VA Connecticut Health Care System’s West Haven campus as viewed from West Springs Street on July 20, 2021.
Westport – Federal investigation found that on November 13, 2020, a simple cast iron flange in an aging steam line in a Veterans Affairs Medical Center building suddenly snapped into four pieces, releasing high-pressure steam and killing two men die.
The VA’s investigation into the accident recounted the events of the morning, describing how Joseph O’Donnell, a contractor hired to repair the leak in the pipeline, entered the basement of Building 22 after the repair, accompanied by Euel Sims Jr., the plumbing supervisor, and The failure of equipment and safety measures that led to their deaths.Since then, Virginia has made or planned many changes, including a steam upgrade project.
But the report said factors contributing to the 2020 incident included plumbing that was old and no longer meeting current material standards, improperly installed valves and pipes leading to stagnant water, and allegedly not following procedures to keep men safe.
The West Springs Street entrance of the VA Connecticut Health Care System West Haven campus, photographed on July 20, 2021.
Eventually, when the men opened the pipes, steam whizzed through the 6-inch pipe, and the pressure was so great that the flange threaded to the bottom of the vertical dropper snapped into four pieces, blowing steam into the room.Report.
The VA investigation report, released April 15, was obtained by the New Haven Registry through a Freedom of Information request.All personnel names have been edited.
The incident led to a review of West Haven Virginia’s failure, resulting in nine OSHA notices and calls on Congress to rebuild the medical center.
According to the report, the chain of events began in October or November 2020, when Virginia security was informed of a leak in a storage room in Building 22, near the end of the main road at the Campbell Avenue entrance.On November 6, the plumbing department was required to isolate the steam from the building in order to reduce asbestos.Abatement work was completed on November 9, and steam remains off.
On November 13, Danbury resident and Danbury contractor Mulvaney Mechanical steam assembler O’Donnell completed repairs to the leak at 7:45 a.m.At 8:00, Sims, a Navy Seabees veteran and Milford resident, informs his supervisor that he intends to turn steam back on.The three men crossed a street to the building, but Sims’ supervisor was asked to open a separate room in Building 22, the report said.O’Donnell and Sims reportedly proceeded to the basement machinery room in Building 22 to turn on the steam valve.
At approximately 8:10, the report stated, “The utility system supervisor heard a loud bang and saw a stream of steam coming out of the stairwell leading to the machinery room. The loss of steam pressure … was recorded at the boiler plant. … high temperature The alarm triggered a fire alarm, and a security specialist left immediately to investigate the reported alarm in Building 22. Additionally, around this time, the utility systems supervisor and another facility employee were injured while attempting to enter the basement mechanical room.”
The Virginia boiler plant was shut down, and the West Haven Fire Department, Virginia State Police and first responders responded.
“After the steam pressure and temperature in the room dropped, emergency personnel were able to enter the room, but by this time the plumbing shop supervisor and the mechanical contractor were dead,” the report said.Until about 1:00 pm; at about 2:15, the victim was taken away.
An investigation of the VA by Applied Technical Services in Marietta, Georgia, found that the release of superheated steam was so powerful that two men who tried to push open the door to the 8-by-12-foot room couldn’t.One of them scalded his foot from the hot water, the report said.
Image from the U.S. Department of Veterans Affairs “West Haven Steam Rupture, Board of Inquiry Investigation” report memo, dated April 15, 2021, showing “Pipe Configuration – Time of Investigation.”
“When the cast iron flange failed, the 6″ main steam line was able to drain into the room,” the report said. “The room was pressurized with steam when steam began to flow into the room from the unrestricted steam line.This pressure creates thousands of pounds of force on the inside of the door, forcing it to close.At this point, it is impossible to open the door without heavy equipment.”
The two-week period between the first report of the steam leak in Building 22 and the date of the accident, combined with improperly installed drip pipes, was the likely cause of the death, the report said.The steam has been shut down, “resulting in a large build-up of condensate and cooling the pipes, which may have been a factor in the accident,” it said.With about three-quarters of a gallon of water in the dropper, there is no drain or drain valve required.
Investigators said the cracked flange was attached to a blank flange at the end of the dropper and should have been welded, not threaded, to the pipe.
The flanges ruptured after “a typical high-impact moment of water hammer,” the report said.Water hammer is a hydraulic shock wave caused by water or steam being suddenly forced to stop or change direction and then slammed against a valve or other obstacle.It is usually caused by the accumulation of water in the steam pipes.
When the valve opens and steam enters the piping in the mechanical room, it hits the cooler water in the dropper with devastating consequences.”This renewed steam flow may cause sudden heating and flashing of stagnant or unremoved condensate in any undrained portion of the main steam piping,” the report said. ” and “is the most likely cause of sudden failure of grey cast iron flanges”.
“The target flange experienced an overload failure due to a load beyond what it could handle,” the report states.
Image from the April 15, 2021 U.S. Department of Veterans Affairs “West Haven Steam Rupture, Board of Inquiry” report memo showing “flange damage” in Building 22.
“The elapsed time between entering the space and opening the valves to the position they found indicates that the system was not properly re-energized. This type of system requires a slow and gradual temperature and pressure equilibration,” it noted.
“Workers have opened 75% of steam valve #1. They also opened the ball valve located on the main steam line condensate return line filter,” the report said. Two other valves were also open, one 5 % to 6%, the other one opened 11%.
Image from U.S. Department of Veterans Affairs “West Haven Steam Rupture, Board of Inquiry” report memo, dated April 15, 2021, showing “Threaded Pipe Connection, Drip Bottom.”
“The opening of the ball valve should provide immediate feedback to workers in the form of steam flow and condensate flow to prove it is working,” the investigators said. “The exact sequence in which each valve opens is unclear, but it is best to open the condensate line first.” Small ball valve.”
However, while the report states that opening the ball valve will drain condensate from the line or higher, it will not drain all the water in the drip line “and this area of the main steam line still contains 3/4 gallon of condensate.”
The report said the plumbing in Building 22 violated multiple codes.Cast iron flanges are no longer permitted on steam piping systems under these codes, but are not prohibited by VA or ASME codes, the report said.”There is no evidence that Virginia has directed anyone in the past to remove or replace the flange,” it said.
Additionally, a steam trap was installed too close to the bottom of the drip pipe, “the isolation valve is a butterfly valve, which is not allowed under the VA code,” the report said.
Another problem, the report said, was “the inability to isolate any of the three main steam lines, making it impossible for the boiler plant to ensure the safety of the entire boiler plant”.
VA Connecticut Health Care System’s West Haven campus as viewed from West Springs Street on July 20, 2021.
Investigators also accused the VA of lacking procedures designed to protect workers in hazardous material situations.A lockout/tagout system prevents the steam from being turned back on by anyone other than the person who turned it off.
According to the report: “A VA lock and chain were found in the space near the room valve, indicating that the system may have been locked. However, there are no lockout tagout (LOTO) logs, permits or LOTO procedures for the system. No office searches have found LOTO logs or procedures for these valves or buildings.”
Communication between safety, plumbing, and engineering also failed: “The boiler plant was not notified of this shutdown, nor was it notified of a continued shutdown. It is unclear whether engineering leadership or security were aware of this day. work in progress,” the report noted.”The team was unable to determine why the contractor was in the room. The team found no evidence of additional locking imposed by the contractor.”
On May 12, OSHA issued nine notices regarding unsafe or unhealthy working conditions in Connecticut, including notifying boiler plant operators to log off/tag out on production lines; failing to inform Mulvaney Mechanical of its LOTO procedures; or orderly shutdown of equipment” so that condensate can be drained from the system.It said “procedures have not been developed, documented and used to control potentially hazardous energy” or the technology used to operate the valve.
In addition, OSHA found that the VA did not ensure that the workplace was free of hazards that could result in death or injury, and that supervisors were not trained on how to recognize and reduce hazards within their area of responsibility.
Image from U.S. Department of Veterans Affairs “West Haven Steam Rupture, Board of Inquiry” report memo, dated April 15, 2021, showing “Steam Line Schematic, Basement 22.”
OSHA previously cited three violations in 2015: Checking energy control procedures at least annually; failing to provide training after installing a new steam line valve in Building 22; and failing to attach personal LOTO equipment to group LOTO equipment by employees.
“These fatalities could have been avoided if employers followed safety standards designed to prevent the uncontrolled release of steam,” OSHA regional director Steven Biassi said at the time.”Sadly, these well-known protections were not in place and two workers lost their lives unnecessarily.”
The Campbell Avenue entrance of the VA Connecticut Health Care System West Haven campus, photographed on July 20, 2021.
Pamela Redmond, a spokeswoman for West Haven Medical Center in Virginia, said in an email that the Virginia system in Connecticut “has been in a state of flux since the tragic events of November 13, 2020. Hard work has been done to improve safety and major updates have been made to safety procedures.”
The VA Connecticut Healthcare System West Haven campus as viewed from Spring Street on July 20, 2021.
Facilities Management Services “is in the process of redesigning or dismantling the steam system in Building 22. Once the new system is installed, a new LO/TO procedure will be developed,” she wrote.
She also said: “On December 20, 2020, a double shut-off and bleed valve system was installed at the boiler plant in the steam main of Building 22 where the accident occurred. The new valve system allows the release of stored or surplus energy, for example from the system condensed water discharged from the
Redmond said two major buildings are undergoing steam upgrade projects, and the system has been contracted to replace the steam traps in its Building 22.
“The Virginia Connecticut State continues to work closely with our regional office, the Veterans Health Administration and OSHA to ensure the safety of everyone at our locations of care,” Redmond wrote.
Sen. Richard Blumenthal, D-Conn., a member of the U.S. Senate Veterans Affairs Committee, said he is advocating for an infrastructure fund to “rebuild and rebuild the West Haven Virginia facility” and several other Virginia hospitals across the country.
President Joe Biden’s $2.65 trillion American jobs plan includes $18 billion to modernize VA hospitals and clinics.”While the median age in private U.S. hospitals is about 11, the median age in the VA’s hospital portfolio is 58,” the White House fact sheet said.
“The Nov. 13 tragedy was just the worst of recent infrastructure failures,” Blumenthal said.“This report is extremely persuasive; it is convincing not only [highlighting] deficiencies in existing facilities, but also the urgency of renovating buildings and bringing structures into the 21st century, rather than just using better methods. Lan and other short-term fixes to patch the flaws. Virginia should invest in a whole new structure.”
Blumenthal said the West Haven Medical Center in Virginia needs to be rebuilt, but he could not publicly estimate how much that would cost.”I’ve personally spoken to Veterans Affairs Secretary Dennis McDonough on multiple occasions, and he’s very aware of the need for urgent action,” he said.
Post time: Mar-02-2022
