Event Notification Report for November 07, 2006

PROCESS GAS LEAK DETECTOR FAILURE

"At 0859 on 11/7/2006, the Plant Shift Superintendent (PSS) was notified of a failure of the C-337A process gas leak detector (PGLD) YE-613-21 to alarm during TSR [Technical Safety Requirements] surveillance 2.2.4.1-1. TSR surveillance 2.2.4.1-1 is a quarterly test to verify that the PGLD will detect a UF6 release, alarm, and alert personnel. PGLD YE-613-21 provides coverage for the north section of the facility UF6 piping trench. Staff review of the failure, suggest that PGLD YE-613-21 may have failed prior to being removed from service to perform the 11/7/06 TSR surveillance. PGLD YE-613-21 was replaced and tested satisfactorily. Additional testing and engineering review of PGLD YE-613-21 is being performed to ensure the operability of the PGLD and to develop any needed corrective actions.

"This event is reportable as a 24 hour event in accordance with 10CFR 76.120(c)(2)(i). This is an event in which equipment is disabled or fails to function as designed when: a.) the equipment is required by a TSR to prevent releases, prevent exposures to radiation and radioactive materials exceeding specified limits, mitigate the consequences of an accident, or restore this facility to a pre-established safe condition after an accident; b.) the equipment is required by a TSR to be available and operable and either should have been operating or should have operated on demand, and c.) no redundant equipment is available and operable to perform the required safety function.

"The NRC Senior Resident Inspector has been notified of this event.

"PGDP Problem Report No. ATRC-06-3670; PGDP Event Report No. PAD-2006-10; NRC Worksheet No. 42972."

FAILURE OF PROCESS GAS LEAK DETECTION SYSTEM

"At 1607 on 11/7/2006, the Plant Shift Superintendent (PSS) was notified of a failure of the C-333 Unit 6 Cell 3 process gas leak detection (PGLD) system. C-333 operators were alerted to the Unit 6 Cell 3 PGLD failure by the receipt of an Area Control Room alarm. The operators responded to the Unit 6 Cell 3 cell panel and discovered that the PGLD system was inoperable. C-333 Unit 6 Cell 3 and associated piping were operating above atmospheric pressure (Cascade Mode 2) at the time of the PGLD failure. The operators initiated a continuous smoke watch of the area with lost PGLD coverage until the associated equipment and piping pressure was reduced below atmospheric pressure in accordance with TSR LCO 2.4.4.1. The PGLD system is required per TSR 2.4.4.1 to be operable when a cascade cell and associated piping is above atmospheric pressure (Cascade Mode 2).

"This event is reportable as a 24 hour event in accordance with 10CFR 76.120(c)(2)(i). This is an event in which equipment is disabled or fails to function as designed when: a.) the equipment is required by a TSR to prevent releases, prevent exposures to radiation and radioactive materials exceeding specified limits, mitigate the consequences of an accident, or restore this facility to a pre-established safe condition after an accident; b.) the equipment is required by a TSR to be available and operable and either should have been operating or should have operated on demand, and c.) no redundant equipment is available and operable to perform the required safety function.

"The NRC Senior Resident Inspector has been notified of this event.

"PGDP Problem Report No. ATRC-06-3679; PGDP Event Report No. PAD-2006-11; NRC Worksheet No. 42973."

The licensee stated that the equipment and piping pressure was reduced in order to allow the process to continue operating in a condition where the PGLD system is not required to be operable. The licensee is investigating the cause of the failure but it is preliminarily believed to be a failure of an instrumentation power supply.

MEDICAL EVENT - LESS THAN PRESCRIBED DOSE OF YTTRIUM - 90

The Radiation Safety Office for the licensee reported an event where a patient received less than the prescribed dose during a treatment for liver cancer using Yttrium - 90 microspheres. Specifically, the patient was prescribed 9.8 millicuries to the liver using Yttrium - 90 SirTex Sirspheres using a intrahepatic catheter. The patient only received 6.5 millicuries due to problems in the administration of the dose.

After administering about half of the treatment dose, the physician started to encounter injection resistance which is not uncommon with this treatment due to vasculature loading. The physician stopped the treatment and was trying to view the microsphere placement in the liver using fluoroscopy when he noted some unusual "clumping" of the microspheres between the delivery vial and a 3-way stop cock that connects to the catheter. Because of the clumping and the resistance, the physician elected to discontinue the administration of the remainder of the dose.

The licensee has contacted SirTex and plans to send the delivery device with the clumped microspheres to SirTex when the Yttrium - 90 has decayed away (in a couple weeks) for further evaluation of the product.

The licensee has also contacted the Region 3 NRC inspector (Piskura) about this event.

A "Medical Event" may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

*** UPDATE FROM SCHULTZ TO KNOKE AT 14:29 ON 01/11/07 ***

The RSO called to indicate this event was reviewed by Region 3 and was determined to not meet the criteria for a reportable event, therefore the event is being retracted. Notified R3DO (Kozak) & NMSS (Janet Schlueter).

ACTUATION OF AN OFFSITE EMERGENCY SIREN

"At 1526 on 11/07/2006 the BFN (Browns Ferry Nuclear) Shift Manager was notified by the Operations Duty Specialist (ODS) that siren 32 in Morgan County had to be disabled due to alarming for no reason. It was later determined that this event was identified by an outside citizen who notified Morgan County personnel and @ 1550 on 11/10/2006 that Corporate TVA personnel notified the State of Alabama of the status of the alarming siren. The late reporting has been entered into the corrective action program and discussed with the NRC Resident.

"This event is reportable an a 4-hour Non-Emergency Notification 10CFR50.72 (b)(2)(xi) as 'Any event resulting in notification to other government agencies that has been or will be made.' "

The NRC Resident Inspector was notified of this event at 1340 CDST on 11/14/2006.