“Root Cause Analysis of a hypothetical event involving loss and recovery of a well-logging source Cs-137 during transport”

Abstract Lessons learned following an event involving radioactive source(s) at a radiation facility, it is important to determine its root causes so that effective corrective actions can be implemented. As stated in IAEA Safety Standards Series No. SF-1, Fundamental Safety Principles: “Processes must be put in place for the feedback and analysis of operating experience”. If this process is completed effectively, the probability of a similar event occurring is significantly reduced. Analysis of events is a way for improving the national infrastructure related to safety & security regulation and emergency preparedness. Root-cause analysis is a tool required to identify factors that lead to the occurrence of an event and to develop the effective strategies to avoid the recurrence of such events. The aim of this work is to investigate the root cause analysis of an event (hypothetical) involving loss of a well-logging source (Cs-137) and its subsequent recovery during transport to logging site from the base unit of the well-logging facility. Analysis was done to find out the causes of the incident which includes, “immediate causes (IC)”, “underlying causes (UC)” and “root causes (RC)”. Fish-bone diagram analysis method is used to find out IC, UC and RC. Gap analysis is carried for various steps involved during transport of the well-logging source(s) to the logging site, during transit and return to the base. The recommendations at “Engineering Controls”, “Administrative Controls” during transport of well-logging source(s) in transport container and measures at “Institute level” and “Regulatory level” are arrived based on results of the analysis.