An interdisciplinary, learning-focused, and joint Federal and Laboratory team investigated the causes of an electrical accident at Technical Area (TA) 53 at Los Alamos National Laboratory. This event affected nine Los Alamos employees, two of whom required hospitalization. The Joint Accident Investigation Team determined the direct cause of the accident to be cleaning fluid sprayed into the air gap between an energized switchgear bus and the grounded enclosure. The aerosolized fluid created a path to ground, resulting in an arc-flash. The root cause was less-than-adequate management of control implementation. This report identifies relevant facts; determines direct, contributing, and root causes; provides detailed analysis; and establishes conclusions and judgments of need to prevent recurrence.
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