Rahoton: Me ya faru ranar da ma'aikata biyu suka mutu a West Haven, Virginia

VA Connecticut Health Care System's West Haven harabar kamar yadda aka gani daga titin West Springs a kan Yuli 20, 2021. Westport - Binciken Tarayya ya gano cewa a ranar Nuwamba 13, 2020, ƙaramin simintin ƙarfe mai sauƙi a cikin layin tururi na tsufa a cikin ginin Cibiyar Kiwon Lafiyar Tsohon soji ba zato ba tsammani. An tsince shi kashi hudu, ya saki tururi mai tsananin zafi ya kashe mutane biyu suka mutu. Binciken da VA ta yi kan hatsarin ya ba da labarin abubuwan da suka faru a safiyar, inda ya bayyana yadda Joseph O'Donnell, dan kwangilar da ya dauki hayar gyara bututun mai, ya shiga cikin ginin ginin ginin 22 bayan an gyara shi, tare da Euel Sims Jr., na'urar famfo. mai kulawa, da kuma gazawar kayan aiki da matakan tsaro da suka kai ga mutuwarsu.Tun daga lokacin, Virginia ta yi ko ta tsara sauye-sauye da yawa, gami da aikin haɓaka tururi. Sai dai rahoton ya ce abubuwan da suka haifar da lamarin na shekarar 2020 sun hada da aikin famfo da suka tsufa kuma ba su cika ka'idojin da ake amfani da su a halin yanzu ba, da bawuloli da bututun da aka sanya ba daidai ba, da ke kai ga tsugunar da ruwa, da kuma zargin rashin bin hanyoyin da za a kiyaye maza. Ƙofar titin West Springs na harabar VA Connecticut Health Care System West Haven, an ɗauki hoton ranar 20 ga Yuli, 2021. Daga ƙarshe, lokacin da mutanen suka buɗe bututun, tururi ya buge ta cikin bututu mai inci 6, kuma matsa lamba ya yi yawa sosai har flange zare zuwa kasan digo a tsaye ya tsinke kashi hudu, yana hura tururi zuwa dakin.Rahoto. Rahoton binciken VA, wanda aka saki ranar 15 ga Afrilu, an samu ta hanyar rajistar New Haven ta hanyar neman 'Yancin Bayanai. An gyara duk sunayen ma'aikata. Lamarin ya haifar da sake duba gazawar West Haven Virginia, wanda ya haifar da sanarwar OSHA tara da kuma kira ga Majalisa da ta sake gina cibiyar kiwon lafiya. A cewar rahoton, jerin abubuwan sun fara ne a watan Oktoba ko Nuwamba 2020, lokacin da aka sanar da jami'an tsaro na Virginia game da yoyon fitsari a wani dakin ajiyar kaya a Gini 22, kusa da karshen babban titin da ke kofar Campbell Avenue.A ranar 6 ga Nuwamba, Ana buƙatar sashen aikin famfo don ware tururi daga ginin don rage asbestos. An kammala aikin ragewa a ranar 9 ga Nuwamba, kuma tururi ya ragu. A ranar 13 ga Nuwamba, mazaunin Danbury kuma dan kwangilar Danbury Mulvaney Mechanical tururi mai tarawa O'Donnell ya kammala gyare-gyaren ɗigon ruwa da ƙarfe 7:45 na safe Da ƙarfe 8:00, Sims, tsohon sojan Navy Seabees kuma mazaunin Milford, ya sanar da mai kula da shi cewa yana da niyyar mayar da tururi. Mutanen uku sun tsallaka titi zuwa ginin, amma an bukaci mai kula da Sims ya bude wani daki na daban a Ginin 22, rahoton ya ce. tururi bawul. Da misalin karfe 8:10, rahoton ya bayyana cewa, "Mai kula da tsarin amfani da kayan aiki ya ji kara mai karfi kuma ya ga kogin tururi yana fitowa daga matakalar da ke kaiwa dakin injina. An yi asarar tururin tururi ... an rubuta shi a masana'antar tukunyar jirgi. Zazzabi mai girma Ƙararrawar ta haifar da ƙararrawar wuta, kuma ƙwararren jami'in tsaro ya tafi nan da nan don bincika ƙararrawar da aka ruwaito a Ginin 22. Bugu da ƙari, a wannan lokacin, mai kula da tsarin kayan aiki da wani ma'aikacin wurin sun ji rauni yayin ƙoƙarin shiga ɗakin ginin ginin. ." An rufe masana'antar tukunyar jirgi ta Virginia, kuma Ma'aikatar kashe gobara ta West Haven, 'yan sandan jihar Virginia da masu ba da amsa na farko sun mayar da martani. "Bayan matsin tururi da zafin jiki a cikin dakin ya ragu, jami'an agajin gaggawa sun iya shiga dakin, amma a wannan lokacin mai kula da shagunan famfo da kuma dan kwangilar inji sun mutu," in ji rahoton. Har zuwa karfe 1:00 na dare; da misalin karfe 2:15 aka tafi da wanda aka kashe. Wani bincike na VA ta aikace-aikacen fasaha na fasaha a Marietta, Georgia, ya gano cewa sakin tururi mai zafi yana da ƙarfi sosai cewa maza biyu da suka yi ƙoƙarin tura ƙofar zuwa ɗakin mai ƙafa 8-by-12 sun kasa. Daya daga cikin Rahoton ya ce sun kona kafarsa daga ruwan zafi. Hoto daga Ma'aikatar Harkokin Tsohon Sojoji ta Amurka "West Haven Steam Rupture, Kwamitin Bincike na Hukumar Bincike", mai kwanan wata 15 ga Afrilu, 2021, yana nuna "Tsarin Bututu - Lokacin Bincike." "Lokacin da simintin ƙarfe na simintin ya gaza, babban layin tururi na 6" ya sami damar matsewa cikin ɗakin," rahoton ya ce. yana haifar da dubban fam na ƙarfi a cikin ƙofar, yana tilasta shi rufewa. A wannan lokacin, ba zai yiwu a buɗe ƙofar ba tare da kayan aiki masu nauyi ba." Tsawon makonni biyu tsakanin rahoton farko na zubar da tururi a Ginin 22 kuma ranar da hatsarin ya faru, haɗe da bututun ɗigo da ba su dace ba, shine zai iya haifar da mutuwar, in ji rahoton. An rufe tururi, "wanda ya haifar da tarin kwarjini da kuma sanyaya bututun, wanda zai iya haifar da mutuwar. sun kasance sanadin hatsarin, "in ji shi. Tare da kusan kashi uku cikin huɗu na galan na ruwa a cikin digo, babu magudanar ruwa ko magudanar ruwa da ake buƙata. Masu bincike sun ce flange ɗin da aka fashe an makala shi ne a gefen wani flange mara kyau a ƙarshen magudanar ruwa. dropper kuma yakamata a yi masa walda, ba zare ba, zuwa bututu. The flanges ruptured bayan "wani hali high-tasiri lokaci na ruwa guduma," rahoton ya ce. Ruwa guduma wani na'ura mai aiki da karfin ruwa girgiza kalaman da ruwa ko tururi da ake yi ba zato ba tsammani tilasta tsayawa ko canja hanya sa'an nan kuma slammed da bawul ko wani cikas. Yawanci yana faruwa ne sakamakon tarin ruwa a cikin bututun tururi. Lokacin da bawul ɗin ya buɗe kuma tururi ya shiga cikin bututun a cikin ɗakin injin, yana bugun ruwa mai sanyaya a cikin digo tare da mummunan sakamako. bututu," in ji rahoton. "da" shine mafi kusantar sanadin gazawar farat ɗin simintin ƙarfe na simintin ƙarfe". Rahoton ya ce "Fushin da aka yi niyya ya fuskanci gazawar lodin kaya saboda nauyi fiye da abin da zai iya dauka," in ji rahoton. Hoto daga Ma'aikatar Tsohon Sojoji na Amurka Afrilu 15, 2021 "West Haven Steam Rupture, Board of Inquiry" rahoton rahoton yana nuna "lalacewar flange" a cikin Ginin 22. "Lokacin da ya wuce tsakanin shiga sararin samaniya da buɗe bawuloli zuwa matsayin da suka samu. yana nuna cewa tsarin bai sake samun kuzari yadda yakamata ba. "Ma'aikata sun bude kashi 75% na bututun ruwa # 1. Sun kuma bude bawul din kwallon da ke kan babban layin layin tururi condensate dawo da layin," rahoton ya ce. Wasu bawuloli biyu kuma an buɗe, ɗaya 5% zuwa 6%, ɗayan ya buɗe 11%. Hoto daga Ma'aikatar Harkokin Tsohon Sojoji ta Amurka "West Haven Steam Rupture, Board of Inquiry" memo rahoton, mai kwanan wata Afrilu 15, 2021, yana nuna "Haɗin Bututun Zare, Ditsin Qasa." "Bude bawul ɗin ƙwallon ya kamata ya ba da amsa ga ma'aikata nan da nan ta hanyar tururi da kwararar ruwa don tabbatar da cewa yana aiki," in ji masu binciken. "Ainihin jerin da kowane bawul ya buɗe ba a sani ba, amma yana da kyau a fara buɗe layin condensate da farko." Small ball bawul." Duk da haka, yayin da rahoton ya ce bude ball bawul zai zubar da condensate daga layi ko mafi girma, ba zai kwashe duk ruwan da ke cikin drip line "kuma wannan yanki na babban layin tururi har yanzu ya ƙunshi 3. / 4 gallon na condensate." Rahoton ya ce aikin famfo a Ginin 22 ya keta ka'idoji da yawa. Ba a sake ba da izinin yin amfani da flanges baƙin ƙarfe a kan tsarin bututun tururi a ƙarƙashin waɗannan lambobin, amma lambobin VA ko ASME ba su hana su ba, in ji rahoton. Babu wata shaida da ke nuna cewa Virginia ta umarci kowa a baya don cire ko maye gurbin flange, "in ji shi. Bugu da ƙari, an shigar da tarkon tururi kusa da kasan bututun drip, "bawul ɗin keɓewa shine bawul ɗin malam buɗe ido, wanda shine Rahoton ya ce, ba a ba da izini a ƙarƙashin lambar VA ba, in ji rahoton. Wata matsala kuma, in ji rahoton, ita ce "rashin iya ware ko ɗaya daga cikin manyan layukan tururi guda uku, wanda hakan ya sa ba za a iya tabbatar da lafiyar masana'antar tukunyar jirgi ba." VA Connecticut Health Care System's West Haven kamar yadda aka gani daga titin West Springs ranar 20 ga Yuli, 2021. Masu bincike sun kuma zargi VA da rashin hanyoyin da aka tsara don kare ma'aikata a cikin yanayi masu haɗari. Tsarin kullewa/tagout yana hana tururi daga komawa baya. akan kowa sai wanda ya kashe. A cewar rahoton: "An sami makullin VA da sarkar a cikin sararin samaniya kusa da bawul ɗin dakin, wanda ke nuna cewa mai yiwuwa an kulle tsarin. Koyaya, babu rajistan ayyukan kullewa (LOTO), izini ko hanyoyin LOTO na tsarin. Babu wani bincike na ofis da ya sami LOTO logs ko matakai na waɗannan bawuloli ko gine-gine." Sadarwa tsakanin aminci, famfo, da injiniya kuma ta gaza: "Ba a sanar da masana'antar tukunyar jirgi game da wannan rufewar ba, kuma ba a sanar da ta ci gaba da rufewa ba. Babu tabbas ko jagorancin injiniya ko tsaro sun san wannan ranar. aikin yana ci gaba, "in ji rahoton. A ranar 12 ga Mayu, OSHA ta ba da sanarwar tara game da rashin tsaro ko yanayin aiki mara kyau a cikin Connecticut, gami da sanar da masu aikin shukar tukunyar jirgi don fita/tambayi kan layin samarwa; kasa sanar da Mulvaney Mechanical na tsarin LOTO; ko kuma rufe kayan aiki cikin tsari" ta yadda za a iya fitar da condensate daga tsarin. Ya ce "ba a samar da tsarin ba, rubutawa da amfani da shi don sarrafa makamashi mai haɗari" ko fasahar da ake amfani da ita don sarrafa bawul. Bugu da ƙari, OSHA ta gano cewa VA ba ta tabbatar da cewa wurin aiki ba shi da haɗari da zai iya haifar da mutuwa ko rauni, kuma ba a horar da masu kula da yadda za su gane da kuma rage haɗari a cikin yankunan da ke da alhakin. Hoto daga Ma'aikatar Harkokin Tsohon Sojoji ta Amurka "West Haven Steam Rupture, Kwamitin Bincike" memo, mai kwanan wata Afrilu 15, 2021, yana nuna "Tsarin Layin Steam, Basement 22." A baya OSHA ta ambaci cin zarafi guda uku a cikin 2015: Duba hanyoyin sarrafa makamashi aƙalla kowace shekara; kasawar bayar da horo bayan shigar da sabon bawul ɗin layin tururi a Ginin 22; da rashin haɗa kayan LOTO na sirri zuwa rukuni na kayan LOTO ta ma'aikata. "Da za a iya guje wa waɗannan asarar rayuka idan masu daukar ma'aikata sun bi ka'idodin aminci da aka tsara don hana sakin tururi ba tare da kulawa ba," in ji darektan yankin OSHA Steven Biassi a lokacin. "Abin baƙin ciki, waɗannan sanannun kariyar ba a cikin wurin kuma ma'aikata biyu sun rasa rayukansu. ba dole ba." Ƙofar Campbell Avenue na harabar VA Connecticut Health Care System West Haven, wanda aka yi hoton a ranar 20 ga Yuli, 2021. Pamela Redmond, mai magana da yawun Cibiyar Kiwon Lafiya ta West Haven a Virginia, ta ce a cikin imel cewa tsarin Virginia a Connecticut "ya kasance a cikin halin da ake ciki tun bayan munanan abubuwan da suka faru na Nuwamba 13, 2020. An yi aiki tuƙuru don inganta aminci kuma an yi manyan sabuntawa ga hanyoyin aminci." The VA Connecticut Healthcare System West Haven harabar kamar yadda ake kallo daga titin Spring on Yuli 20, 2021. Sabis na Gudanar da Kayayyaki "yana kan aiwatar da sake fasalin ko rushe tsarin tururi a Ginin 22. Da zarar an shigar da sabon tsarin, sabon LO/TO za a bunkasa hanya," ta rubuta. Ta kuma ce: “A ranar 20 ga Disamba, 2020, an sanya na’urar kashe-kashe da zubar jini sau biyu a matatar tukunyar jirgi da ke babban tururi na Gini 22 inda hatsarin ya afku. Sabon tsarin bawul din yana ba da damar sakin makamashin da aka adana ko ragi, alal misali daga na'urar da aka tara ruwa da aka fitar daga Redmond ya ce manyan gine-gine guda biyu suna gudanar da ayyukan inganta tururi, kuma an ba da kwangilar tsarin don maye gurbin tarkon tururi a Gininsa na 22. Redmond ya rubuta "Jihar Connecticut Connecticut tana ci gaba da yin aiki kafada da kafada da ofishinmu na yanki, Hukumar Kula da Lafiya ta Tsohon Sojoji da OSHA don tabbatar da amincin kowa a wuraren kula da mu," Redmond ya rubuta. Sen. Richard Blumenthal, D-Conn., memba a kwamitin kula da tsofaffin sojoji na Majalisar Dattijan Amurka, ya ce yana ba da shawarar samar da asusun samar da ababen more rayuwa don "sake ginawa da sake gina ginin West Haven Virginia" da wasu asibitocin Virginia da dama a duk fadin kasar. Shirin aikin Amurka na dala tiriliyan 2.65 na Shugaba Joe Biden ya hada da dala biliyan 18 don sabunta asibitoci da asibitocin VA." Yayin da matsakaicin shekarun asibitocin Amurka masu zaman kansu ya kai kusan 11, matsakaicin shekarun da ke cikin fayil din asibitin VA ya kai 58, "in ji takardar gaskiyar fadar White House. "Mummunan bala'i na 13 ga Nuwamba shine kawai mafi munin gazawar ababen more rayuwa na baya-bayan nan," in ji Blumenthal. "Wannan rahoton yana da gamsarwa sosai; yana da gamsarwa ba wai kawai nakasu ba ne a cikin wuraren da ake da su ba, har ma da gaggawar sabunta gine-gine da kawo gine-gine a cikin karni na 21, maimakon amfani da ingantattun hanyoyin kawai. Lan da sauran gyare-gyare na gajeren lokaci don daidaita lahani. Ya kamata Virginia ta saka hannun jari a cikin sabon tsari. " Blumenthal ya ce Cibiyar Kiwon Lafiya ta West Haven da ke Virginia na bukatar sake ginawa, amma ya kasa kimanta nawa ne kudin da za a kashe a bainar jama'a. "Na yi magana da Sakataren Harkokin Tsohon Sojoji Dennis McDonough a lokuta da yawa, kuma yana sane da bukatar hakan. daukar matakin gaggawa,” inji shi.