Type A Accident Investigation Board report on the January 17, 1996, electrical accident with injury in Technical Area 21 Tritium Science and Fabrication Facility Los Alamos National Laboratory. Final report

An electrical accident was investigated in which a crafts person received serious injuries as a result of coming into contact with a 13.2 kilovolt (kV) electrical cable in the basement of Building 209 in Technical Area 21 (TA-21-209) in the Tritium Science and Fabrication Facility (TSFF) at Los Alamos National Laboratory (LANL). In conducting its investigation, the Accident Investigation Board used various analytical techniques, including events and causal factor analysis, barrier analysis, change analysis, fault tree analysis, materials analysis, and root cause analysis. The board inspected the accident site, reviewed events surrounding the accident, conducted extensive interviews and document reviews, and performed causation analyses to determine the factors that contributed to the accident, including any management system deficiencies. Relevant management systems and factors that could have contributed to the accident were evaluated in accordance with the guiding principles of safety management identified by the Secretary of Energy in an October 1994 letter to the Defense Nuclear Facilities Safety Board and subsequently to Congress