PERUVIANS CONCLUDE INVESTIGATION OF COBALT-60

C O N F I D E N T I A L LIMA 001924 SIPDIS SIPDIS STATE FOR WHA SHAPIRO ALSO FOR WHA/AND, WHA/EPSC, EB/ESC, INL/LP E.O. 12958: DECL: 05/08/2016 TAGS: SNAR PREL KSAF TRGY ENRG TSPL ASEC KNNP VE PE SUBJECT: PERUVIANS CONCLUDE INVESTIGATION OF COBALT-60 REMOVAL REF: A. CARACAS 1297 ¶B. LIMA 1809 ¶C. CARACAS 1234 ¶D. CARACAS 1233 Classified By: Deputy Chief of Mission Phyllis Powers; Reason 1.4 (B,D) ¶1. (U) Summary: After exhaustive interviews, investigators from GOP nuclear regulator IPEN believe that a poorly trained Caddin employee removed the Co-60 source in Lima without realizing it. IPEN, Caddin and Rapiscan officials discounted the possibility that the Co-60 removal was a malicious act. IPEN faults poor design, labeling, training and Caddin conduct; Rapiscan faults Caddin conduct. IPEN does not believe there are any significant health effects to the less than 10 people exposed in Peru. IPEN and the Foreign Ministry indicated that the GOP does not plan to ask for IAEA assistance but would answer any questions the IAEA investigators might have. IPEN has completed a preliminary report; the final version should be completed in 10 days. NAS continues to evaluate future contracting with Rapiscan; if NAS continues to work with Rapiscan, x-ray rather than gamma ray technology will likely be used. End Summary. CAPSULE REMOVAL A MISTAKE -------------- ¶2. (SBU) During the evening of May 12, DepEconCouns met for several hours with GOP nuclear regulatory agency IPEN director and investigators. IPEN blamed the improper Cobalt-60 (Co-60) removal on a combination of several factors: poor system design, poor labeling, inadequate training by Rapiscan, faulty supervision by Caddin and failure to follow standard monitoring procedures. IPEN and Rapiscan had spent many hours interviewing the involved employees from Caddin, Rapiscan's Peru representative. IPEN is convinced that Caddin engineer Ricardo Depuy's removal of the Co-60 source was inadvertent. Depuy thought he was removing only the electric motor cylinder, leaving the Co-60 source safely inside the lead canister. Depuy, although certified by Rapiscan and IPEN to operate Rapiscan's GaRDS detection system, was not the primary operator for Caddin. The primary engineer/operator did not participate since his wife was pregnant when in December 2005 the GaRDS unit was disassembled for shipping to Venezuela; he was afraid that exposure to even low levels of radiation might cause his wife to abort the baby. ¶3. (SBU) Depuy told investigators that he had watched the disassembly for shipping of the electric motor cylinder by a Rapiscan employee in approximately March of 2005. The Rapiscan employee had disconnected the motor cylinder from the lead canister that housed the source; but he did it correctly, leaving the source within the canister. (Note: This procedure was followed because the motor needed repair; normally the motor cylinder would stay attached to the lead canister for shipping of the source. End Note.) When Depuy was tasked to prepare the GaRDS system for shipping, he reportedly recalled his March 2005 viewing of the motor disassembly and thought that this was a required step for shipping the GaRDS separately from the Co-60 source. Depuy withdrew the motor cylinder with attached rod, leaving the Co-60 source exposed. He did not realize that he had failed to leave the rod and source inside the lead canister. Depuy placed the motor cylinder (with exposed source) in a box, then inside the truck, as he believed the small part was best kept with the vehicle. He then thought the canister, with the source inside (he believed) was ready to be shipped separately. At some point (unclear when),Depuy used the Victoreen monitor to meter only the lead canister, and found nothing extraordinary. ¶4. (C) IPEN officials said that a combination of factors led to Depuy's grossly incorrect action. Rapiscan's design was faulty in that it was too easy for a technician to remove the cylinder with source exposed. In IPEN's opinion, the motor cylinder should have been labeled to warn that only trained technicians should attempt to disassemble it. It should also have warned that exposure of the source is possible if the unit was disassembled. Rapiscan (according to IPEN) did not adequately train Caddin employees in preparation of the system for shipping; they were trained only to operate the system, plus some minor maintenance. Nevertheless, Depuy should have realized that there was no good reason to spend the several hours dismantling the motor cylinder/lead canister assembly. IPEN officials said that the Rapiscan instruction manual was deficient in its explanation for how to prepare the system for shipping. Finally, Depuy and other Caddin employees clearly should have metered for radiation the vehicle, canister, and motor cylinder when it was separated from the canister -- before and after the dismantling-for-shipping procedures. Standard Victoreen monitoring procedures, had they been followed, would have shown immediately that the source was unshielded. ¶5. (SBU) Rapiscan engineer Ted Alston told DepEconCouns on May 12 that Depuy's actions continued to mystify him in its inappropriateness. But after talking with Depuy, Alston did not think Depuy had acted maliciousy. Alston questioned how much Depuy had been involved in GaRDS operations after Depuy's initial Rapiscan training. The GaRDS system is designed for easy shipping: when 8 bolts are removed, the box housing the canister and motor is removed and the entire box is shipped separately from the vehicle. On two prior occaisons, the system had been disassembled for shipment (once the vehicle and once the motor/source housing) to the U.S. for repair or service. (Note: we see some discrepancies between the Caddin and Rapiscan stories regarding timing when the motor cylinder was shipped back for repair. End Note.) ¶6. (SBU) Alston explained that the system was designed to make it very difficult for the source to be pulled out accidentally; nevertheless, the fact that Depuy did it might require that Rapiscan reconsider the design of this part of the system to make it even more difficult to accidentally expose the source. Alston noted that it was inconceivable to him that Depuy would not have used the Victoreen to monitor the before and after stages of his disassembly, to protect himself if nothing else. Victoreen metering of the lead canister with the source inside would have shown a higher reading than the surroundings, so Depuy could have been alerted by a too-low reading on the canister as well as a too-high reading of the vehicle -- had Depuy bothered to use the Victoreen. IPEN REPORT DUE IN TEN DAYS -------------- ¶7. (U) DepEconCouns had a brief opportunity to review the preliminary report that IPEN officials had completed on May 12, but IPEN was unwilling to release it as updates were necessary to reflect final interviews with Caddin and Rapiscan officials. IPEN also asked Rapiscan for additional technical data on the system, which will be incorporated into the final report. IPEN officials said that they would give DepEconCouns the final report when completed, probably during the week of May 22. HEALTH EFFECTS MINIMAL - NO NEED FOR IAEA -------------- ¶8. (U) IPEN officials do not believe that anyone in Peru was significantly exposed to radiation, based on interviews with the Caddin actors and blood test results for all Caddin employees, showing no extraordinary radiation-related values. Depuy's exposure was probably around an hour, with only around 5 to 10 minutes of being near the source as he exposed it, placed it in a box and put the box in the control module of the truck. Caddin President/owner Alfonso Paredes was exposed for the longest time: 1.5 to 2 hours spent driving the vehicle from Chorillos to the Callao port (the truck walls provided some minimal shielding). An estimated five people in Peru were exposed. IPEN investigators have not yet established the identities of longshoremen involved in loading the vehicle, but they consider the exposure of those people to have been less than Depuy or Paredes. IPEN has no way to find out which ship crew members might have been exposed. ¶9. (SBU) Based on its investigation and assessment, IPEN: (1) understands how the incident happened, and (2) concludes that there were no significant radiation exposures, IPEN has no intention to ask the IAEA for assistance. However, IPEN Director for Standards and Authorizations Carlos Ampuero said that IPEN would answer any questions that IAEA investigators might have. IPEN requested that any radiation meterings taken in Venezuela be forwarded to IPEN, so that IPEN could have an authoritative basis for calculating Lima exposures. FOREIGN MINISTRY MEETING -------------- ¶10. (C) On May 12, DepEconCouns met with MFA North America Director Nestor Popolizio and assorted consular and Americas office officials. Popolizio confirmed that at this time there were no plans to ask IAEA for assistance. The GOP had received no communications from the Government of Venezuela concerning the radiation events. Popolizio asked that we work together on managing the incident, and asked if we would share any press statements with him as soon as produced so that the GOP could be prepared. Popolizio asked for confirmation that no Peruvians were exposed in Venezuela or on the transport ship. NAS CONTRACT UPDATE -------------- ¶11. (C) NAS is still evaluating its options with Rapiscan, regarding lease of two maritime container scanners. Rapiscan has offered to supply an x-ray system that should have adequate penetration for NAS purposes. Since the x-ray source can be switched off, unlike gamma radiation, there will be much less chance for accidental exposure. IPEN told DepEconCouns that at this time the agency does not intend to withdraw Caddin certifications for operating the GaRDS. On the other hand according to Alston, Rapiscan would seek another Peruvian representative for its systems. STRUBLE