The Occupational Safety and Health Administration released a report Wednesday blaming a lack of safeguards at the Veterans' Affairs Hospital in West Haven for the deaths of two men in a steam explosion in November 2020.
The two men, 60-year-old Euel Sims, an employee of the VA Facility Maintenance Service, and 36-year-old Joseph O'Donnell, a contractor working for Mulvaney Mechanical Inc. were killed as they worked on a steam boiler at the West Haven facility on Nov. 13. According to state police, super-heated water vapor filled a room and led to an explosion.
The report determined the VA failed to protect the men from struck-by and burn hazards. OSHA also found what it called numerous deficiencies in the facility's lockout/tagout program.
“These fatalities could have been prevented if the employer had complied with safety standards that are designed to prevent the uncontrolled release of steam,” said OSHA Area Director Steven Biasi in Bridgeport. “Tragically, these well-known protective measures were not in place and two workers needlessly lost their lives.”
According to the report, OSHA found the VA failed to:
- Properly shut down to avoid additional or increased hazard(s) to employees.
- Relieve or render safe all potentially hazardous residual energy such as condensate water.
- Maintain adequate procedures for isolating each steam main branch supplying campus buildings.
- Conduct a periodic inspection of all lockout-tagout procedures to correct any deviations or inadequacies.
- Provide adequate training to supervisory employees.
- Retrain employees when there was a change in their job assignments, or a change in machines, equipment or processes that presented a new hazard.
- Notify affected employees of the application and removal of lockout or tagout devices.
- Inform Mulvaney Mechanical of VACT’s lockout/tagout procedures.
- Ensure each authorized employee affix a personal lockout or tagout device to the group lockout device before working on the machine or equipment.
The agency issued nine notices of unsafe and unhealthful working conditions to the VA. The VA has 15 business days to correct the problems or to appeal OSHA's findings.
OSHA also cited Mulvaney Mechanical Inc. for four violations for failing to:
- Develop, document and use lockout/tagout procedures for the control of potentially hazardous energy.
- Adequately train employees on the methods necessary to isolate and control energy.
- Inform VACT of Mulvaney Mechanical’s lockout/tagout procedures.
- Ensure that each authorized employee affixed a personal lockout or tagout device to the group lockout device.
The agency also proposed $38,228 in penalties for Mulvaney Mechanical Inc. The company also has 15 business days to comply or to contest the findings.
“This critical report strongly reinforces my repeated calls for renovating and rebuilding the VA West Haven facility to bring it into the 21st century," Sen. Richard Blumenthal said in a statement after the release of the report. "Like many such facilities around the country – but more so – this hospital desperately and urgently needs significant, serious investment. Our veterans deserve no less. Dedicated doctors, nurses, and other medical staff continue to provide world-class healthcare at this facility while coping with aging, decaying, and outmoded facilities."