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While all Health Board officials initially knew that their alarm system should report temperature changes in the cold storage facility all the time, a super-administrator had reset the warning to only off-duty hours in 2019 without their knowledge. When the refrigerating equipment could not cope with the heat wave that hit Estonia, the warning system did not react. The warning of the State Real Estate Company (RKAS) did not work either.
Üllar Lanno, director general of the Health Board, admitted at a news conference on Tuesday, explaining the circumstances of the cold storage facility failure, that the chronological sequence of events has been established, bit it is still not clear why the temperature went up. “It is difficult to say why the temperature began to rise. A technical assessment of the equipment will clear it,” Lanno said. The temperature of the cold storage unit should be 2–8 degrees Centigrade.
The builder (RKAS) had installed an automatic warning system in the storage units, which was supposed to sound alarm when temperature should rise, while the Health Board also used another monitoring system based on GPS which shows the location and the temperature indicator.
The warning system settings until September 23, 2019, stipulated that the warning signal was sent only on off-duty hours when there were no people in the building. But the Health Board decided to set the system to send an alarm message via SMS at any time when the temperature should undergo dangerous changes.
Unfortunately, only a month after that setting, on October 30, someone reset the system so that it would only send the warning in the off hours.
“The system settings can be changed only by a person with the rights of super-administrator,” Lanno said. As far as Postimees knows, there are only four individuals with such powers. Who made the change? The Health Board itself cannot check who reset the warning system and why. Therefore it was decided to arrange a meeting with the warning system enterprise as soon as possible to learn who had made the decision.
But on fatal June 25, the rise of the temperature was not discovered in the morning; it was noticed only about one o’clock p.m. when a staff member entered the storeroom. Temperature was 15.2 degrees at that time. An RKAS technician was summoned, who made the entry in the logbook after completing his work: “The roof is too hot, equipment restored, everything OK”.
But the question remains: why did the refrigeration equipment fail in the cold storage units where the state’s supply of vaccines and medicines is stored? The building belongs to RKAS and the Health Board rents it; the refrigeration equipment had been installed by RKAS. Annual rent paid by the Health Board is 1,230,888.19 euros, VAT included.
Although the Health Board had insured all the equipment, the insurance would not pay in case of breakdown. But as far as Postimees knows, there was nothing wrong with the refrigeration equipment; it just was not designed to cool down hot air for a long time.
Üllar Lanno said that he was unable to specify what RKAS had actually designed. In his words, the Health Board wanted that temperature in the cold storage units remained between 2 and 8 degrees Centigrade. “If we keep in mind that the state buildings are constructed by the lowest bidder, we have to make concessions,” Lanno admitted.
Tiit Kollo, technical director and engineer of the company Filter AS, told Postimees that according to the media reports the refrigeration equipment simply could not cope with the sustained heat wave.
“The internal temperature of the buildings might have been so high by that time that the equipment could no longer direct the heat out of the unit,” Kollo said. The Midsummer week saw the breaking of Estonia’s heat records; the weather service recorded heat up to 32 degrees in Tallinn. The warm nights only complicated the situation, Kollo added.
The same is happening now to other production equipment, he said. “It has been over 30 degrees outdoors for more than a week, the nights are hot as well, the refrigeration equipment is placed on the roof where the temperature reaches 45 degrees in sunlight – this means that the equipment cannot refrigerate any more,” Kollo explained.
“It is important to us as the state that we could recover the three million euros, that we would not take the loss. If we announce in advance that somebody is responsible, it will weaken our position in the court case against the insurance company,” Prime Minister Kaja Kallas said last week. Several critics have claimed that the premier invited to carry out a state-level insurance fraud.
“We have agreed in the government to form a multilateral commission so as to provide an adequate outsider judgment,” Tanel Kiik commented on the prime minister’s statement.
“What Prime Minister Kaja Kallas referred to is that we should not start assigning guilt hastily, without clarifying the circumstances, because in that case we might create a retroactive impression that the guilty party has already been determined,” Kiik explained Kallas’ statement.