Ripoti: Zomwe zidachitika tsiku lomwe antchito awiri adamwalira ku West Haven, Virginia

Kampasi ya VA Connecticut Health Care System's West Haven monga momwe amawonera kuchokera ku West Springs Street pa Julayi 20, 2021. Westport - Kafukufuku wa Federal adapeza kuti pa Novembara 13, 2020, chitsulo chosavuta choponyera mumzere wokalamba mu nyumba ya Veterans Affairs Medical Center mwadzidzidzi. kudulidwa mu zidutswa zinayi, kutulutsa nthunzi yothamanga kwambiri ndikupha amuna awiri akufa. Kafukufuku wa VA pa ngoziyi adafotokozanso zomwe zidachitika m'mawa, pofotokoza momwe a Joseph O'Donnell, wochita ganyu adalemba ganyu kuti akonzenso kutayikira kwa payipi, adalowa m'chipinda chapansi pa Nyumba 22 atakonza, limodzi ndi Euel Sims Jr., mapaipi amadzi. woyang'anira, ndi Kulephera kwa zida ndi njira zotetezera zomwe zidapangitsa kuti afe.Kuyambira pamenepo, Virginia wapanga kapena kukonza zosintha zambiri, kuphatikiza pulojekiti yokweza nthunzi. Koma lipotilo linati zinthu zomwe zachititsa kuti m’chaka cha 2020 zichitike ndi monga mipope ya madzi yomwe inali yakale komanso yosakwaniritsa zinthu zomwe zilipo panopa, ma valve osakhazikika komanso mapaipi opangitsa kuti madzi asasunthike, komanso akuti sakutsatira ndondomeko zoteteza amuna. Pakhomo la West Springs Street la kampasi ya VA Connecticut Health Care System ku West Haven, yomwe inajambulidwa pa July 20, 2021. Pambuyo pake, pamene amunawo anatsegula mapaipi, nthunzi inadutsa paipi ya inchi 6, ndipo kupanikizika kunali kwakukulu kwambiri moti flange. ulusi mpaka pansi ofukula dropper anadula mu zidutswa zinayi, kuwomba nthunzi mu chipinda. Report. Lipoti la kafukufuku wa VA, lomwe linatulutsidwa pa April 15, linapezedwa ndi New Haven Registry kupyolera mu pempho la Ufulu wa Information.Maina onse ogwira ntchito asinthidwa. Chochitikacho chinayambitsa kuunikanso kulephera kwa West Haven Virginia, zomwe zinachititsa kuti zidziwitso zisanu ndi zinayi za OSHA ndikupempha Congress kuti imangenso chipatala. Malinga ndi lipotilo, zochitika zambiri zidayamba mu Okutobala kapena Novembala 2020, pomwe chitetezo cha Virginia chidadziwitsidwa za kutayikira m'chipinda chosungiramo zinthu ku Building 22, pafupi ndi kumapeto kwa msewu waukulu pakhomo la Campbell Avenue. dipatimenti yokonza mapaipi anafunika kuti adzipatula nthunzi m'nyumbayo kuti achepetse asibesitosi. Ntchito yochepetsetsa inamalizidwa pa November 9, ndipo nthunzi imakhalabe yozimitsa. Pa Novembara 13, wokhala ku Danbury komanso kontrakitala wa Mulvaney Mechanical wophatikizira nthunzi O'Donnell adamaliza kukonza zomwe zidatsikirako nthawi ya 7:45 am nthawi ya 8:00, Sims, wakale wakale wa Navy Seabees komanso wokhala ku Milford, adauza woyang'anira wake kuti akufuna kubweza. Amuna atatuwo adawoloka msewu kupita ku nyumbayo, koma woyang'anira Sims adafunsidwa kuti atsegule chipinda chosiyana mu Building 22, lipotilo lidatero. valavu ya nthunzi. Cha m’ma 8:10, lipotilo linati: “Woyang’anira ntchito yoyang’anira ntchitoyo anamva phokoso lalikulu ndipo anaona nthunzi ikutuluka m’makwerero opita kuchipinda cha makina. . … kutentha kwakukulu Alamu anayambitsa alamu yamoto, ndipo katswiri wina wa chitetezo ananyamuka nthawi yomweyo kuti akafufuze za alamu yomwe inanenedwa mu Nyumba 22. Kuwonjezera apo, panthawiyi, woyang'anira makina ogwiritsira ntchito zipangizo zamakono ndi wogwira ntchito wina anavulala pamene ankayesa kulowa m'chipinda chapansi pa makina opangira makina. ." Malo opangira boiler a ku Virginia adatsekedwa, ndipo dipatimenti yamoto ya West Haven, Police State Police ndi oyankha oyamba adayankha. "Nthunziyo itatsika komanso kutentha m'chipindacho, ogwira ntchito zadzidzidzi anatha kulowa m'chipindacho, koma panthawiyi woyang'anira malo opangira mapaipi ndi makina opanga makina anali atamwalira," lipotilo linatero. cha m’ma 2:15, wophedwayo anatengedwa. Kufufuza kwa VA ndi Applied Technical Services ku Marietta, Georgia, anapeza kuti kutulutsidwa kwa nthunzi yotentha kwambiri kunali kwamphamvu kwambiri moti amuna awiri omwe anayesa kukankhira khomo la chipinda cha 8-by-12-foot sakanatha. adawotcha phazi lake ndi madzi otentha, lipotilo linatero. Chithunzi chochokera ku US Department of Veterans Affairs "West Haven Steam Rupture, Board of Inquiry Investigation" lipoti la memo, la Epulo 15, 2021, losonyeza "Kusintha kwa Pipe - Nthawi Yofufuza." Lipotilo linati: "Pamene chitsulo chachitsulo chachitsulo chinalephera, 6" mzere waukulu wa nthunzi unatha kulowa m'chipindacho. imapanga zikwi za mphamvu za mapaundi mkati mwa chitseko, ndikuukakamiza kuti utseke.Panthawiyi, sizingatheke kutsegula chitseko popanda zipangizo zolemera. ndipo tsiku la ngoziyo, kuphatikiza ndi mapaipi odonthezera osayikidwa bwino, ndiwo adayambitsa imfayo, lipotilo linati. zakhala zomwe zachititsa ngoziyo, "idatero. Pafupifupi magawo atatu mwa anayi a galoni ya madzi mu dropper, palibe valve yopopera kapena yotulutsa madzi. chotsitsacho ndipo chimayenera kukhala chowotcherera, osati ulusi, ku chitoliro. Ma flanges anaphulika pambuyo pa "mphindi yowonongeka kwambiri ya nyundo yamadzi," lipotilo linati. Nyundo yamadzi ndi hydraulic shock wave yomwe imayambitsidwa ndi madzi kapena nthunzi mwadzidzidzi kukakamizidwa kuti ayime kapena kusintha njira ndiyeno kumenyana ndi valve kapena chopinga china. Nthawi zambiri zimachitika chifukwa cha kudzikundikira kwa madzi mu mapaipi a nthunzi. Vavu ikatsegula ndipo nthunzi ilowa m'chipinda chopangira makina, imagunda madzi ozizira omwe ali mudonthozi ndi zotsatirapo zowononga." Kutuluka kwa nthunzi kumeneku kungayambitse kutentha kwadzidzidzi ndi kung'anima kwa condensate yosasunthika kapena yosachotsedwa pagawo lililonse losakongoletsedwa la nthunzi yaikulu. bomba," lipotilo lidatero. ” ndi “ndicho chomwe chimayambitsa kulephera kwadzidzidzi kwa ma flanges achitsulo cha imvi”. Lipotilo linanenanso kuti: “Cholingacho chinalephera kuchulukirachulukira chifukwa cholemetsa kwambiri kuposa chomwe chikanatha kupirira. Chithunzi chochokera ku Epulo 15, 2021 US department of Veterans Affairs "West Haven Steam Rupture, Board of Inquiry" lipoti memo yowonetsa "kuwonongeka kwa flange" mu Building 22. "Nthawi idadutsa pakati pa kulowa mumlengalenga ndikutsegula ma valve pamalo omwe adapeza. zikuwonetsa kuti dongosololi silinakhazikitsidwenso bwino lomwe limafunikira kutentha pang'ono komanso pang'onopang'ono komanso kuwongolera kuthamanga," idatero. "Ogwira ntchito atsegula 75% ya valavu ya nthunzi # 1. Anatsegulanso valavu ya mpira yomwe ili pa fyuluta yaikulu ya nthunzi ya condensate kubwerera," lipotilo linatero. Ma valve ena awiri anali otseguka, imodzi 5% mpaka 6%, ina inatsegula 11%. Chithunzi chochokera ku US Department of Veterans Affairs "West Haven Steam Rupture, Board of Inquiry" lipoti la memo, la Epulo 15, 2021, lomwe likuwonetsa "Kulumikizana kwa Pipe Ya Threaded, Drip Bottom." "Kutsegula kwa valve ya mpira kuyenera kupereka ndemanga mwamsanga kwa ogwira ntchito monga kutuluka kwa nthunzi ndi kutuluka kwa condensate kuti atsimikizire kuti ikugwira ntchito," ofufuzawo adatero. "Zotsatira zenizeni zomwe valve iliyonse imatsegula sizidziwika, koma ndi bwino kutsegula mzere wa condensate poyamba." Vavu yaing'ono ya mpira." Komabe, pomwe lipotilo likunena kuti kutsegula valavu ya mpira kumakhetsa ma condensate kuchokera pamzere kapena kupitilira apo, sikungakhetse madzi onse pamzere wodontha "ndipo gawo ili la mzere waukulu wa nthunzi likadali ndi 3 / 4 galoni za condensate." Lipotilo linati ma plumbing mu Building 22 anaphwanya ma code angapo. Ma flanges achitsulo saloledwanso pamapaipi a nthunzi pansi pa ma code awa, koma sakuletsedwa ndi ma code a VA kapena ASME, lipotilo linatero. palibe umboni wosonyeza kuti Virginia adalamula aliyense m'mbuyomu kuti achotse kapena kuchotsa flange," idatero. osaloledwa pansi pa VA code, "lipotilo linati." Vuto lina, lipotilo linati, "kulephera kusiyanitsa mizere itatu yayikulu ya nthunzi, zomwe zimapangitsa kuti makina otenthetsera azitha kuonetsetsa chitetezo cha chowotchera chonsecho" VA Connecticut Health Care System's West Haven campus monga momwe amawonera kuchokera ku West Springs Street pa July 20, 2021. Ofufuza adatsutsanso VA chifukwa chosowa njira zotetezera ogwira ntchito pazochitika zoopsa. ndi wina aliyense kupatula munthu amene wazimitsa. Malinga ndi lipotilo: "Loko la VA ndi unyolo zidapezeka m'malo pafupi ndi valavu yachipinda, zomwe zikuwonetsa kuti dongosololi lidatsekedwa. Komabe, palibe zipika za Lockout tagout (LOTO), zilolezo kapena njira za LOTO zamakina. Palibe kusaka m'maofesi komwe kwapeza zipika za LOTO kapena njira za mavavu kapena nyumbazi." Kulumikizana pakati pa chitetezo, mapaipi, ndi mainjiniya kunalepheranso: "Bowola silinadziwitsidwe za kutsekedwa uku, komanso silinadziwitsidwe za kutseka kopitilira. Sizikudziwika ngati utsogoleri wa uinjiniya kapena chitetezo amadziwa za tsikuli. ntchito ikuchitika," lipotilo lidatero." Gululi silinathe kudziwa chifukwa chomwe kontrakitala anali m'chipindacho. Gululo silinapeze umboni wa kutseka kwina koperekedwa ndi kontrakitala." Pa Meyi 12, OSHA idapereka zidziwitso zisanu ndi zinayi zokhuza kusakhala kwachitetezo kapena kusagwira ntchito bwino ku Connecticut, kuphatikiza kudziwitsa opanga makina otenthetsera kuti atuluke / kutulutsa mizere yopangira; kulephera kudziwitsa Mulvaney. Makina a njira zake za LOTO; kapena kutsekedwa mwadongosolo kwa zipangizo" kotero kuti condensate ikhoza kuchotsedwa ku dongosolo. Inanena kuti "njira sizinapangidwe, zolembedwa ndikugwiritsidwa ntchito kulamulira mphamvu zomwe zingakhale zoopsa" kapena teknoloji yomwe imagwiritsidwa ntchito poyendetsa valve. Kuphatikiza apo, OSHA idapeza kuti VA sinawonetsetse kuti malo ogwirira ntchito alibe zoopsa zomwe zingayambitse imfa kapena kuvulala, komanso kuti oyang'anira sanaphunzitsidwe momwe angazindikire ndi kuchepetsa zoopsa zomwe zili m'dera lawo. Chithunzi chochokera ku US Department of Veterans Affairs "West Haven Steam Rupture, Board of Inquiry" lipoti la memo, la Epulo 15, 2021, lowonetsa "Steam Line Schematic, Basement 22." OSHA inatchula kale zophwanya katatu mu 2015: Kuwona njira zoyendetsera mphamvu zamagetsi osachepera chaka chilichonse; kulephera kupereka maphunziro atatha kukhazikitsa valavu yatsopano ya nthunzi mu Building 22; ndi kulephera kulumikiza zida za LOTO zaumwini pagulu la zida za LOTO ndi antchito. "Zophazi zikanatha kupewedwa ngati olemba ntchito akutsatira ndondomeko za chitetezo zomwe zimapangidwira kuti asatuluke mosalamulirika," mkulu wa bungwe la OSHA, Steven Biassi, adanena panthawiyo. mosafunikira." Khomo la Campbell Avenue la kampasi ya VA Connecticut Health Care System ku West Haven, lojambulidwa pa Julayi 20, 2021. Pamela Redmond, wolankhulira West Haven Medical Center ku Virginia, adanena mu imelo kuti dongosolo la Virginia ku Connecticut "lakhala m'malo ambiri. zasintha kuyambira pa Novembara 13, 2020. Ntchito zolimba zachitika pofuna kukonza chitetezo ndipo zosintha zazikulu zachitika pazachitetezo." Kampasi ya VA Connecticut Healthcare System ku West Haven monga momwe amawonera kuchokera ku Spring Street pa July 20, 2021. Facilities Management Services "ali m'kati mwa kukonza kapena kugwetsa makina a nthunzi mu Building 22. Kachitidwe katsopano kamene kamayikidwa, LO/TO yatsopano. ndondomeko idzakonzedwa," adatero. Ananenanso kuti: “Pa Disembala 20, 2020, makina otsekera komanso otulutsa magazi adayikidwa pa fakitale yowotchera yomwe ili panyumba yayikulu ya Building 22 pomwe ngoziyi idachitika. Dongosolo latsopano la ma valve limalola kutulutsa mphamvu zosungidwa kapena zochulukirapo, mwachitsanzo kuchokera kumadzi otulutsa madzi otulutsidwa ku Redmond adati nyumba zazikulu ziwiri zikuchita ntchito zokweza nthunzi, ndipo dongosololi lapangidwa kuti lisinthe misampha ya nthunzi mu Building 22 yake. "Virginia Connecticut State ikugwirabe ntchito limodzi ndi ofesi yathu yachigawo, Veterans Health Administration ndi OSHA kuonetsetsa chitetezo cha aliyense pamalo athu osamalira," adatero Redmond. Sen. Richard Blumenthal, D-Conn., membala wa US Senate Veterans Affairs Committee, adati akulimbikitsa thumba lachitukuko kuti "amangenso ndi kumanganso malo a West Haven Virginia" ndi zipatala zina zingapo ku Virginia m'dziko lonselo. Pulojekiti ya Purezidenti Joe Biden ya $ 2.65 thililiyoni ya ntchito zaku America ikuphatikiza $ 18 biliyoni kuti zipatala ndi zipatala za VA zikhale zamakono." "Tsoka la Nov. 13 linali loipitsitsa kwambiri la zowonongeka zowonongeka kwaposachedwa," adatero Blumenthal. "Lipotili ndi lokopa kwambiri; ikukhutiritsa osati [kuonetsa] zofooka m’maofesi omwe alipo, komanso kufunika kokonzanso nyumba ndi kubweretsa zomanga m’zaka za zana la 21, m’malo mongogwiritsa ntchito njira zabwino koposa. Lan ndi kukonza kwina kwakanthawi kochepa kuti athetse zolakwikazo. Virginia akuyenera kugulitsa zinthu zatsopano. ” Blumenthal adati West Haven Medical Center ku Virginia ikufunika kumangidwanso, koma sakanatha kuwerengera poyera kuti zingawononge ndalama zingati." kuchitapo kanthu mwachangu," adatero.