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.
You are accessing a U.S. Government information system.
Unauthorized or improper use or access of this system may result in disciplinary action, as well as civil and criminal penalties.
By using this information system, you understand and consent to the following:
You have no reasonable expectation of privacy when you use this information system; this includes any communications or data transiting,
stored on or traveling to or from this information system. At any time, and for any lawful government purpose, the government may monitor,
intercept, search and seize any communication or data transiting, stored on or traveling to or from this information system.
The government may disclose or use any communications or data transiting, stored on or traveling to or from this information system for any lawful government purpose.
Classified or Official Use Only information is not allowed on this website.
Need help? Contact the System Administrator 509-376-4821 or
firstname.lastname@example.org. Their hours of operation are 6 AM to 4 PM PT Monday through Thursday.