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Jan 09, 2024

Report: What happened the day two workers died at the West Haven VA

The VA Connecticut Health Care System's West Haven Campus viewed from West

The VA Connecticut Health Care System's West Haven Campus viewed from West Spring Street on July 20, 2021.

WEST HAVEN — On Nov. 13, 2020, a simple cast iron flange in an aging steam pipeline in a building at the Veterans Affairs medical center suddenly broke in four pieces, releasing high-pressure steam and killing two men, a federal investigation has found.

The VA's investigation of the accident recounts the events of that morning, describing how Joseph O’Donnell, a contractor hired to fix a leak in the pipe, entered the basement of Building 22 after making the repair, accompanied by Euel Sims Jr., a plumbing supervisor, and the failures in equipment and safety measures that contributed to their deaths. Since then, the VA has made or plans a number of changes, including a steam upgrade project.

But contributing factors to the 2020 accident included pipes that are old and no longer comply with current materials standards, improperly installed valves and pipes that allowed water to build up, and an alleged failure to follow procedures to ensure the men's safety, according to the report.

The West Spring Street entrance to the VA Connecticut Health Care System's West Haven Campus photographed on July 20, 2021.

Ultimately, when the men opened the line, steam roared through the 6-inch pipe with such force that a flange, threaded onto the bottom of a vertical drip leg, broke into four pieces, allowing steam to blow into the room, according to the report.

The New Haven Register obtained the VA investigation report, issued April 15, through a Freedom of Information request. All personnel names were redacted.

The incident led to a review of the failures at the West Haven VA, resulting in nine notices from the Occupational Safety and Health Administration and a call for Congress to rebuild the medical center.

According to the report, the series of events began in October or November 2020, when the VA's safety department was told there was a leak in a storage room in Building 22, near the end of the main roadway leading from the Campbell Avenue entrance. On Nov. 6, the plumbing department was asked to isolate the steam from the building so asbestos could be abated. The abatement was completed Nov. 9 and the steam remained off.

On Nov. 13, O’Donnell, a Danbury resident and steamfitter for Danbury-based contractor Mulvaney Mechanical, finished repairing the leak at 7:45 a.m. At 8, Sims, a Navy Seabees veteran and resident of Milford, notified his supervisor that he was going to turn the steam back on. The three men walked across a street to the building, but Sims’ supervisor was asked to open a separate room in Building 22, the report stated. O’Donnell and Sims continued to the basement mechanical room of Building 22 to open the steam valves, according to the report.

At about 8:10, the report states, "The Utility System Supervisor heard a loud noise and saw a plume of steam come out of the stairwell that leads to the mechanical room. A loss of Steam Pressure … was logged at the boiler plant. … A high heat alarm triggered the fire alarm, and a safety specialist immediately left to investigate the reported alarm at building 22. Also, approximately at this time the Utility System Supervisor and another facility employee were injured when they attempted to enter the basement mechanical room."

The VA's boiler plant was shut down, and the West Haven Fire Department, VA police and emergency personnel responded.

"After the steam pressure and temperature dropped in the room, Emergency personnel were able to enter the room, but at that point, the plumbing shop supervisor and the mechanical contractor had died," the report states. That was not until about 1 p.m.; the victims were removed at about 2:15.

The investigation for the VA by Applied Technical Services of Marietta, Ga., found that the super-hot steam was released with such force that the two men trying to push open the door to the 8-by-12-foot room could not. One was burned on his foot by hot water, the report states.

Images from the U.S. Department of Veterans Affairs "West Haven Steam Rupture, Board of Inquiry Investigation" report memorandum dated April 15, 2021, showing "Piping configuration - time of investigation."

"When the cast iron flange failed, the 6" main steam line was able to vent into the room," the report stated. "When steam began flowing into the room from the unrestricted steam line, the room was pressurized by the steam. This pressure resulted in several thousand pounds of force on the inside of the door forcing it closed. At this point opening the door without heavy equipment would have been physically impossible."

The two weeks between when steam was first reported leaking in Building 22 and the day of the accident, combined with an improperly installed drip leg, likely contributed to the deaths, the report states. The steam had been turned off, "allowing for significant amounts of condensate to build up and cool the line, and a likely contributing factor to the accident," it states. There was about three-fourths of a gallon of water in the drip leg, which did not have a required drain or blowdown valve.

The flange that broke apart, which was attached to a blank flange at the end of the drip pipe, should have been welded, not threaded, onto the pipe, the investigators said.

The report said the flange broke after a "onetime instantaneous high impact typical of a water hammer." Water hammer is a hydraulic shockwave caused when water or steam suddenly is forced to stop or change direction and then slams into a valve or other obstruction. It often is caused by water collecting in a steam pipe.

When valves were opened and steam entered the pipe in the mechanical room, it hit the cooler water in the drip pipe, with devastating results. "This renewed steam flow likely resulted in the sudden heating and flashing of the stranded or unremoved condensate in any undrained portion of the main steam line," according to the report. That could have created a sudden "violent and dynamic" shock to the flange and "was the most probable cause of the sudden failure of the … gray cast iron flange," the report said.

"The subject flange suffered an overload failure due to receiving more load than it could withstand," the report states.

An images from the U.S. Department of Veterans Affairs "West Haven Steam Rupture, Board of Inquiry Investigation" report memorandum dated April 15, 2021 showing a "Broken Flange" from Building 22.

"The elapsed time between entering the space and opening the valves to their found positions indicates that the system was not properly reenergized. This type of system requires a slow and gradual temperature and pressure equalization," it states.

The report said "the workers had opened steam valve #1 75%. They had also opened the ball valve located on the strainer for condensate return line on the main steam line." Two other valves were opened as well, one 5 to 6 percent and another 11 percent, according to the report.

Images from the U.S. Department of Veterans Affairs "West Haven Steam Rupture, Board of Inquiry Investigation" report memorandum dated April 15, 2021, showing the "Threaded Pipe Connection, bottom of drip leg."

The investigators stated: "The opening of the ball valve should have provided immediate feedback to the workers in the form of steam flow and condensate flow as a verification that it was working. The exact sequencing of the opening of each valve is unknown, but it would have been good practice to open the small ball valve on the condensate line first."

However, while the report said opening the ball valve would have drained condensate at the level of the pipe or higher, it would not have drained all of the water in the drip leg "and this area of the main steam pipe would have still contained 3/4 of a gallon of accumulated condensate."

The report said the pipelines in Building 22 violated several specifications. Cast iron flanges no longer are allowed in steam pipe systems, according to those specifications, but they are not prohibited by the VA or by the American Society of Mechanical Engineers’ codes, the report said. "There was no evidence that the VA had instructed anyone in the past to remove or replace the flange," it said.

Also, a steam trap, used to allow condensate or non-steam gases to be drained from the system while keeping the steam tightly sealed inside the pipes, was installed too close to the bottom of the drip leg and "the isolation valves were butterfly valves, which are not allowed per VA specification," the report said.

Another issue was the inability "to isolate any of the three main steam lines leaving the boiler plant short of securing the entire boiler plant," the report said.

The VA Connecticut Health Care System's West Haven Campus viewed from West Spring Street on July 20, 2021.

The investigators also faulted the VA for a lack of procedures intended to protect workers in hazardous materials situations. A lockout/tagout system prevents anyone other than the person who turned off the steam to turn it back on.

According to the report: "A VA lock and chain were found within the space near the valves in the room, indicating that the system may have been locked out. However, a Lockout Tagout (LOTO) log, permits, or LOTO procedures for this system did not exist. Neither the staff nor a search of the office turned up a LOTO log or procedures for these valves or the building."

Communication among safety, plumbing and engineering personnel also was faulted: "The Boiler Plant was not notified of this shutdown, nor its continued shutdown. It is unclear if engineering leadership or safety were aware of the work taking place on this day," the report states. "The team was not able to determine why the Contractor was within the mechanical room. The team did not find evidence of an additional lock applied by the Contractor."

On May 12, OSHA issued nine notices of unsafe or unhealthful working conditions at the Connecticut VA, including not notifying boiler plant operators of the logout/tagout isolation in the line; not informing Mulvaney Mechanical of its LOTO procedures; and not ensuring there was an "orderly shutdown of machine or equipment" so condensate could be drained from the system. It said "procedures were not developed, documented and utilized for the control of potentially hazardous energy" or for techniques to use to operate the valves.

Also, OSHA found that the VA did not ensure the workplace was free of hazards that could cause death or injury and that supervisors were not trained in how to recognize and abate hazards in their areas of responsibility.

Images from the U.S. Department of Veterans Affairs "West Haven Steam Rupture, Board of Inquiry Investigation" report memorandum dated April 15, 2021, showing a "Schematic of steam piping, basement building 22."

Three violations had been cited previously by OSHA in 2015: Energy control procedures were not inspected at least annually; training was not provided after new steam line valves were installed in Building 22; and employees did not affix personal LOTO devices to the group LOTO device.

"These fatalities could have been prevented if the employer had complied with safety standards that are designed to prevent the uncontrolled release of steam," OSHA Area Director Steven Biasi said at the time. "Tragically, these well-known protective measures were not in place and two workers needlessly lost their lives."

The Campbell Avenue entrance to the VA Connecticut Health Care System's West Haven Campus photographed on July 20, 2021.

Pamela Redmond, a spokeswoman for the West Haven VA medical center, said in an email that the Connecticut VA system "has worked diligently since the tragic incident on November 13, 2020, to enhance safety and has made significant updates in safety procedures."

The VA Connecticut Health Care System's West Haven Campus viewed from Spring Street on July 20, 2021.

Facilities Management Service staff "is in the process of redesigning or dismantling the Building 22 steam system. A new LO/TO procedure will be developed once that new system is installed," she wrote.

She also said, "A double block and bleed valve system was installed on December 20, 2020, in the Boiler Plant on the steam main supplying Building 22 where the incident occurred. The new valve system allows the release of stored or residual energy such as condensate water to be drained from the system."

Redmond said a steam upgrade project is being undertaken in the two main buildings, and the system has awarded a contract to replace its steam trap in Building 22.

"VA Connecticut continues to work closely with our regional office, the Veterans Health Administration and OSHA to ensure the safety of everyone at our sites of care," Redmond wrote.

U.S. Sen. Richard Blumenthal, D-Conn., a member of the Senate Committee on Veterans’ Affairs, said he is advocating for infrastructure funds "to rebuild and reconstruct the West Haven VA facility" and several other VA hospitals across the nation.

President Joe Biden's $2.65 trillion American Jobs Plan includes $18 billion to modernize VA hospitals and clinics. "While the median age of U.S. private sector hospitals is roughly 11 years, the Veterans Affairs’ hospital portfolio has a median age of 58," according to a White House fact sheet.

"The Nov. 13 tragedy was simply the most serious of the latest infrastructure failures," said Blumenthal. "The report is profoundly compelling; compelling not only as to [highlight] the defects in the existing facility but also the urgency of renovating the building and to bringing the structure into the 21st century rather than just patching the deficiencies with short-term fixes like better flanges. The VA should be investing in an entirely new structure."

Blumenthal said the West Haven VA medical center needs to be rebuilt, but he couldn't publicly estimate how much that would cost. "I’ve spoken personally numerous times with the VA Secretary Denis McDonough, and he understands perfectly well the need for urgent action," he said.

He said that, at this point, making piecemeal repairs to the West Haven VA hospital is akin to running an old vehicle — the cost of upkeep and repairs is more costly over time than building a new facility.

U.S. Rep. Rosa L. DeLauro, D-3, said she has spoken with VA leadership and believes they are addressing the breakdown in safety communication "in a formidable way."

Today, she said she has "the utmost confidence" VA leadership is taking the issue of worker safety seriously.

"The federal government has an obligation to protect and care for our veterans and their families and all federal employees that work at VA facilities," she said.

DeLauro, chairwoman of the House Appropriations Committee, said the bill providing funds for military construction, the VA and related agencies, passed by her committee June 30, includes $2.2 billion for VA construction, an increase of $458 million from this year, and "will help ensure the safety and security of Connecticut's VA facilities."

The VA hospital complex sits on a hilltop and its two main buildings can be seen for miles. According to a 1992 New York Times story, it began as a tuberculosis center in 1918 and became an Army hospital after World War I. After closing in the 1940s, it reopened in the 1950s as a VA hospital. In the 1990s, the center underwent a renovation.

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