Event Notification Report for January 24, 2001

GROUNDWATER RESTORATION SPILL INTO AN ONSITE DRY DRAW IN JOHNSON COUNTY, WYOMING (48-hour report in accordance with the license)

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

"Reported Event - A groundwater restoration spill was discovered on 01-24-01, which was estimated at 13,392 gallons. License Section 12.4 states that the 'NRC staff considers any spill of 10,000 gallons or more to be significant from an operations standpoint, regardless of the chemical and radioactive characteristics of the spill.' Therefore, the NRC [Operations] Center is notified as instructed by this license section. Note that the Wyoming Department of Environmental Quality was also notified."

"Spill Date, Time, and Gallons - January 23 (10:00 [MST]) to January 24, 2001 (10:00 [MST]), estimated at 13,392 gallons"

"Spill Location - Irigaray Project, Unit 9, Well HP-63, NW, NW, S16, T45N, R77W, Johnson County, WY. The spill entered a dry draw where it was contained and didn't enter any surface water or leave the NRC permit area."

"Spill Cause - The spill resulted from human error when the pump in restoration well LP-63 was inadvertently energized and allowed to pump groundwater onto the surface."

"Spill Source and Analysis - The spill consisted of groundwater from a wellfield which had completed the final phase of restoration. The spill contained only 3.1 mg/I uranium as U."

"Health or Environmental Hazards, and Corrective Actions - No recovery of the spill was conducted since the groundwater was from a wellfield which had completed the final phase of restoration and is considered clean. The nearest community is Linch, Wyoming, approximately 21 miles to the SSE. No health or environmental hazards are anticipated."

"Written Notification - A written notification will be submitted to NRC Fuel Cycle Licensing Branch Chief within 7 days."

The licensee stated that the water was considered to be clean and that this event was reported because of the quantity of water involved in the spill. The licensee also stated that drinking water standards for uranium content are 5 mg/l and the spill contained only 3.1 mg/I uranium as U. In addition, the licensee reported that a Wyoming Department of Environmental Quality representative was onsite when the spill occurred and that the State representative did not have any problem with the spill.

It was determined that there was no adverse impact to the public or the environment.

(Call the NRC Operations Center for licensee contact information.)

24-HR REPORT REQUIRED BY STATION ADMINISTRATIVE ORDERS FOR THE FIRE PROTECTION PLAN

"Indian Point #2 Station

"High Pressure Fire Header Impairment

"Fire Impairment and Surveillance per Station Administration Order 703.

"NRC event # 37683. The high pressure Fire Water Protection System is degraded due to planned maintenance work. The inner and outer high-pressure fire headers are split to provide protection for work on the valves for 12 Fire Main Booster Pump. 12 Fire main booster pump is inoperable during this tag-out. The diesel fire pump is in service as the alternate fire protection for the outside fire header. 11 and 12 fire maintenance pumps are supplying the inside header with 11 Fire Main Booster Pump available as a back up. SAO-703 states one fire main booster pump out of service is a 7-day action statement to return it to operable status. The headers being separated or any part of the fire protection piping or valves not being able to perform its function other than the specific instances described in SAO-703 requires an alternate fire protection system shall be established. This was established within 24 hours to ensure compliance with SAO-703 as described above. A special report shall be submitted to the NRC Regional Administrator of the Region 1 Office outlining this event within 14 Days."

The licensee informed the NRC resident inspector.

MEDICAL MISADMINISTRATION

A Cs-137 vaginal cylinder implant was loaded at 9:30 am on 1/23/01. The written directive called for a total implant time of 49 hours. During a check of the patient at 7:30 am on 1/24/01, the authorized user found the loaded vaginal cylinder on the patient's toilet seat. The patient's nurse stated that the source came out at about 6:30 am on 1/24/01 (i.e., after about 42% of the prescribed dose was delivered). The licensee was not sure how the source got to where it was found. The authorized user placed the cylinder in a lead pig and transported it to the secured storage area. The authorized user decided to write another written directive and reload the patient at 10:00 am on 1/24/01 with a prescribed implant time of 7 hours. After the 7 hours, the sources were explanted as intended. The authorized user decided to deliver the remaining radiation dose to the treatment site via teletherapy.

At 6:00 am on 1/24/01, the nurse emptied the patient's foley bag and noted that the patient was in bed. Between 6:00 and 6:30 am on 1/24/01, the nurse noticed that the patient was leaving the bathroom to go back to bed. The nurse also noticed that the patient's "T-binder" (used to hold the applicator in place), was loose, so she tightened it. The authorized user visited the patient at 7:30 am and noticed that the T-binder was on the bathroom floor and the loaded vaginal cylinder was on the toilet seat. Based on nurse interviews, all nurses caring for the patient were badged, and none of them handled the applicator.

***** UPDATE/RETRACTION AT 1043 EST ON 02/16/01 FROM JEFF LIMMER TO LEIGH TROCINE *****

An investigation was performed, and the NRC Region 3 office (Tony Go and Geoffrey Wright) notified the license that there was patient intervention. Therefore, the licensee is retracting this event.

The NRC operations officer notified the R3DO (Monte Phillips) and NMSS EO (Brian Smith).