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Type A Accident Investigation Board Report on the January 17, 1996, Electrical Accident With Injury in Building 209, Technical Area 21, Tritium Science and Fabrication Facility, Los Alamos National Laboratory

April 1, 1996

The electrical accident with injury at the Los Alamos National Laboratory (LANL) on January 17, 1996, resulted from failures of Department of Energy (DOE), contractor, and subcontractor management. Significant, sitewide, programmatic weaknesses in the Laboratory's safety management program and failure to correct them were the principal causes of the accident. This was particularly true of the inadequacies in work planning, authorization, and control procedures that contributed to the injury.