Tshaj Tawm: Dab tsi tshwm sim hnub ob tus neeg ua haujlwm tuag hauv West Haven, Virginia

VA Connecticut Health Care System's West Haven lub tsev kawm ntawv raws li tau saib los ntawm West Springs Street thaum Lub Xya Hli 20, 2021. Westport - Tsoom Fwv Teb Chaws tshawb nrhiav pom tias thaum Lub Kaum Ib Hlis 13, 2020, ib qho yooj yim cam khwb cia hlau flange nyob rau hauv ib qho kev laus zog kab hauv Veterans Affairs Medical Center lub tsev dheev snapped rau hauv plaub daim, tso cov cua kub siab thiab tua ob tug txiv neej tuag. VA txoj kev tshawb nrhiav txog qhov xwm txheej tau hais txog cov xwm txheej thaum sawv ntxov, piav qhia txog yuav ua li cas Yauxej O'Donnell, tus neeg ua haujlwm ntiav los kho qhov xau hauv cov kav dej, nkag mus rau hauv qab daus ntawm Lub Tsev 22 tom qab kho, nrog Euel Sims Jr., cov kav dej. Tus neeg saib xyuas, thiab Kev tsis ua haujlwm ntawm cov cuab yeej siv thiab kev ntsuas kev nyab xeeb uas ua rau lawv tuag.Txij li ntawd los, Virginia tau ua lossis npaj ntau yam kev hloov pauv, suav nrog kev txhim kho chav ua haujlwm. Tab sis tsab ntawv ceeb toom tau hais tias muaj feem cuam tshuam rau xyoo 2020 qhov xwm txheej suav nrog cov kav dej uas qub thiab tsis ua raws li cov qauv khoom siv tam sim no, teeb tsa tsis raug thiab cov kav dej ua rau cov dej tsis zoo, thiab raug liam tias tsis ua raws li cov txheej txheem kom cov txiv neej muaj kev nyab xeeb. West Springs Street nkag ntawm VA Connecticut Health Care System West Haven lub tsev kawm ntawv, yees duab rau lub Xya hli ntuj 20, 2021. Thaum kawg, thaum cov txiv neej qhib cov kav dej, chav cua whizzed los ntawm 6-nti yeeb nkab, thiab lub siab tau zoo heev uas lub flange. threaded mus rau hauv qab ntawm lub ntsug dropper snapped rau hauv plaub daim, tshuab chav rau hauv chav tsev.Report. Daim ntawv tshaj tawm kev tshawb nrhiav VA, tshaj tawm lub Plaub Hlis 15, tau txais los ntawm New Haven Registry los ntawm Kev Thov Kev ywj pheej ntawm cov ntaub ntawv.Txhua tus neeg ua haujlwm npe tau raug kho. Qhov xwm txheej no ua rau muaj kev tshuaj xyuas ntawm West Haven Virginia qhov ua tsis tiav, ua rau muaj cuaj OSHA ceeb toom thiab hu rau Congress kom rov tsim kho lub chaw kho mob. Raws li tsab ntawv ceeb toom, cov xov xwm ntawm cov xwm txheej tau pib thaum Lub Kaum Hli lossis Kaum Ib Hlis 2020, thaum Virginia kev ruaj ntseg tau ceeb toom txog kev xau hauv chav cia hauv Tsev 22, ze rau qhov kawg ntawm txoj kev loj ntawm Campbell Avenue nkag. Thaum Lub Kaum Ib Hlis 6, Cov kav dej kav dej yuav tsum tau cais cov chav ntawm lub tsev kom txo tau cov asbestos.Abatement ua hauj lwm tau ua tiav rau lub Kaum Ib Hlis 9, thiab chav tseem tawm. Thaum Lub Kaum Ib Hlis 13, Danbury tus neeg nyob hauv thiab Danbury tus neeg cog lus Mulvaney Mechanical steam assembler O'Donnell ua tiav kev kho qhov xau thaum 7:45 sawv ntxov Thaum 8:00, Sims, Navy Seabees qub tub rog thiab cov neeg nyob hauv Milford, ceeb toom rau nws tus thawj saib xyuas tias nws npaj siab tig rov qab los. on.Peb tus txiv neej hla ib txoj kev mus rau lub tsev, tab sis Sims tus thawj saib xyuas tau hais kom qhib ib chav sib cais hauv Tsev 22, tsab ntawv ceeb toom tau hais tias. chav valve. Thaum kwv yees li 8:10, tsab ntawv ceeb toom tau hais tias, "Tus saib xyuas kev siv hluav taws xob tau hnov ​​​​ib lub suab nrov thiab pom cov kwj deg tawm ntawm lub stairwell coj mus rau chav tshuab. . … Kub kub Lub tswb nrov ua rau muaj hluav taws kub, thiab tus kws tshaj lij kev ruaj ntseg tau tawm tam sim ntawd los tshawb xyuas lub tswb ceeb toom hauv Tsev 22. Tsis tas li ntawd, nyob rau lub sijhawm no, tus saib xyuas lub tshuab hluav taws xob thiab lwm tus neeg ua haujlwm tau raug mob thaum sim nkag mus rau hauv chav ua haujlwm hauv qab daus. ." Virginia boiler cog tau raug kaw, thiab West Haven Fire Department, Virginia State Tub ceev xwm thiab thawj cov neeg teb tau teb. "Tom qab lub zog siab thiab qhov kub thiab txias hauv chav poob qis, cov neeg ua haujlwm kub ntxhov tuaj yeem nkag mus rau hauv chav tsev, tab sis los ntawm lub sijhawm no, tus saib xyuas cov kav dej thiab cov neeg ua haujlwm kho tshuab tau tuag," tsab ntawv ceeb toom tau hais. Txog thaum txog 1:00 teev tsaus ntuj; thaum txog 2:15, tus neeg raug tsim txom raug coj mus lawm. Kev tshawb xyuas ntawm VA los ntawm Applied Technical Services nyob rau hauv Marietta, Georgia, pom tias qhov tso tawm ntawm cov chav superheated muaj zog heev uas ob tug txiv neej uas sim thawb qhib qhov rooj mus rau chav 8-los-12-ko taw ua tsis tau.Ib qho ntawm lawv scalded nws ko taw los ntawm cov dej kub, daim ntawv qhia hais tias. Duab los ntawm US Department of Veterans Affairs "West Haven Steam Rupture, Pawg Neeg Saib Xyuas Kev Tshawb Fawb" daim ntawv qhia memo, hnub tim 15 Lub Plaub Hlis 2021, uas qhia txog "Kev teeb tsa Yeeb Nkab - Lub Sijhawm Kev Tshawb Fawb." "Thaum cov cam khwb cia hlau flange ua tsis tiav, 6" lub ntsiab chav kab muaj peev xwm ntws mus rau hauv chav tsev, "Lub chav tau pressurized nrog chav thaum chav pib ntws mus rau hauv chav tsev los ntawm cov kab tsis muaj kev txwv. tsim phav phav quab yuam nyob rau sab hauv ntawm lub qhov rooj, yuam kom kaw.Thaum lub sijhawm no, nws tsis tuaj yeem qhib qhov rooj yam tsis muaj cov cuab yeej hnyav. "Lub sijhawm ob lub lis piam ntawm thawj daim ntawv tshaj tawm ntawm cov pa xau hauv Tsev 22 thiab hnub ntawm qhov kev huam yuaj, ua ke nrog cov kav dej tsis zoo, yog qhov yuav ua rau muaj kev tuag, daim ntawv tshaj tawm hais tias.Lub qhov cub tau raug kaw, "ua rau muaj kev tsim loj ntawm condensate thiab txias cov kav dej, uas yuav ua rau muaj kev sib tsoo loj heev. tau ua ib qho xwm txheej ntawm qhov xwm txheej, "nws hais.Raws li peb-quarters ntawm ib nkas loos dej hauv lub tee dej, tsis tas yuav tsum muaj qhov ntws los yog qhov dej valve. lub dropper thiab yuav tsum tau welded, tsis threaded, rau cov yeeb nkab. Cov flanges ruptured tom qab "ib lub sij hawm muaj kev cuam tshuam loj heev ntawm dej rauj," daim ntawv qhia hais tias. Dej rauj yog hydraulic shock yoj tshwm sim los ntawm dej los yog nthwv dej tau dheev raug yuam kom nres los yog hloov cov kev taw qhia thiab ces slammed tiv thaiv lub valve los yog lwm yam teeb meem. Nws feem ntau yog tshwm sim los ntawm kev sib sau ntawm cov dej hauv cov kav dej. Thaum lub valve qhib thiab chav nkag mus rau hauv cov kav dej hauv chav kho tshuab, nws tsoo cov dej txias hauv lub tee dej nrog qhov tshwm sim loj heev. "Qhov kev rov ua dua tshiab no tuaj yeem ua rau cua sov tam sim ntawd thiab flashing ntawm stagnant los yog unremoved condensate nyob rau hauv ib qho undrained feem ntawm lub ntsiab chav. piping," daim ntawv ceeb toom hais. "thiab" yog qhov feem ntau yuav ua rau tsis ua tiav ntawm grey cam khwb cia hlau flanges". "Lub hom phiaj flange tau ntsib overload tsis ua hauj lwm vim lub load tshaj qhov nws yuav lis," tsab ntawv ceeb toom hais. Duab los ntawm Lub Plaub Hlis 15, 2021 US Department of Veterans Affairs "West Haven Steam Rupture, Board of Inquiry" qhia memo uas qhia "flange puas" hauv Tsev 22. "Lub sijhawm dhau los ntawm kev nkag mus rau qhov chaw thiab qhib lub valve rau txoj haujlwm lawv pom. qhia tau hais tias lub kaw lus tsis tau rov ua kom muaj zog zoo li no yuav tsum tau ua kom qeeb thiab maj mam kub thiab siab sib npaug, "nws tau sau tseg. "Cov neeg ua haujlwm tau qhib 75% ntawm chav valve # 1. Lawv kuj tau qhib lub pob valve nyob rau ntawm lub ntsiab chav kab condensate rov qab lim lim," tsab ntawv ceeb toom tau hais. Ob lub valve kuj tseem qhib, ib qho 5% mus rau 6%, lwm qhov qhib 11%. Duab los ntawm US Department of Veterans Affairs "West Haven Steam Repture, Pawg Neeg Tshawb Fawb" daim ntawv qhia memo, hnub tim 15 Lub Plaub Hlis 2021, qhia "Threaded Pipe Connection, Drip Bottom." "Kev qhib lub pob valve yuav tsum muab cov lus tawm tswv yim tam sim rau cov neeg ua haujlwm hauv daim ntawv ntawm cov dej ntws thiab cov dej condensate los ua pov thawj tias nws ua haujlwm," cov kws tshawb nrhiav tau hais. "Qhov tseeb ib ntus uas txhua lub valve qhib tsis meej, tab sis nws yog qhov zoo tshaj los qhib cov kab condensate ua ntej." Lub pob valve me me. "Txawm li cas los xij, thaum daim ntawv tshaj tawm hais tias qhib lub pob valve yuav ntws cov condensate los ntawm txoj kab lossis siab dua, nws yuav tsis ntws tag nrho cov dej hauv cov drip kab "thiab qhov chaw ntawm cov kab tseem ceeb no tseem muaj 3. / 4 nkas loos ntawm condensate. " Daim ntawv tshaj tawm hais tias cov kav dej hauv Tsev 22 tau ua txhaum ntau txoj cai.Cast hlau flanges tsis raug tso cai rau ntawm cov kav dej hauv qab cov lej no, tab sis tsis txwv los ntawm VA lossis ASME cov lej, daim ntawv tshaj tawm hais tias. Tsis muaj pov thawj tias Virginia tau hais kom ib tus neeg yav dhau los tshem tawm lossis hloov lub flange, "Nws tau hais tias. Tsis tas li ntawd, lub tshuab nqus tsev vacuum tau teeb tsa ze ze rau hauv qab ntawm cov yeeb nkab, "qhov kev rho tawm yog lub npauj npaim valve, uas yog. Tsis tso cai raws li VA code," tsab ntawv ceeb toom tau hais tias lwm qhov teeb meem, tsab ntawv ceeb toom tau hais tias, yog "qhov tsis muaj peev xwm cais tawm ib qho ntawm peb lub ntsiab lus tseem ceeb, ua rau nws tsis tuaj yeem ua rau cov nroj tsuag boiler kom muaj kev nyab xeeb ntawm tag nrho cov boiler cog". . ntawm lwm tus neeg uas tsis yog tus neeg uas muab nws tawm. Raws li tsab ntawv ceeb toom: "Lub VA xauv thiab saw tau pom nyob rau hauv qhov chaw nyob ze ntawm chav tsev valve, qhia tias lub kaw lus yuav raug kaw. Txawm li cas los xij, tsis muaj lockout tagout (LOTO) cav, tso cai lossis LOTO cov txheej txheem rau lub kaw lus. Tsis muaj kev tshawb fawb hauv chaw ua haujlwm tau pom LOTO cov cav lossis cov txheej txheem rau cov li qub lossis cov tsev no." Kev sib txuas lus ntawm kev nyab xeeb, kav dej, thiab engineering kuj ua tsis tau: "Lub boiler cog tsis tau ceeb toom txog qhov kev kaw no, thiab tsis tau ceeb toom txog kev kaw txuas ntxiv. Nws tsis paub meej tias engineering kev coj noj coj ua lossis kev ruaj ntseg tau paub txog hnub no. ua hauj lwm nyob rau hauv kev kawm, "daim ntawv qhia tau sau tseg. Pab pawg pom tsis muaj pov thawj ntawm kev kaw lus ntxiv los ntawm tus neeg cog lus. "Lub Tsib Hlis 12, OSHA tau tshaj tawm cuaj daim ntawv ceeb toom hais txog kev ua haujlwm tsis zoo lossis tsis noj qab haus huv hauv Connecticut, suav nrog kev ceeb toom rau cov tswv lag luam boiler kom tshem tawm / tawm ntawm cov kab ntau lawm; ua tsis tau rau Mulvaney Mechanical ntawm nws cov txheej txheem LOTO; los yog kev txiav txim kaw ntawm cov khoom siv "kom cov condensate tuaj yeem ntws tawm ntawm qhov system.Nws hais tias "cov txheej txheem tsis tau tsim, sau tseg thiab siv los tswj cov khoom muaj kev phom sij" lossis cov cuab yeej siv los ua haujlwm ntawm lub valve. Tsis tas li ntawd, OSHA tau pom tias VA tsis tau ua kom lub chaw ua haujlwm tsis muaj kev phom sij uas tuaj yeem ua rau tuag lossis raug mob, thiab cov thawj coj tsis tau kawm txog yuav ua li cas paub txog thiab txo cov kev phom sij hauv lawv lub luag haujlwm. Daim duab los ntawm US Department of Veterans Affairs "West Haven Steam Repture, Board of Inquiry" daim ntawv qhia memo, hnub tim 15, 2021, uas qhia "Steam Line Schematic, Hauv qab 22." OSHA yav dhau los hais txog peb qhov kev ua txhaum cai hauv xyoo 2015: Tshawb xyuas cov txheej txheem tswj hluav taws xob tsawg kawg ib xyoos ib zaug; tsis muab kev cob qhia tom qab kev txhim kho lub tshuab hluav taws xob tshiab hauv lub tsev 22; thiab tsis xa cov khoom siv LOTO tus kheej rau pawg LOTO cov cuab yeej los ntawm cov neeg ua haujlwm. "Cov neeg tuag no tuaj yeem zam tau yog tias cov tswv ntiav ua raws li cov qauv kev nyab xeeb tsim los tiv thaiv kev tso tawm tsis muaj zog," OSHA tus thawj coj hauv cheeb tsam Steven Biassi tau hais thaum lub sijhawm ntawd. tsis tsim nyog." Campbell Avenue nkag ntawm VA Connecticut Health Care System West Haven tsev kawm ntawv, yees duab thaum Lub Xya Hli 20, 2021. Pamela Redmond, tus cev lus rau West Haven Medical Center hauv Virginia, tau hais hauv email tias Virginia system hauv Connecticut "tau nyob hauv ib qho xeev xwm txheej txij li thaum muaj xwm txheej xwm txheej tshwm sim thaum lub Kaum Ib Hlis 13, 2020. Kev ua hauj lwm nyuaj tau ua los txhim kho kev nyab xeeb thiab kev hloov tshiab loj tau ua rau cov txheej txheem kev nyab xeeb. " VA Connecticut Healthcare System West Haven lub tsev kawm ntawv raws li tau pom los ntawm Spring Street thaum Lub Xya Hli 20, 2021. Cov Kev Pabcuam Kev Tswj Xyuas Kev Pabcuam "yog nyob rau hauv tus txheej txheem ntawm redesigning los yog dismantling lub chav tsev nyob rau hauv lub tsev 22. Thaum lub tshiab system yog ntsia, ib tug tshiab LO/TO. txheej txheem yuav raug tsim, "nws sau. Nws kuj tau hais tias: "Lub Kaum Ob Hlis 20, 2020, ob chav kaw thiab los ntshav valve tau teeb tsa ntawm lub boiler cog nyob rau hauv chav tsev loj ntawm Lub Tsev 22 qhov chaw muaj xwm txheej tshwm sim. Lub kaw lus valve tshiab tso cai rau kev tso tawm ntawm lub zog khaws cia lossis cov khoom siv ntxiv, piv txwv li los ntawm lub kaw lus condensed dej tawm los ntawm Redmond tau hais tias ob lub tsev loj tab tom ua haujlwm ua haujlwm hauv chav ua haujlwm, thiab lub kaw lus tau cog lus los hloov cov chav ntxiab hauv nws Lub Tsev 22. "Lub xeev Virginia Connecticut tseem ua haujlwm ze nrog peb lub chaw haujlwm hauv cheeb tsam, Veterans Health Administration thiab OSHA kom muaj kev nyab xeeb ntawm txhua tus ntawm peb qhov chaw saib xyuas," Redmond sau. Sen. Richard Blumenthal, D-Conn., ib tug tswv cuab ntawm US Senate Veterans Affairs Committee, tau hais tias nws tab tom tawm tswv yim rau cov peev txheej tsim kho kom "tsim thiab rov tsim kho West Haven Virginia cov chaw" thiab ntau lub tsev kho mob Virginia thoob plaws lub tebchaws. Thawj Tswj Hwm Joe Biden cov phiaj xwm $ 2.65 trillion Asmeskas txoj haujlwm suav nrog $ 18 nphom txhawm rau txhim kho VA cov tsev kho mob thiab chaw kho mob. "Thaum lub hnub nyoog nruab nrab hauv tsev kho mob hauv Teb Chaws Asmeskas yog kwv yees li 11, lub hnub nyoog nruab nrab hauv VA lub tsev kho mob cov ntaub ntawv yog 58," White House daim ntawv tseeb hais. "Lub Kaum Ib Hlis 13 qhov xwm txheej tsuas yog qhov phem tshaj plaws ntawm kev ua haujlwm tsis ntev los no," Blumenthal tau hais.“Daim ntawv tshaj tawm no yog qhov txaus siab heev; nws ntseeg tsis tau tsuas yog [qhov tseem ceeb] qhov tsis zoo ntawm cov chaw uas twb muaj lawm, tab sis kuj tseem yog qhov tseem ceeb ntawm kev kho vaj tse thiab nqa cov qauv mus rau xyoo pua 21st, tsis yog siv txoj hauv kev zoo dua. Lan thiab lwm yam kev kho luv luv los kho qhov tsis zoo. Virginia yuav tsum nqis peev rau tag nrho cov qauv tshiab. " Blumenthal tau hais tias West Haven Medical Center hauv Virginia yuav tsum tau tsim kho dua tshiab, tab sis nws tsis tuaj yeem kwv yees kwv yees li qhov yuav raug nqi rau pej xeem." kev txiav txim ceev, "nws hais.