Event Notification Report for September 28, 1999

OFFSITE NOTIFICATION DUE TO RAW SEWAGE RELEASE TO HUDSON RIVER

The licensee notified the New York Department of Environmental Conservation (spill report 9907789) regarding the release of less than ten gallons of sewage to the Hudson River. At approximately 2043 on 9/27/1999, sewage was spilled from the warehouse sewage holding pit to a storm drain, which discharges to the Hudson River. Plant personnel secured the spill source, diked the drain, and cleaned up the residue. The NRC resident inspector has been informed of this event by the licensee.

SUPPRESSION POOL CLEANUP ISOLATED DURING LEVEL INSTRUMENTATION CALIBRATION.

The following text is a portion of a facsimile received from the licensee:

"While performing a scheduled calibration of Containment Spent Fuel Pool Level Transmitter, SFC-LT11B, a low level isolation signal was actuated, which resulted in the [Division] II Suppression Pool Cleanup (SPC) isolation valve, RHS-AOV62, isolating. The SPC system responded as designed. Abnormal Operating Procedure, AOP-0003, Automatic Isolations, was entered, and the SPC system was secured per the System Operating Procedure (SOP). Calibration on the level transmitter was secured. The work instructions and referenced calibration data did not include any note or potential isolation of the SPC system. As written, the work instructions only referenced input to a computer point, an alarm, and a control room indication. At the time of this event, the SPC system was not aligned to the dryer pool, and thus was not causing any changes in the bulk water volume of the pool. Operation of the SPC system did not contribute to this event. Also, the SPC system performs a non-safety function. Thus, its isolation did not impact safe plant operation."

The licensee notified the NRC resident inspector.

POSSIBLE MEDICAL MISADMINISTRATION AT WOMACK ARMY MEDICAL CENTER (24-hour report)

At 1000 on 09/29/99, the radiation safety officer was notified of a potential medical misadministration at Womack Army Medical Center located at Fort Bragg in North Carolina. The following information was provided:

At 1100 on 09/28/99, a patient was scheduled to received 2 mCi of I-131 as part of a yearly whole body scan. (The patient had a history of thyroid cancer, and the patient's thyroid had previously been removed.) At 1105, a technician measured a dose of 2.76 mCi of I-131. The technician then made a revision to the dose on the paperwork and administered the dose prior to obtaining the authorized user's approval of the change Apparently, the technician assumed that the authorized user would approve the change. The authorized user subsequently signed the paperwork (after the dose was administered).

This was in violation of the licensee's Quality Management Program which requires the authorized user to approve (either verbally or in writing) dose revisions prior to administration. The licensee stated that the authorized user's verbal approval of a dose revision can be given prior to the administration if the authorized user is not physically available to sign an approval prior to performance of an administration involving a dose revision. In that case, the paperwork can be signed by the authorized user after the administration.

The licensee stated that adverse health effects are not expected as a result of this event. At the time of this event notification, it was not known whether or not the patient and/or attending physician had been notified of the potential medical misadministration.

The licensee notified the NRC Region 2 office (Hector Bermudez).

(Call the NRC operations center for licensee contact telephone numbers.)