Lack of hazardous energy control safeguards, unexpected steam release led to two workers’ deaths at Department of Veterans Affairs’ West Haven campus

BRIDGEPORT, CT – Two workers at a West Haven veterans’ healthcare facility suffered fatal injuries caused by hot steam after a metal fixture on a main steam line blew off. The workers had just finished making repairs to the steam pipe within the U.S. Department of Veterans Affairs Connecticut Healthcare System West Haven campus in November 2020.

A U.S. Department of Labor Occupational Safety and Health Administration inspection determined that VACT failed to protect employees from struck-by and burn hazards and the agency identified numerous deficiencies in the facility’s lockout/tagout program. One of the workers was an employee of VACT and the other was an employee of Mulvaney Mechanical Inc., a Danbury-based contractor. 

“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, Connecticut. “Tragically, these well-known protective measures were not in place and two workers needlessly lost their lives.”

 OSHA also found the VACT program failed to:

• Properly shutdown 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.

OSHA issued nine notices of unsafe and unhealthful working conditions to VACT for one willful, three repeat and five serious violations. Under Executive Order 12196, federal agencies must comply with the same safety and health standards as private sector employers covered under the OSH Act. The federal agency equivalent to a private sector citation is the Notice of Unsafe and Unhealthful Working Conditions.

The VACT has 15 business days from receipt of the notices to comply, request an informal conference with OSHA’s area director or appeal the notices by submitting a summary of the agency’s position on the unresolved issues to OSHA’s regional administrator. OSHA cannot propose monetary penalties against another federal agency for failure to comply with OSHA standards. If the U.S. Department of Veterans Affairs were a private sector employer, the total penalty amount would be $621,218.

OSHA cited Mulvaney Mechanical Inc. for four serious violations with $38,228 in proposed penalties 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.

Mulvaney Mechanical Inc. has 15 business days from receipt of its citations and penalties to comply, request an informal conference with OSHA’s area director or contest the findings before the independent Occupational Safety and Health Review Commission.

Under the Occupational Safety and Health Act of 1970, employers are responsible for providing safe and healthful workplaces for their employees. OSHA’s role is to help ensure these conditions for America’s workers by setting and enforcing standards, and providing training, education and assistance under the Occupational Safety and Health Act.

Ed. Note: An earlier news release located the U.S. Department of Veterans Affairs’ Connecticut Healthcare System West Haven campus inaccurately as a Bridgeport facility when, in fact it is located in West Haven.