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