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VA deaths report finds protocols not followed, issues remain

HARTFORD, Conn. (AP) — A federal investigation released Monday of a hot steam accident that killed two workers conducting maintenance on a boiler system at a Veterans Affairs hospital in Connecticut substantiates a whistleblower’s allegations that employees did not follow proper protocols to control hazardous energy or receive adequate training, among other violations.

The report, released by the Office of Special Counsel, includes 18 recommendations for corrective action, including a comprehensive safety training program. However, a letter accompanying the new report indicates the whistleblower and Special Counsel Henry Kerner remain concerned that safety hazards at the VA hospital in West Haven have still not been addressed — two years after the deadly incident.

“I too am distressed by the continued failure to ensure the facility is safe for employees and veterans,” Kerner wrote in a letter to President Joe Biden. “It is unacceptable that life-threatening safety hazards remain in place at the West Haven VA despite numerous calls for the agency to correct them.”

Kerner wrote that he intends to follow up with the hospital in 60 days to make sure the recommendations are fully implemented.

Last year, a report from the Occupational Safety and Health Administration concluded that the deaths of VA maintenance worker Euel Sims, 60, a Navy Veteran from Milford, and private contractor Joseph O’Donnell, 36, of Danbury, could have been prevented. Three others were also injured during the rapid release of hot water vapor on Nov. 13, 2020.

The workers had just finished repairing a steam pipe in a maintenance building on the West Haven VA campus when a fixture broke off the pipe, flooding the work area rapidly with steam, OSHA officials said. The accident happened as workers were refilling the pipe with steam, authorities said.

The Office of Special Counsel report indicates all three specific allegations made by an unnamed whistleblower, identified as an HVAC technician, were substantiated. They include allegations that West Haven VA employees did not document or use procedures to control hazardous energy from the steam lines; supervisors and employees did not receive adequate training on equipment procedures or how to recognize a boiler room hazard; and workers did not conduct periodic inspections of energy control procedures.

The report also found more recent issues, including a failure of staff and supervisors during a March 6, 2022, boiler shutdown to follow numerous new procedures for shutting down equipment, isolating it from its energy source and preventing the release of potentially hazardous energy while maintenance was being conducted. The process is known as a lockout/tagout procedure.

“The procedures used during the March 6, 2022, boiler shut down did not isolate all potential energy sources by physical locks or tags to prevent premature reenergizing of the equipment,” according to the report, which noted how employees were placed “at risk for severe injury or death.”

The report also notes there are “significant vacancies for both supervisors and staff” in facilities management services at the West Haven hospital. Investigators further found “multiple areas of concern for employee safety” but no formal method for workers to report concerns with equipment or systems.


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