʻia ka hale hoʻoheheʻe ʻo Virginia, a ua pane aku ka West Haven Fire Department, Virginia State Police a me nā mea pane mua. "Ma hope o ka hāʻule ʻana o ke kaomi mahu a me ka mahana o ka lumi, ua hiki i nā limahana pilikia ke komo i loko o ka lumi, akā i kēia manawa ua make ka luna hale kūʻai paipu a me ka mea hana mīkini," wahi a ka hōʻike. A hiki i ka hola 1:00 pm; ma kahi o 2:15, ua lawe ʻia ka mea i pepehi ʻia. ʻO ka hoʻokolokolo ʻana o ka VA e Applied Technical Services ma Marietta, Georgia, ua ʻike ʻia ua ikaika loa ka hoʻokuʻu ʻia ʻana o ka mokumahu wela loa i hiki ʻole i nā kāne ʻelua i hoʻāʻo e pana i ka puka o ka lumi 8-by-12-foot. ua hoʻā ʻia kona wāwae mai ka wai wela, wahi a ka hōʻike. Kiʻi mai ka US Department of Veterans Affairs "West Haven Steam Rupture, Board of Inquiry Investigation" hōʻike memo, i hoʻopaʻa ʻia ma ʻApelila 15, 2021, e hōʻike ana i ka "Pipe Configuration - Time of Investigation." "I ka hāʻule ʻana o ka flange hao, ua hiki i ka laina mahu nui 6" ke kahe i loko o ka lumi," wahi a ka hōʻike. "Ua kaomi ʻia ka lumi me ka mahu i ka wā i hoʻomaka ai ka mahu e kahe i loko o ka lumi mai ka laina mahu ʻole. e hana ana i mau tausani paona ikaika ma loko o ka puka, e koi ana e pani. I keia manawa, he mea hiki ole ke wehe i ka puka me ka mea kaumaha ole. a ʻo ka lā o ka ulia pōpilikia, hui pū ʻia me nā paipu kulu i hoʻokomo pono ʻole ʻia, ʻo ia ke kumu o ka make, wahi a ka hōʻike. 'o ia kekahi kumu o ka ulia pōpilikia," wahi a ia. Me kahi o ekolu hapaha o ke galani o ka wai i loko o ka dropper, 'aʻohe wai hoʻokahe a wai pahu hopu i koi 'ia. Ua 'ōlelo mai ka poʻe noiʻi ua hoʻopili ʻia ka flange mahā i kahi flange hakahaka ma ka hopena o ka mea kulu a pono e wili ia, aole i kaula, i ka paipu. Ua haki ʻia nā flanges ma hope o "kahi manawa maʻamau o ka hāmare wai," i ʻōlelo ʻia e ka hōʻike. ʻO ka hāmare wai he hawewe hoʻohāhā hydraulic i hoʻokumu ʻia e ka wai a i ʻole ka mahu i koi koke ʻia e kū a hoʻololi i ke ala a laila hoʻopaʻa ʻia i kahi valve a i ʻole kekahi mea pale. He mea maʻamau ia ma muli o ka hōʻiliʻili ʻana o ka wai i loko o nā paipu mahu. I ka wehe ʻana o ka pahu a komo ka mahu i loko o ka paipu i loko o ka lumi mīkini, paʻi ia i ka wai maʻalili i loko o ka pahu me nā hopena pōʻino. paipu," wahi a ka hōʻike. "a ʻo ia ke kumu nui loa o ka hāʻule koke ʻana o nā flanges hao hina hina". "Ua loaʻa i ka flange target kahi hemahema ma muli o kahi ukana ma mua o ka mea hiki ke mālama," wahi a ka hōʻike. Kiʻi mai ka ʻApelila 15, 2021 US Department of Veterans Affairs "West Haven Steam Rupture, Board of Inquiry" hōʻike memo e hōʻike ana i ka " flange damage " ma ka Hale 22. e hōʻike ana ʻaʻole i hoʻoulu hou ʻia ka ʻōnaehana i kēia ʻano o ka ʻōnaehana e pono ai ka lohi a me ka hoʻohālikelike ʻana i ke kaomi," wahi a ia. "Ua wehe ka poʻe hana i ka 75% o ka pahu mahu #1. Ua wehe pū lākou i ka pahu pōlele i loaʻa ma ka laina hoʻihoʻi condensate laina hoʻihoʻi nui," wahi a ka hōʻike. Ua wehe pū ʻia ʻelua mau kiwikā ʻē aʻe, hoʻokahi 5% a 6%, ʻo kekahi i wehe ʻia he 11%. Kiʻi mai ka US Department of Veterans Affairs "West Haven Steam Rupture, Board of Inquiry" hōʻike memo, i hoʻopaʻa ʻia ma ʻApelila 15, 2021, e hōʻike ana i ka "Threaded Pipe Connection, Drip Bottom." "ʻO ka wehe ʻana o ka valve pōleʻa e hāʻawi koke i nā manaʻo i nā limahana ma ke ʻano o ka kahe mahu a me ke kahe condensate e hōʻoia i ka hana ʻana," wahi a nā mea noiʻi. "ʻAʻole maopopo ke kaʻina pololei o ka wehe ʻana o kēlā me kēia valve, akā ʻoi aku ka maikaʻi e wehe mua i ka laina condensate." ʻO ka valve pōpō liʻiliʻi." Eia naʻe, ʻoiai ka hōʻike ʻana o ka wehe ʻana i ka pahu pōleʻa e hoʻokahe i ka condensate mai ka laina a i ʻole ke kiʻekiʻe, ʻaʻole ia e hoʻokahe i ka wai a pau i ka laina kulu "a ʻo kēia wahi o ka laina mokuahi nui aia nō 3 /4 galani condensate." Ua ʻōlelo ka hōʻike i ka paipu ma ka Hale 22 ua uhaki i nā code lehulehu. ʻAʻole ʻae ʻia nā flanges hao hao ma nā ʻōnaehana paipu mahu ma lalo o kēia mau code, akā ʻaʻole i pāpā ʻia e nā code VA a i ʻole ASME, wahi a ka hōʻike." ʻAʻole ia he hōʻike e kuhikuhi ana ʻo Virginia i kekahi i ka wā ma mua e wehe a pani paha i ka flange," wahi a ia. ʻAʻole i ʻae ʻia ma lalo o ke code VA, "wahi a ka hōʻike. ʻO kekahi pilikia, i ʻōlelo ʻia e ka hōʻike, "ʻo ka hiki ʻole ke hoʻokaʻawale i kekahi o nā laina mokuahi nui ʻekolu, ʻaʻole hiki i ka mea kanu boiler ke hōʻoia i ka palekana o ka hale paila holoʻokoʻa" . e kekahi mea ʻē aʻe ma waho o ka mea nāna i hoʻopau. Wahi a ka hōʻike: "Ua loaʻa kahi laka VA a me ke kaulahao ma kahi kokoke i ka valve lumi, e hōʻike ana ua paʻa paha ka ʻōnaehana. Eia nō naʻe, ʻaʻohe lockout tagout (LOTO) log, ʻae a i ʻole nā ​​kaʻina hana LOTO no ka ʻōnaehana. ʻAʻole i loaʻa i nā ʻimi keʻena nā lāʻau LOTO a i ʻole nā ​​​​kaʻina hana no kēia mau kiwi a hale paha." Ua hāʻule pū ka kamaʻilio ʻana ma waena o ka palekana, ka paipu, a me ka ʻenekinia: "ʻAʻole i hoʻolaha ʻia ka hale paila no kēia pani ʻana, ʻaʻole hoʻi i haʻi ʻia no ka pani mau ʻana. ʻAʻole maopopo i ka ʻike ʻana o ke alakaʻi ʻenehana a i ʻole ka palekana i kēia lā. ke holomua nei ka hana," wahi a ka hōʻike. ʻAʻole i loaʻa i ka hui kahi hōʻike no ka laka hou aʻe i kau ʻia e ka mea hana ʻaelike." Ma ka lā 12 o Mei, ua hoʻopuka ʻo OSHA i ʻeiwa mau leka e pili ana i nā kūlana hana palekana a maikaʻi ʻole paha ma Connecticut, me ka hoʻomaopopo ʻana i nā mea kanu boiler e haʻalele / hōʻailona ma nā laina hana; ʻaʻole e haʻi iā Mulvaney Mechanical o kona mau kaʻina hana LOTO; a i ʻole ka hoʻopaʻa ʻana i nā mea hana" i hiki ke hoʻokaʻawale ʻia ka condensate mai ka ʻōnaehana. Eia kekahi, ua ʻike ʻo OSHA ʻaʻole i hōʻoia ka VA i ka ʻole o ka wahi hana i nā pōʻino i hiki ke hopena i ka make a i ʻole ka hōʻeha, a ʻaʻole i aʻo ʻia nā luna hoʻomalu i ka ʻike a hōʻemi i nā pōʻino i loko o kā lākou kuleana. Kiʻi mai ka US Department of Veterans Affairs "West Haven Steam Rupture, Board of Inquiry" hōʻike memo, i hoʻopaʻa ʻia ma ʻApelila 15, 2021, e hōʻike ana i "Steam Line Schematic, Basement 22." Ua ʻōlelo mua ʻo OSHA i ʻekolu mau hewa i ka makahiki 2015: Ke nānā ʻana i nā kaʻina hana mana ikehu ma ka liʻiliʻi loa i kēlā me kēia makahiki; ʻaʻole i hāʻawi i ka hoʻomaʻamaʻa ma hope o ka hoʻokomo ʻana i kahi pahu laina mokuahi hou ma ka Hale 22; a me ka hoʻopili ʻole ʻana i nā lako LOTO pilikino e hui pū i nā lako LOTO e nā limahana. "Ua hiki ke pale ʻia kēia mau mea make inā hahai nā mea hana i nā kūlana palekana i hoʻolālā ʻia e pale i ka hoʻokuʻu ʻole ʻia o ka mahu," i ʻōlelo ai ka luna o ka mokuahi OSHA ʻo Steven Biassi i kēlā manawa. pono ole." ʻO ka puka komo ʻo Campbell Avenue o ka VA Connecticut Health Care System West Haven campus, i kiʻi ʻia ma Iulai 20, 2021. ʻO Pamela Redmond, he waha ʻōlelo no West Haven Medical Center ma Virginia, i ʻōlelo ʻia ma ka leka uila ʻo ka ʻōnaehana Virginia ma Connecticut "ua i loko o kahi ʻO ke kūlana o ka neʻe ʻana mai nā hanana pōʻino o Nowemapa 13, 2020. Ua hana nui ʻia e hoʻomaikaʻi i ka palekana a ua hana ʻia nā mea hou i nā kaʻina hana palekana. " ʻO ka pā kula ʻo VA Connecticut Healthcare System West Haven e like me ka nānā ʻana mai Spring Street ma Iulai 20, 2021. ʻO nā lawelawe hoʻokele waiwai "ke hana nei i ka hoʻolālā hou ʻana a i ʻole ka wehe ʻana i ka ʻōnaehana mahu ma ka Hale 22. Ke hoʻokomo ʻia ka ʻōnaehana hou, kahi LO/TO hou. e hoʻomohala ʻia ke kaʻina hana, ”kākau ʻo ia. Ua ʻōlelo pū ʻo ia: "I ka lā 20 o Dekemaba, 2020, ua hoʻokomo ʻia kahi ʻōnaehana paʻa ʻelua a me ke kahe koko i ka mea kanu boiler ma ka hale mahu o ka Hale 22 kahi i kū ai ka ulia. Ua ʻae ka ʻōnaehana valve hou i ka hoʻokuʻu ʻana o ka ikehu i mālama ʻia a i ʻole ke koena o ka ikehu, no ka laʻana mai ka ʻōnaehana i hoʻokuʻu ʻia mai ka Redmond i ʻōlelo ʻia ʻelua mau hale nui e hana ana i nā papahana hoʻomaikaʻi mahu, a ua ʻaelike ʻia ka ʻōnaehana e pani i nā pahele mahu ma kāna Hale 22. "Ke hoʻomau nei ka mokuʻāina ʻo Virginia Connecticut me kā mākou keʻena kūloko, ka Veterans Health Administration a me OSHA e hōʻoia i ka palekana o nā mea āpau ma kā mākou wahi mālama," kākau ʻo Redmond. Ua ʻōlelo ʻo Sen. Richard Blumenthal, D-Conn., he lālā o ka US Senate Veterans Affairs Committee, ke kākoʻo nei ʻo ia i kahi waihona kālā e "kūkulu hou a kūkulu hou i ka hale ʻo West Haven Virginia" a me kekahi mau halemai Virginia ʻē aʻe ma ka ʻāina. ʻO ka hoʻolālā hana a Pelekikena Joe Biden he $ 2.65 trillion ʻAmelika e pili ana i $ 18 biliona e hoʻololi i nā halemai VA a me nā keʻena lapaʻau. "ʻO ka pōʻino o Nov. 13 ʻo ia wale nō ka pōʻino loa o ka hāʻule ʻana o ka ʻoihana hou," wahi a Blumenthal. ʻaʻole ia e hōʻoiaʻiʻo wale i nā hemahema o nā hale e kū nei, akā ʻo ka wikiwiki o ka hoʻoponopono hou ʻana i nā hale a me ka lawe ʻana i nā hale i ke kenekulia 21, ma mua o ka hoʻohana ʻana i nā ala maikaʻi aʻe. ʻO Lan a me nā hoʻoponopono pōkole ʻē aʻe e hoʻopaʻa i nā hemahema. Pono ʻo Virginia e hoʻokomo i kahi hale hou. " Ua ʻōlelo ʻo Blumenthal e pono ke kūkulu hou ʻia ʻo West Haven Medical Center ma Virginia, akā ʻaʻole hiki iā ia ke koho i ka lehulehu i ka nui o ke kumukūʻai." hana wikiwiki," i ʻōlelo ai ʻo ia.