ʻO VA Connecticut Health Care System's West Haven campus e like me ka nānā ʻana mai West Springs Street ma Iulai 20, 2021.
Westport - Ua ʻike ʻia ka noiʻi Federal ma Nowemapa 13, 2020, ua ʻoki koke ʻia kahi flange hao maʻalahi i loko o kahi laina mokumahu kahiko i loko o ka hale Veterans Affairs Medical Center i ʻehā mau ʻāpana, e hoʻokuʻu ana i ka mahu kiʻekiʻe a make ʻelua mau kāne.
ʻO ka hoʻokolokolo ʻana o ka VA i ka ulia i hōʻike ʻia i nā hanana o ke kakahiaka, e wehewehe ana i ke ʻano o Joseph O'Donnell, kahi mea hana ʻaelike i hoʻolimalima e hoʻoponopono i ka leak i loko o ka pipeline, i komo i ka haʻahaʻa o ka Hale 22 ma hope o ka hoʻoponopono ʻana, i ukali ʻia e Euel Sims Jr., ka paipu paipu. luna, a ʻO ka hemahema o nā lako a me nā hana palekana i alakaʻi i ko lākou make.
Akā ua ʻōlelo ka hōʻike i nā mea e pili ana i ka hanana 2020 e pili ana i ka paipu kahiko a ʻaʻole i hoʻokō i nā kūlana waiwai o kēia manawa, nā kīwī i hoʻokomo pono ʻia a me nā paipu e alakaʻi ana i ka wai stagnant, a ʻōlelo ʻia ʻaʻole e hahai i nā kaʻina hana e mālama ai i nā kāne.
ʻO ka puka komo o ke alanui ʻo West Springs o ke kahua ʻo VA Connecticut Health Care System West Haven, i kiʻi ʻia ma Iulai 20, 2021.
ʻO ka hopena, i ka wā i wehe ai nā kāne i nā paipu, lele maila ka mahu i loko o ka paipu 6-iniha, a ua nui loa ke kaomi ʻana a hiki i ka lepa i hoʻopaʻa ʻia i lalo o ka pahu hoʻoheheʻe kūpaʻa i ʻehā mau ʻāpana, e puhi ana i ka mahu i loko o ka lumi. Hōʻike.
ʻO ka hōʻike hoʻokolokolo VA, i hoʻokuʻu ʻia i ka lā 15 ʻApelila, ua loaʻa mai e ka New Haven Registry ma o kahi noi Freedom of Information. Ua hoʻoponopono ʻia nā inoa limahana a pau.
ʻO ka hanana i alakaʻi i ka loiloi o West Haven Virginia i hāʻule ʻole, ka hopena i ʻeiwa mau leka OSHA a kāhea aku i ka Congress e kūkulu hou i ke kikowaena olakino.
Wahi a ka hōʻike, ua hoʻomaka ke kaulahao o nā hanana i ʻOkakopa a i ʻole Nowemapa 2020, i ka wā i hōʻike ʻia ai ka palekana o Virginia no kahi leak i loko o kahi lumi mālama ma ka Hale 22, kokoke i ka hopena o ke ala nui ma ke komo ʻana o Campbell Avenue. Ua koi ʻia ka ʻoihana paipu e hoʻokaʻawale i ka mahu mai ka hale i mea e hōʻemi ai i ka asbestos.
Ma ka lā 13 o Nowemapa, ua hoʻopau ka noho ʻana o Danbury a me ka mea hana ʻaelike Mulvaney Mechanical ʻo Mulvaney Mechanical ʻo O'Donnell i ka hoʻoponopono ʻana i ka leak ma ka hola 7:45 amI ka hola 8:00, ua haʻi aku ʻo Sims, he kanaka Navy Seabees a he kamaʻāina ʻo Milford, i kona luna e manaʻo ana e hoʻihoʻi i ka mahu. Ua hele na kanaka ekolu i ke alanui a hiki i ka hale, aka, ua noiia ka luna nana o Sims e wehe i keena kaawale ma ka Hale 22, wahi a ka hoike. Ua hoikeia mai ua hele aku o O'Donnell a me Sims i ka lumi mīkini ma lalo o ka hale 22 e hoohuli i ka pahu mahu.
Ma kahi o ka hola 8:10, ua ʻōlelo ka hōʻike, "Ua lohe ka luna hoʻokele waiwai i kahi paʻi nui a ʻike i kahi kahe o ka mahu e puka mai ana mai ke alapiʻi e alakaʻi ana i ka lumi mīkini. Ua hoʻopaʻa ʻia ka nalo ʻana o ke kaomi mahu… ma ka hale paila. … kiʻekiʻe wela Ua hoʻāla ʻia ka puʻupuʻu i kahi puʻupuʻu ahi, a ua haʻalele koke kekahi loea palekana no ka noiʻi ʻana i ka alarm i hōʻike ʻia ma ka Hale 22. Eia hou, i kēia manawa, ua ʻeha ka luna hoʻokele waiwai a me kekahi limahana o ka hale hana i ka wā e hoʻāʻo ana e komo i ka lumi mīkini lalo. ”
Ua pani ʻia ka hale hoʻoheheʻe ʻo Virginia, a ua pane aku ka West Haven Fire Department, Virginia State Police a me nā mea pane mua.
"Ma hope o ka hāʻuleʻana o ka mahu a me ka mahana o ka lumi, hiki i nā limahana pilikia ke komo i loko o ka lumi, akā i kēia manawa ua make ka luna hale kūʻai paipu a me ka mea hana mīkini," wahi a ka hōʻike. A hiki i ka hola 1:00; ma kahi o 2:15, ua lawe ʻia ka mea i pepehi ʻia.
ʻO ka hoʻokolokolo ʻana o ka VA e Applied Technical Services ma Marietta, Georgia, ua ʻike ʻia ua ikaika loa ka hoʻokuʻu ʻia ʻana o ka mokumahu wela loa i hiki ʻole i nā kāne ʻelua i hoʻāʻo e pana i ka puka o ka lumi 8-by-12-foot. ua hoʻā ʻia kona wāwae mai ka wai wela, wahi a ka hōʻike.
Kiʻi mai ka US Department of Veterans Affairs "West Haven Steam Rupture, Board of Inquiry Investigation" memo hōʻike, i hoʻopaʻa ʻia ma ʻApelila 15, 2021, e hōʻike ana i ka "Pipe Configuration - Time of Investigation."
"I ka hāʻule ʻana o ka flange hao, ua hiki i ka laina mahu nui 6" ke kahe i loko o ka lumi," wahi a ka hōʻike. "Ua paʻi ka lumi i ka mahu i ka wā i hoʻomaka ai ka mahu e kahe i loko o ka lumi mai ka laina mahu ʻole. ka puka me ka mea kaumaha ole.
ʻO ka manawa ʻelua pule ma waena o ka hōʻike mua o ka lele ʻana o ka mahu ma ka Hale 22 a me ka lā o ka pōʻino, i hui pū ʻia me nā paipu kulu i hoʻokomo pono ʻole ʻia, ʻo ia ke kumu o ka make, wahi a ka hōʻike. Ua pani ʻia ka mahu, " ka hopena i ka nui o ka condensate a me ka hoʻoluʻu ʻana i nā paipu, ʻo ia paha ke kumu o ka pōʻino, "i ʻōlelo ai. .
Ua ʻōlelo ka poʻe noiʻi, ua hoʻopili ʻia ka flange mahā i kahi flange blank ma ka hope o ka mea hoʻoheheʻe a pono e wili ʻia, ʻaʻole i hoʻopaʻa ʻia i ka paipu.
Ua haki ʻia nā flanges ma hope o "kahi manawa kiʻekiʻe o ka hāmare wai," i ʻōlelo ʻia e ka hōʻike. ʻO ka hāmare wai he hawewe hoʻohāhā hydraulic i hana ʻia e ka wai a i ʻole ka mahu i koi koke ʻia e kū a hoʻololi i ke ala a laila hoʻopaʻa ʻia i kahi valve a i ʻole kekahi mea keakea. He mea maʻamau ia ma muli o ka hōʻiliʻili ʻana o ka wai i loko o nā paipu mahu.
I ka wehe ʻana o ka pahu a komo ka mahu i loko o ka paipu i loko o ka lumi mīkini, paʻi ia i ka wai maʻalili i loko o ka pahu me nā hopena pōʻino. paipu," wahi a ka hōʻike. " a "ʻo ia ke kumu nui loa o ka hāʻule koke ʻana o nā flanges hao hina".
"Ua loaʻa i ka flange target kahi hemahema ma muli o kahi ukana ma mua o ka mea hiki ke mālama," wahi a ka hōʻike.
Kiʻi mai ka ʻApelila 15, 2021 US Department of Veterans Affairs "West Haven Steam Rupture, Board of Inquiry" hōʻike memo e hōʻike ana i ka "flange damage" ma ka Hale 22.
"ʻO ka manawa i hala ma waena o ke komo ʻana i ka lewa a me ka wehe ʻana i nā kīwaha i ke kūlana i loaʻa iā lākou e hōʻike ana ʻaʻole i hoʻōla hou ʻia ka ʻōnaehana. Pono kēia ʻano ʻōnaehana i kahi mahana lohi a mālie a me ka hoʻohālikelike ʻana, "i ʻōlelo ai.
“Ua wehe nā limahana i ka 75% o ka pahu mahu #1. Ua wehe pū nō hoʻi lākou i ke kīpē pōleʻa i loaʻa ma ke kānana laina hoʻihoʻi condensate nui, "wahi a ka hōʻike. Ua wehe pū ʻia ʻelua mau kiwikā ʻē aʻe, hoʻokahi 5% a 6%, ʻo kekahi i wehe ʻia he 11%.
Kiʻi mai ka US Department of Veterans Affairs "West Haven Steam Rupture, Board of Inquiry" hōʻike memo, i hoʻopaʻa ʻia ma ʻApelila 15, 2021, e hōʻike ana i ka "Threaded Pipe Connection, Drip Bottom."
"ʻO ka wehe ʻana o ka valve pōleʻa e hāʻawi koke i nā manaʻo i nā limahana ma ke ʻano o ka kahe mahu a me ka kahe condensate e hōʻoia i ka hana ʻana," wahi a nā mea noiʻi. "ʻAʻole maopopo ke kaʻina pololei e wehe ai kēlā me kēia valve, akā ʻoi aku ka maikaʻi e wehe mua i ka laina condensate." kiwi kinipōpō liʻiliʻi.”
Eia nō naʻe, ʻoiai ka hōʻike e hōʻike ana ʻo ka wehe ʻana i ka pahu pōleʻa e hoʻokahe i ka condensate mai ka laina a i ʻole ke kiʻekiʻe, ʻaʻole ia e hoʻokahe i ka wai a pau i ka laina drip "a ʻo kēia wahi o ka laina mokuahi nui i loaʻa i ka 3/4 galani condensate. .”
Ua ʻōlelo ka hōʻike, ʻaʻole i ʻae ʻia ka paipu ma ka Hale 22 i nā code he nui. ʻAʻole ʻae ʻia nā flanges hao ma nā ʻōnaehana paipu mahu ma lalo o kēia mau code, akā ʻaʻole i pāpā ʻia e nā code VA a i ʻole ASME, wahi a ka hōʻike. i ka wā ma mua e wehe a hoʻololi paha i ka flange, "wahi a ia.
Hoʻohui ʻia, ua hoʻokomo ʻia kahi pahele mahu ma kahi kokoke loa i ka lalo o ka paipu kahe, "ʻo ka valve kaʻawale he valve butterfly, ʻaʻole i ʻae ʻia ma lalo o ke code VA," wahi a ka hōʻike.
ʻO kekahi pilikia, wahi a ka hōʻike, "ʻo ka hiki ʻole ke hoʻokaʻawale i kekahi o nā laina mokuahi nui ʻekolu, ʻaʻole hiki i ka mea kanu paila ke hōʻoia i ka palekana o ka mea kanu paila holoʻokoʻa".
ʻO VA Connecticut Health Care System's West Haven campus e like me ka nānā ʻana mai West Springs Street ma Iulai 20, 2021.
Ua hoʻopiʻi ka poʻe noiʻi i ka VA no ka nele i nā kaʻina hana i hoʻolālā ʻia e pale i nā limahana i nā kūlana koʻikoʻi.
Wahi a ka hōʻike: "Ua loaʻa kahi laka VA a me ke kaulahao ma kahi kokoke i ka valve lumi, e hōʻike ana ua paʻa paha ka ʻōnaehana. Eia nō naʻe, ʻaʻohe palapala lockout tagout (LOTO), ʻae a i ʻole nā kaʻina hana LOTO no ka ʻōnaehana. ʻAʻohe ʻimi keʻena i loaʻa nā lāʻau LOTO a i ʻole nā kaʻina hana no kēia mau kiwi a hale paha.
ʻAʻole i haʻi ʻia ke kamaʻilio ʻana ma waena o ka palekana, ka paipu, a me ka ʻenekinia: “ʻAʻole i hoʻolaha ʻia ka hale paila no kēia pani ʻana, ʻaʻole hoʻi i haʻi ʻia no ka pani mau ʻana. ʻAʻole maopopo i ka ʻike ʻana o ke alakaʻi ʻenekinia a palekana paha i kēia lā. ke holomua nei ka hana," wahi a ka hōʻike. ʻAʻole i loaʻa i ka hui kahi hōʻike no ka laka hou aʻe i kau ʻia e ka mea ʻaelike. "
Ma ka lā 12 o Mei, ua hoʻopuka ʻo OSHA i ʻeiwa mau leka hoʻolaha e pili ana i nā kūlana hana palekana a maikaʻi ʻole paha ma Connecticut, me ka hoʻomaopopo ʻana i nā mea hoʻohana o nā mea kanu boiler e haʻalele i nā laina hana; ʻaʻole i hōʻike iā Mulvaney Mechanical i kāna mau hana LOTO; a i ʻole ka hoʻopaʻa pono ʻana o nā mea hana" i hiki ke hoʻokaʻawale ʻia ka condensate mai ka ʻōnaehana. Ua ʻōlelo ʻia "ʻaʻole i kūkulu ʻia nā kaʻina hana, palapala a hoʻohana ʻia e hoʻomalu i ka ikehu weliweli" a i ʻole ka ʻenehana i hoʻohana ʻia e hana i ka valve.
Eia kekahi, ua ʻike ʻo OSHA ʻaʻole i hōʻoia ka VA i ka ʻole o ka wahi hana i nā pōʻino i hiki ke hopena i ka make a i ʻole ka hōʻeha, a ʻaʻole i aʻo ʻia nā luna hoʻomalu i ka ʻike a hōʻemi i nā pōʻino i loko o kā lākou kuleana.
Kiʻi mai ka US Department of Veterans Affairs "West Haven Steam Rupture, Board of Inquiry" hōʻike memo, i hoʻopaʻa ʻia ma ʻApelila 15, 2021, e hōʻike ana i ka "Steam Line Schematic, Basement 22."
Ua ʻōlelo mua ʻo OSHA i ʻekolu mau hewa i ka makahiki 2015: Ke nānā ʻana i nā kaʻina hana mana ikehu ma ka liʻiliʻi loa i kēlā me kēia makahiki; ʻaʻole i hāʻawi i ka hoʻomaʻamaʻa ma hope o ka hoʻokomo ʻana i kahi pahu laina mokuahi hou ma ka Hale 22; a me ka hoʻopili ʻole ʻana i nā lako LOTO ponoʻī e hui pū i nā lako LOTO e nā limahana.
"Ua hiki ke pale ʻia kēia mau mea make inā hahai nā mea hana i nā kūlana palekana i hoʻolālā ʻia e pale i ka hoʻokuʻu ʻole ʻia o ka mahu," i ʻōlelo ai ka luna hoʻomalu o ka mokuahi OSHA ʻo Steven Biassi i kēlā manawa. pono ʻole.
ʻO ka puka komo ʻana o ke alanui Campbell o ke kahua ʻo VA Connecticut Health Care System West Haven, i kiʻi ʻia ma Iulai 20, 2021.
ʻO Pamela Redmond, he waha ʻōlelo no West Haven Medical Center ma Virginia, i ʻōlelo ʻia ma ka leka uila ʻo ka ʻōnaehana Virginia ma Connecticut "ua i loko o kahi kūlana o ka holo ʻana mai nā hanana pōʻino o Nowemapa 13, 2020. Ua hana ikaika ʻia e hoʻomaikaʻi i ka palekana a ua hana ʻia nā mea hou i nā kaʻina hana palekana. "
ʻO ka pā kula ʻo VA Connecticut Healthcare System West Haven e like me ka nānā ʻana mai Spring Street ma Iulai 20, 2021.
ʻO nā lawelawe hoʻokele waiwai "ke hana nei i ka hoʻolālā hou ʻana a i ʻole ka wehe ʻana i ka ʻōnaehana mahu ma ka Hale 22. Ke hoʻokomo ʻia ka ʻōnaehana hou, e kūkulu ʻia kahi kaʻina LO / TO hou," i kākau ai ʻo ia.
Ua ʻōlelo pū ʻo ia: "I ka lā 20 o Dekemaba, 2020, ua hoʻokomo ʻia kahi ʻōnaehana paʻa ʻelua a me ke kahe koko i ka mea kanu boiler ma ka hale mahu o ka Hale 22 kahi i kū ai ka ulia. Hiki i ka ʻōnaehana valve hou ke hoʻokuʻu i ka ikehu i mālama ʻia a i ʻole ke koena o ka ikehu, no ka laʻana mai ka ʻōnaehana hoʻoheheʻe wai i hoʻokuʻu ʻia mai ka
Ua ʻōlelo ʻo Redmond, ʻelua mau hale nui e hana ana i nā papahana hoʻomaikaʻi mahu, a ua ʻaelike ʻia ka ʻōnaehana e pani i nā pahele mahu ma kāna Hale 22.
"Ke hoʻomau nei ka mokuʻāina ʻo Virginia Connecticut me kā mākou keʻena kūloko, ka Veterans Health Administration a me OSHA e hōʻoia i ka palekana o nā mea āpau ma kā mākou wahi mālama," kākau ʻo Redmond.
Ua ʻōlelo ʻo Sen. Richard Blumenthal, D-Conn., he lālā o ka US Senate Veterans Affairs Committee, ke kākoʻo nei ʻo ia i kahi waihona kālā e "kūkulu hou a kūkulu hou i ka hale ʻo West Haven Virginia" a me kekahi mau halemai Virginia ʻē aʻe ma ka ʻāina.
ʻO ka hoʻolālā hana a Pelekikena Joe Biden he $ 2.65 trillion ʻAmelika e pili ana i $ 18 biliona e hoʻololi i nā halemai VA a me nā keʻena lapaʻau.
"ʻO ka pōʻino o Nov. 13 wale nō ka pōʻino loa o nā hemahema ʻoihana hou," wahi a Blumenthal. ʻaʻole ia e hōʻoiaʻiʻo wale i nā hemahema o nā hale e kū nei, akā ʻo ka wikiwiki o ka hoʻoponopono hou ʻana i nā hale a me ka lawe ʻana i nā hale i ke kenekulia 21, ma mua o ka hoʻohana ʻana i nā ala maikaʻi aʻe. ʻO Lan a me nā hoʻoponopono pōkole ʻē aʻe e hoʻopaʻa i nā hemahema. Pono ʻo Virginia e hoʻokomo i kahi hale hou. "
Ua ʻōlelo ʻo Blumenthal e pono ke kūkulu hou ʻia ke Keʻena Lapaʻau ʻo West Haven ma Virginia, akā ʻaʻole hiki iā ia ke koho i ka lehulehu i ka nui o ke kumukūʻai. hana wikiwiki, "wahi āna.
Ka manawa hoʻouna: Mar-02-2022
