VA Connecticut Health Care System's West Haven campus inotariswa kubva kuWest Springs Street musi waChikunguru 20, 2021.
Westport - Kuferefeta kweFederal kwakawana kuti muna Mbudzi 13, 2020, simbi yakakandwa mumutsara wekuchembera muchivako cheVeterans Affairs Medical Center yakangoerekana yatsemuka kuita zvidimbu zvina, kuburitsa chitsinga chepamusoro nekuuraya 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.
Iyo West Springs Street yekupinda yeVA Connecticut Health Care System West Haven kambasi, yakatorwa mifananidzo munaChikunguru 20, 2021.
Pakupedzisira, apo varume vakavhura pombi, chiutsi chakarira nepapombi yema-inch 6, uye dzvinyiriro yakanga yakakura kwazvo zvokuti flange yakarukwa kusvika pasi pechidonhedzo chakamira chakadamburwa kuita zvidimbu zvina, ichifuridzira utsi mumba.
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 wegadziriro yezvishandiso akanzwa ruzha rukuru uye akaona kuyerera kwechitsinga chichibuda pamanera anoenda kuimba yemichina. Kurasikirwa kwesimba remhepo ... kwakanyorwa pabiiler plant. ... tembiricha yakakwira Alarm yakamutsa aramu yemoto, uye nyanzvi yezvekuchengetedza akabva angobuda kuti aongorore alarm yakashumwa muBuilding 22. Pamusoro pazvo, panguva ino, maneja wezvirongwa zveutility uye mumwe mushandi wepanzvimbo vakakuvara vachiedza kupinda mukamuri yepasi. ”
Iyo Virginia boiler plant yakavharwa, uye West Haven Fire Dhipatimendi, Virginia State Mapurisa uye vekutanga vakapindura vakapindura.
“Pashure pokunge mhepo yaipisa uye tembiricha yadzikira muimba yacho, vashandi vekukurumidzira vakakwanisa kupinda mukamuri racho, asi panguva ino maneja wechitoro chepombi dzepombi nomugadziri wemichina vakanga vafa,” mushumo wacho wakadaro. Kusvikira kuma1:00 masikati; nenguva dzinenge 2:15, nyakukuvadzwa wacho akatorwa.
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, wemusi waKubvumbi 15, 2021, unoratidza "Pipe Configuration - Nguva Yekuferefeta."
"Apo simbi yakakandwa yakatadza, 6" mutsetse mukuru wakakwanisa kupinda mukamuri," mushumo wakadaro. "Imba yacho yakamanikidzwa nemhepo apo mhepo yakatanga kuyerera ichipinda mukamuri kubva mumutsara usina muganhu. Kumanikidza uku kunogadzira zviuru zvemapaundi echisimba mukati memukova, zvichiita kuti uvhare. Panguva ino, hazvibviri kuvhura. gonhi risina midziyo inorema.”
Nguva yemavhiki maviri pakati pemushumo wekutanga wekudonha kwemhepo muBuilding 22 uye zuva retsaona, zvakasanganiswa nemapaipi ekudonha zvisina kufanira, ndiyo yakakonzera rufu, chirevo chakadaro. zvichiita kuti pave nekukura kukuru kwe condensate uye kutonhora kwepombi, izvo zvingave zvakakonzera tsaona, "yakadaro. Neanenge zvikamu zvitatu zvezvina zvegaroni yemvura mu dropper, hapana dhiraivha kana dhiraivha inodiwa. .
Vaongorori vakati iyo flange yakatsemuka yakasungirirwa kune isina chinhu flange kumagumo kwedonhwe uye yaifanira kunge yakasungirirwa, kwete shinda, kune pombi.
Maflange akaputika pashure pe“nguva yakajairika yesando yemvura,” wakadaro mushumo. Inowanzokonzerwa nekuunganidza kwemvura mumapombi emvura.
Kana vharuvhu yavhurika uye chiutsi chapinda mupombi mukamuri yemuchina, inorova mvura inotonhorera iri mudonhwe nemhedzisiro inoparadza. pombi,” chirevo chakadaro. ” uye “ndicho chinonyanya kukonzera kutadza kungoerekana kwaitika kwegrey cast iron flanges”.
"Flange yaivavarira yakatadza kuwandisa nekuda kwekuremerwa kwayaikwanisa kubata," mushumo wacho unodaro.
Mufananidzo kubva Kubvumbi 15, 2021 US Dhipatimendi reVeterans Affairs "West Haven Steam Rupture, Board of Inquiry" inoshuma memo inoratidza "flange kukuvara" muChivakwa 22.
“Nguva yakapfuura pakati pekupinda munzvimbo uye kuvhura mavharuvhu panzvimbo yaakawana inoratidza kuti hurongwa uhu hwakange husina kunyatsosimbaradzwa. Rudzi urwu rwehurongwa hunoda kudziya zvishoma nezvishoma uye zvishoma nezvishoma uye kuenzana kwekumanikidza, "yakadaro.
"Vashandi vakavhura makumi manomwe neshanu muzana evhavhavha #1. Vakavhurawo vharuvhu yebhora iri pane main steam line condensate return line sefa,” mushumo wakadaro. 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. "Kutevedzana chaiko kunovhurwa vharuvhu yega yega hakuna kujeka, asi zviri nani kutanga wavhura mutsetse we condensate." Diki bhora vharafu."
Nekudaro, nepo mushumo uchitaura kuti kuvhura vharavha yebhora kunodonhedza condensate kubva pamutsetse kana kumusoro, haizodonhedze mvura yese mumutsetse wekudonha "uye nzvimbo iyi yemutsetse mukuru wemhepo ichine 3/4 galoni ye condensate. .”
Chirevo chakataura kuti mapombi emuBuilding 22 akatyora macode akawanda. Masimbi anokandwa haachabvumirwe pamapombi epombi pasi pemakodhi aya, asi haarambidzwe neVA kana ASME macode, chirevo chakadaro. chero munhu munguva yakapfuura kubvisa kana kutsiva flange, "yakadaro.
Pamusoro pezvo, musungo weutsi wakaiswa padhuze nechepazasi pepombi yekudonha, "vharuvhu yekuzviparadzanisa ivhavhavhavhavha, isingatenderwe pasi peVA kodhi," mushumo wakadaro.
Rimwe dambudziko, rakadaro mushumo, "kusakwanisa kutsaura chero yemitsara mitatu mikuru yeutsi, zvichiita kuti zvisaite kuti boiler plant ive nechokwadi chekuchengetedzwa kwechose cheboiler".
VA Connecticut Health Care System's West Haven campus inotariswa kubva kuWest Springs Street musi waChikunguru 20, 2021.
Vatsvakurudzi vakapomerawo VA yekushayikwa kwemaitiro akagadzirirwa kuchengetedza vashandi mumamiriro ezvinhu ane ngozi.A Lockout/tagout system inodzivirira kuti mhepo isadzoserwe 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, zvibvumirano kana LOTO maitiro eiyo system. Hapana kutsvaga kwemuhofisi kwakawana matanda eLOTO kana maitiro emavharuvhu aya kana zvivakwa. "
Kurukurirano pakati pechengeteko, pombi dzepombi, uye mainjiniya yakakundikanawo: “Injiniya yeboiler haina kuziviswa nezvekudzima uku, uye haina kuziviswa nezvekuramba kudzima. Hazvizivikanwe kana hutungamiriri hweinjiniya kana kuchengetedza vaiziva nezvezuva iri. basa riri kuenderera mberi,” mushumo wacho wakadaro.” Boka racho harina kukwanisa kuona kuti nei mushandi wekondirakiti akanga ari mukamuri racho. Chikwata hachina kuwana humbowo hwekuwedzera kukiya kwakaiswa nekontrakta. "
Musi waChivabvu 12, OSHA yakapa zviziviso zvipfumbamwe maererano nemamiriro ekushanda asina kuchengetedzeka kana asina hutano muConnecticut, kusanganisira kuzivisa vanogadzira boiler plant operators kuti vabude/kubuda pamitsetse yekugadzira; kutadza kuzivisa Mulvaney Mechanical nezvemaitiro ayo eLOTO; 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 midziyo yeLOTO nevashandi.
"Njodzi idzi dzingadai dzakadziviswa dai vashandirwi vakatevera mitemo yekuchengetedza yakagadzirirwa kudzivirira kusunungurwa kusingadzoreki kwemhepo," mukuru weOSHA wedunhu Steven Biassi akati panguva iyoyo. zvisina basa.”
Iyo Campbell Avenue yekupinda yeVA Connecticut Health Care System West Haven kambasi, yakatorwa mifananidzo munaChikunguru 20, 2021.
Pamela Redmond, mutauriri weWest Haven Medical Center muVirginia, akataura mune email kuti iyo Virginia system muConnecticut "yanga iri mumamiriro ekuchinja kubva zviitiko zvinosuruvarisa zveNovember 13, 2020. Basa rakaoma rakaitwa kuvandudza kuchengetedzwa uye kuchengetedzwa. magadzirirwo makuru akaitwa kunzira dzekuchengetedza. "
Iyo VA Connecticut Healthcare System West Haven campus inotariswa kubva kuSpring Street musi waChikunguru 20, 2021.
Facilities Management Services "iri mukugadzirisa kana kuputsa hurongwa hwemhepo muBuilding 22. Kana iyo itsva yaiswa, nzira itsva yeLO / TO ichagadzirwa," 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 akawandisa simba, semuenzaniso kubva kune system yakapfupikiswa mvura inoburitswa kubva
Redmond akati zvivakwa zvikuru zviviri zviri kuita mapurojekiti ekusimudzira mhepo, uye sisitimu iyi yakapihwa chibvumirano chekutsiva zviteyo zveutsi 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 "kuvaka patsva nekuvakazve nzvimbo yeWest Haven Virginia" nezvimwe zvipatara zveVirginia zvakati wandei munyika yose.
Mutungamiri Joe Biden's $2.65 trillion yemabasa ekuAmerica anosanganisira madhora bhiriyoni gumi nemasere ekuvandudza zvipatara zveVA nemakiriniki.
"Njodzi yeNov. 13 yaingova yakaipisisa yekukundikana kwezvivakwa munguva pfupi yapfuura," Blumenthal akati. "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. danho nechimbichimbi,” vakadaro.
Nguva yekutumira: Mar-02-2022
