Chirevo: Chii chakaitika zuva rakafa vashandi vaviri muWest Haven, Virginia

VA Connecticut Health Care System's West Haven campus sezvainoonekwa kubva kuWest Springs Street munaChikunguru 20, 2021. Westport - Federal ongororo yakawana kuti muna Mbudzi 13, 2020, simbi yakapusa yakakandwa mumutsara wekuchembera mune imwe Veterans Affairs Medical Center chivakwa kamwe kamwe. akatsemurwa kuita zvidimbu zvina, kuburitsa mutsinga wepamusoro uye kuuraya varume vaviri vanofa. Kuferefeta kwaVA mutsaona iyi kwakarondedzera zviitiko zvemangwanani, vachitsanangura kuti Joseph O'Donnell, kondirakiti akahaiwa kuti agadzirise kudonha kwepombi, akapinda pasi peChivakwa 22 mushure mekugadzirisa, achiperekedzwa naEuel Sims Jr., pombi yemvura. mutariri, uye Kukundikana kwemidziyo nekuchengetedza matanho zvakakonzera kufa kwavo.Kubva ipapo, Virginia akaita kana kuronga shanduko dzakawanda, kusanganisira chirongwa chekusimudzira chiutsi. Asi gwaro iri rakati zvinhu zvakakonzera chiitiko ichi muna 2020 zvinosanganisira mapombi emvura anga asakara uye asisaenderane nezvinodiwa pari zvino, mavharuvhu nemapombi aikonzera kusamira zvakanaka kwemvura, uye anonzi haasi kutevedzera nzira dzekuchengetedza varume. Kupinda kweWest Springs Street yeVA Connecticut Health Care System kuWest Haven campus, yakatorwa mifananidzo musi waChikunguru 20, 2021. Pakupedzisira, varume pavakavhura pombi, chiutsi chakaputika nepapombi ye6-inch, uye kudzvanywa kwaive kwakakura zvekuti flange. yakarukwa kusvika pasi peinodonhedza yakatwasuka kuita zvidimbu zvina, ichifuridza chiutsi mumba.Report. Chirevo chekuongorora cheVA, chakabudiswa musi waApril 15, chakawanikwa neNew Haven Registry kuburikidza nechikumbiro cheRusununguko rweRuzivo.Mazita ose evashandi akagadziridzwa. Chiitiko ichi chakakonzera kuongororwa kwekutadza kweWest Haven Virginia, zvichikonzera zviziviso zvipfumbamwe zveOSHA uye inodaidza Congress kuti ivakezve nzvimbo yekurapa. Sekureva kwemushumo, kutevedzana kwezviitiko zvakatanga muna Gumiguru kana Mbudzi 2020, apo kuchengetedzwa kweVirginia kwakaziviswa nezvekudonha mukamuri yekuchengetera muChivakwa 22, pedyo nekunoperera mugwagwa mukuru pamusuwo weCampbell Avenue. dhipatimendi repombi dzepombi raidiwa kuti ribvise chitsinga kubva muchivako kuitira kuderedza asbestos. Basa rekudzimisa mvura rakapedzwa musi wa9 Mbudzi, uye chiutsi chinoramba chakadzimwa. Musi waMbudzi 13, mugari weDanbury uye mugadziri wekondirakiti weMulvaney Mechanical anounganidza chiutsi O'Donnell akapedza kugadzirisa pakadonha na7:45 amNa 8:00, Sims, murwi wemauto eNavy Seabees uye mugari weMilford, anoudza mutariri wake kuti anoda kudzosa mvura. Varume vatatu vakayambuka mugwagwa kuenda kuchivakwa, asi mutariri waSims akakumbirwa kuti avhure imwe kamuri muBuilding 22, mushumo wakadaro. steam valve. Panenge pana 8:10, mushumo wacho wakati, "Mutariri wezvishandiso akanzwa ruzha rukuru uye akaona kuyerera kwechitsinga chichibuda pamasitepisi aienda kuimba yemichina. Kurasikirwa kwemhepo ... . … tembiricha yakakwira Aramu yakamutsa aramu yemoto, uye nyanzvi yezvekuchengetedzwa kwenyika akabva angobuda kuti aongorore nezvearamu yakashumwa muChivako 22. Pamusoro pazvo, panguva ino, maneja wezvishandiso uye mumwe mushandi wepo vakakuvara vachiedza kupinda muimba yepasi inogadzirwa nemagetsi. ." Iyo Virginia boiler plant yakavharwa, uye West Haven Fire Dhipatimendi, Virginia State Mapurisa uye vekutanga vakapindura vakapindura. "Mushure mekunge mhepo yakadzika uye tembiricha yaiva mukamuri iyi yadzikira, vashandi vekukurumidzira vakakwanisa kupinda mukamuri racho, asi panguva ino maneja wechitoro chepombi dzepombi nemugadziri wemichina vakanga vafa," mushumo wacho wakadaro. Kusvikira kuma1:00 masikati; dzinenge 2:15, nyakukuvadzwa akaendwa naye. Ongororo yeVA neApplied Technical Services muMarietta, Georgia, yakawana kuti kuburitswa kwemhepo inopisa zvakanyanya kwaive nesimba zvekuti varume vaviri vakaedza kusundira kuvhura musuwo wekamuri ye8-by-12-foot haina. vakapisa tsoka yake kubva mumvura inopisa, chirevo chakadaro. Mufananidzo kubva kuUS Dhipatimendi reVeterans Affairs "West Haven Steam Rupture, Board of Inquiry Investigation" mushumo memo, waApril 15, 2021, unoratidza "Pipe Configuration - Nguva Yekuferefeta." "Apo simbi yakakandwa yakakundikana, 6" main steam line yakakwanisa kunyura mukamuri," mushumo wacho wakadaro. "Mumba wakamanikidzwa nemhepo apo chiutsi chakatanga kuyerera chichipinda mukamuri chichibva mumutsara usina muganhu. inogadzira zviuru zvemapaundi echisimba mukati megonhi, ichimanikidza kuvhara.Panguva ino, hazvibviri kuvhura musuwo pasina midziyo inorema. uye zuva retsaona, pamwe chete nemapombi ekudonha asina kuisirwa zvisina kufanira, ndiyo ingangove yakakonzera rufu, mushumo wakadaro. Chipfunga chavharwa, "zvichikonzera kuvakwa kukuru kwe condensate uye kutonhora kwepombi, izvo zvinogona vakonzera tsaona," rakadaro. Nezvinenge zvikamu zvitatu kubva muzvina zvegironi yemvura mudonhwe, hapadiwi drain kana drain valve inodiwa. Vatsvakurudzi vakati flange yakatsemuka yakanamirwa kune imwe flange isina chinhu pakupera kwe iyo inodonha uye inofanira kunge yakasungwa, kwete tambo, kune pombi. Maflange akaputika mushure me "nguva yakajairwa yepamusoro-soro yesando yemvura," mushumo wakadaro.Nyundo yemvura ndeye hydraulic shock wave inokonzerwa nemvura kana mhepo inongoerekana yamanikidzwa kumira kana kuchinja nzira uye yobva yarova valve kana chimwe chipingamupinyi. Inowanzokonzerwa nekuunganidza kwemvura mumapombi emvura. Kana vharuvhu yavhurwa uye chiutsi chapinda mupombi mukamuri ine michina, inorova mvura inotonhorera iri mudonhwe nemhedzisiro inoparadza. piping," chirevo chakadaro. ” uye “ndicho chinonyanya kukonzera kutadza kungoerekana kwaitika kwegrey cast iron flanges”. "Chirevo cheflange chakatadza kuwandisa nekuda kwekuremerwa kupfuura zvayaigona kubata," chirevo chinodaro. Mufananidzo kubva Kubvumbi 15, 2021 US Department of Veterans Affairs "West Haven Steam Rupture, Board of Inquiry" inoshuma memo inoratidza "flange kukuvara" muChivakwa 22. "Nguva yakapfuura pakati pekupinda munzvimbo nekuvhura mavharuvhu kunzvimbo yavakawana. inoratidza kuti sisitimu iyi haina kupihwa simba zvakare nemhando iyi inoda kunonoka uye zvishoma nezvishoma tembiricha uye kuenzana kwekumanikidza, "yakadaro. "Vashandi vakavhura 75% ye steam valve # 1. Vakavhurawo valve yebhora iri pane main steam line condensate return line filter," akadaro mushumo. Mamwe mavharuvhu maviri aive akavhurikawo, imwe 5% kusvika 6%, imwe yakavhurwa 11%. Mufananidzo kubva kuUS Department of Veterans Affairs "West Haven Steam Rupture, Board of Inquiry" report memo, yaApril 15, 2021, inoratidza "Threaded Pipe Connection, Drip Bottom." "Kuvhurwa kwevhavha yebhora kunofanirwa kupa mhinduro nekukurumidza kuvashandi nenzira yekuyerera kwemhepo uye condensate kuyerera kuratidza kuti iri kushanda," vaongorori vakadaro. "Kunyatsotevedzana kwevhavha yega yega hakuna kujeka, asi zviri nani kuvhura mutsara we condensate kutanga." Diki bhora vharafu." Nekudaro, nepo mushumo uchitaura kuti kuvhura vharavha yebhora kunodhonza condensate kubva mumutsara kana kumusoro, haizodonhedze mvura yese mumutsetse wekudonha "uye iyi nharaunda yemutsetse mukuru wemhepo ichine 3 /4 gallon of condensate. hapana humbowo hunoratidza kuti Virginia akamboraira chero munhu munguva yakapfuura kuti abvise kana kutsiva flange," rakadaro. Uyezve, musungo weutsi wakaiswa padhuze nepazasi pepombi inodonhedza, "vharuvhu yekuzviparadzanisa ivhavhavhavhavhavha, inova. hazvibvumirwi pasi peVA code," mushumo wacho wakadaro. Rimwe dambudziko, rakati mushumo, "kusakwanisa kutsaura chero ipi zvayo yemitsara mitatu mikuru yemhepo, zvichiita kuti zvisakwanisike kuti chigadziro chebhailer ive nechokwadi chekuchengetedzwa kwechose cheboiler". VA Connecticut Health Care System's West Haven campus sezvaionekwa kubva kuWest Springs Street musi waChikunguru 20, 2021. Vatsvakurudzi vakapomerawo VA yekushaikwa kwemaitiro akagadzirirwa kuchengetedza vashandi mumamiriro ezvinhu ane ngozi. kunoitwa nemumwe munhu kunze kwemunhu akaidzima. Maererano neshumo: "A VA kiyi neketani zvakawanikwa munzvimbo iri padyo nevhavha yekamuri, zvichiratidza kuti system yacho inogona kunge yakavharwa. Nekudaro, hapana yekuvhara tagout (LOTO) matanda, mvumo kana LOTO maitiro eiyo system. Hapana tsvakiridzo dzemuhofisi dzakawana matanda eLOTO kana maitirwo emavharuvhu aya kana zvivakwa." Kukurukurirana pakati pekuchengetedza, pombi dzemvura, uye mainjiniya zvakatadzawo: "Injiniya yeboiler haina kuziviswa nezve kudzima uku, uye haina kuziviswa nezve kuenderera mberi kudzima. Hazvizivikanwe kana hutungamiriri hweinjiniya kana kuchengetedza vaiziva nezvezuva iri. basa riri kuenderera mberi," mushumo wakadaro. Chikwata hachina kuwana humbowo hwekuwedzera kukiyiwa kwakaiswa nekondirakiti." Musi wa12 Chivabvu, OSHA yakapa zviziviso zvipfumbamwe maererano nemamiriro asina kuchengetedzeka kana asina hutano ekushanda muConnecticut, kusanganisira kuzivisa ma boiler plant operators kuti arege/kubuda pamitsara yekugadzira; kutadza kuzivisa Mulvaney. Mechanical yayo LOTO maitiro; kana kurongeka kuvharwa kwemidziyo" kuitira kuti condensate ibviswe kubva muhurongwa.Yakati "maitiro haana kugadzirwa, akanyorwa uye anoshandiswa kudzora simba ringangove nengozi" kana tekinoroji inoshandiswa kushandisa vharafu. Pamusoro pezvo, OSHA yakaona kuti VA haina kuona kuti nzvimbo yebasa haina njodzi dzinogona kukonzera rufu kana kukuvara, uye kuti vatariri havana kudzidziswa nezve kuziva nekudzikisa njodzi mukati menzvimbo yavo yebasa. Mufananidzo kubva kuUS Dhipatimendi reVeterans Affairs "West Haven Steam Rupture, Board of Inquiry" report memo, yaApril 15, 2021, inoratidza "Steam Line Schematic, Basement 22." OSHA yakambotaura kukanganisa katatu mu2015: Kutarisa maitiro ekugadzirisa simba zvishoma gore negore; kutadza kupa dzidziso mushure mekuisa vheji nyowani muBuilding 22; uye kutadza kubatanidza midziyo yeLOTO yega kuboka LOTO michina nevashandi. "Kuuraya uku kwaigona kudziviswa kana vashandirwi vakatevera mitemo yekuchengeteka yakagadzirirwa kudzivirira kusunungurwa kusingadzorwi kwemhepo," mukuru weOSHA wedunhu Steven Biassi akati panguva iyoyo. zvisina basa." Musuwo weCampbell Avenue weVA Connecticut Health Care System kuWest Haven campus, wakatorwa mifananidzo musi waChikunguru 20, 2021. Pamela Redmond, mutauriri weWest Haven Medical Center muVirginia, akataura mune email kuti iyo Virginia system muConnecticut "yanga iri munjodzi. mamiriro ekuchinja kubva zviitiko zvinosiririsa zvemusi wa13 Mbudzi, 2020. Kushanda nesimba kwakaitwa kuvandudza kuchengetedzwa uye kuvandudzwa kukuru kwakaitwa kunzira dzekuchengetedza." The VA Connecticut Healthcare System West Haven campus sezvakatariswa kubva kuSpring Street musi waChikunguru 20, 2021. Facilities Management Services "iri mubishi rekugadzira patsva kana kubvisa hurongwa hwechipfunga muBuilding 22. Kana hurongwa hutsva hwangoiswa, LO/TO itsva. nzira ichagadziriswa," akanyora kudaro. Akataurawo kuti: “Musi waZvita 20, 2020, mavharuvhu anovharika uye anobuda ropa akaiswa panzvimbo yeboiler muhari huru yeBuilding 22 pakaitika tsaona. Iyo itsva valve system inobvumira kuburitswa kweakachengetwa kana akawedzera simba, semuenzaniso kubva kuhurongwa hwemvura yakaderedzwa kubva kuRedmond yakati zvivakwa zviviri zvikuru zviri kuita mapurojekiti ekusimudzira utsi, uye sisitimu yakapihwa chibvumirano chekutsiva zviteyo zvechiputi muChivakwa chayo 22. "Virginia Connecticut State inoramba ichishanda pamwe nehofisi yedu yedunhu, Veterans Health Administration uye OSHA kuona kuchengetedzwa kwemunhu wese kunzvimbo dzedu dzekuchengetwa," Redmond akanyora. Sen. Richard Blumenthal, D-Conn., nhengo yeUS Senate Veterans Affairs Committee, vakati vari kukurudzira kuti pave nehomwe yezvivakwa "kuvakazve nekuvakazve nzvimbo yeWest Haven Virginia" nezvimwe zvipatara zveVirginia zvakati wandei munyika yose. Mutungamiri Joe Biden's $2.65 trillion yemabasa ekuAmerica chirongwa chinosanganisira madhora mabhiriyoni gumi nemasere ekuvandudza zvipatara zveVA nemakiriniki." Kunyange zera repakati muzvipatara zvakazvimiririra zveUS ringangoita makore gumi nerimwe, zera repakati muchipatara cheVA's portfolio imakumi mashanu nesere," bepa reWhite House rakadaro. "Njodzi yaNovember 13 yaingova yakaipisisa yekukundikana kwezvivakwa munguva pfupi yapfuura," akadaro Blumenthal. "Mushumo uyu unonyengetedza zvakanyanya; haisi kupwisa kwete bedzi [kusimbisa] kushomeka muzvivakwa zviripo, asiwo kukurumidzira kugadziridza zvivako nokuunza zvivakwa muzana ramakore rechi21, panzvimbo pokungoshandisa nzira dziri nani. Lan uye zvimwe zvigadziriso zvenguva pfupi kuti zvibatanidze zvikanganiso. Virginia anofanira kuisa mari muhurongwa hutsva. " Blumenthal akati West Haven Medical Center iri muVirginia inoda kuvakwa patsva, asi haakwanise kufungidzira pachena kuti imarii. chiito nechimbichimbi,” akadaro.