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Type B Accident Investigation Board Report on the September 1, 1999, Plutonium Intakes at the Savannah River Site FB-Line

February 1, 2000

The September 1, 1999, accident at the Savannah River Site's FB-Line facility occurred when plutonium was released from a failed bagless transfer can, resulting in plutonium intakes by at least seven workers (additional workers are being evaluated). The bagless transfer can was considered by contractor management to be an integral component in the overall safety strategy for the FB-Line. Despite this reliance on the canister’s integrity, adequate quality assurance controls were not in place to ensure that a can with a failed weld would not be stored in the FB-Line vault.