United States Nuclear Regulatory Commission - Protecting People and the Environment

Technical Specifications for Fire Protection Audits (Generic Letter No. 82-21)



                               UNITED STATES 
                       NUCLEAR REGULATORY COMMISSION 
                          WASHINGTON, D. C. 20555 

                              October 6, 1982 

TO ALL LICENSEES AND APPLICANTS OF NUCLEAR POWER REACTORS 

Gentlemen: 

SUBJECT:  TECHNICAL SPECIFICATIONS FOR FIRE PROTECTION AUDITS 
          (Generic Letter No. 82-21) 

The Technical Specifications for fire protection require: 

     (a)  an annual fire protection and loss prevention inspection and audit
          utilizing either qualified offsite licensee personnel or an 
          outside fire protection firm: 

     (b)  a biennial audit of the Fire Protection Program and implementing 
          procedures; and 

     (c)  a triennial fire protection and loss prevention inspection and 
          audit utilizing an outside qualified fire consultant. 

We have received inquiries about the differences between these three audits,
both as to the scope of the audits and the make-up and qualifications of the
inspectors and auditors. We have, therefore, prepared the enclosed guidance 
which is what we believe would be a comprehensive and conscientious audit 
program. Such a program would be responsive to the overall programmatic 
requirements contained in 10 CFR 50.48(a) and guideline positions in BTP 
9.5-1. 

Enclosure 1 discusses the general scope of the three audits and the 
composition and qualifications of the audit teams. Section 10 of Enclosure 2 
provides additional information with regard to the 24 month audit. Enclosure 
2 is excerpted from a document entitled "Nuclear Plant Fire Protection 
Functional Responsibilities, Administrative Controls and Quality Assurance" 
which was sent to all licensees and applicants in 1977. Enclosure 3 
describes elements that should be included in the annual and triennial 
audits. 

This guidance is provided for your information. No written response is 
required. 

                              Sincerely, 


                              Darrell G. Eisenhut, Director 
                              Division of Licensing 

Enclosures: 
As stated 



8210070019   
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                                                             Enclosure 1  

               General Scope of Fire Protection Audits and 
                Composition and Qualifications of Auditors 

                              24-Month Audit 
                        Item h of Section 6.5.2.8. 
                   of Standard Technical Specifications 

The purpose of the 24-month audit of the fire protection program and 
implementing procedures required by item h is to assure that the 
requirements for design, procurement, fabrication, installation, testing, 
maintenance, and administrative controls for the respective programs 
continue to be included in the plant QA program for fire protection and meet 
the criteria of the QA/QC program established by the licensee in accordance 
with BTP-CMEB-9.5.1. These audits should be performed by personnel from the 
licensee's QA organization who do not have direct responsibility for the 
program being audited. These audits would normally encompass an evaluation 
of existing programmatic documents to verify continued adherence to NRC 
requirements. Additional information is contained in Enclosure 2. "Nuclear 
Plant Fire Protection Functional Responsibilities, Administrative Controls 
and Quality Assurance," August 29, 1977. 

                        Annual and 3 year Audits  
                    Items i and j of Section 6.5.2.8  
                   of Standard Technical Specifications 

The purpose of the audits required by items i and j of Section 6.5.2.8 is to
assess the plant fire protection equipment and program implementation in 
depth to verify continued compliance with NRC requirements, the SAR Com-
mitments, and the license conditions. These audits include a more compre-
hensive evaluation of the fire protection program. Elements that should be 
included in these audits are described in Enclosure 3. These audits are 
basically the same; the difference lies in the source of the auditor(s). The 
annual item i audits may be performed by qualified utility personnel who are 
not directly responsible for the site fire protection program or by an 
outside independent fire protection consultant. The three-year item j audit 
must be performed by an outside independent fire protection consultant. 
These audits would normally encompass an evaluation of existing documents 
(other than those addressed under item h) plus an inspection of fire 
protection system operability, and inspection of the integrity of fire 
barriers, and witnessing of procedures to verify that the fire protection 
program has been fully implemented and is adequate for the objects 
protected. Duplicate audits are not required, i.e., the three-year item j 
audit replaces the annual item i audit the year it is performed. 

In our opinion, insurance company inspections do not satisfy any of the 
Technical Specification audit requirements because they do not evaluate 
plant fire protection programs against NRC requirements. Insurance company 
inspections do not reassess or re-evaluate the fire protection program, 
since the insurance company has already agreed to insure the licensee's 
program as it is being implemented. Insurance company inspections are 
generally limited to checking systems and materials for proper condition and 
maintenance, and inspecting hazardous conditions related to property 
protection and life  However, if the insurance company develops an 
inspection that has  
.

                                     -2-  

the proper scope and the inspection team includes a person knowledgeable in 
nuclear safety, we have no objection to an insurance company performing 
these audits in conjunction with a lead auditor from the licensee's QA 
organization. 

Our recommended approach for the fire protection audits is to have each 
audit performed by a qualified audit team. The team should include at least 
a lead auditor from the licensee's QA organization, a systems engineer, and 
a fire protection engineer. The lead auditor should be qualified per ANSI 
N45.2.23 as endorsed by Regulatory Guide 1.146. The systems engineer should 
be knowledgeable in safety systems, operating procedures, and emergency 
procedures. The fire protection engineers (or engineering consultant) should
have the qualifications for membership in the Society of Fire Protection 
Engineers at the grade of member. The fire protection engineer can be a 
licensee employee who is not directly responsible for the site fire 
protection program for two of three years, but must be an outside 
independent fire protection consultant every third year. This audit team 
approach will assure that the technical requirements as well as the QA 
requirements are adequately audited.  
.

                                                               ENCLOSURE 2 

                            QUALITY ASSURANCE 

The quality assurance (QA) program should assure that the requirements for 
design, procurement, installation, testing, and administrative controls for 
the fire protection program for safety related areas approved by NRC are 
satisfied. The Quality Assurance provisions for fire protection should apply
to activities performed after the effective date of the adoption of said 
provisions. The QA program should be under the management control of the QA 
organization. This control consists of (1) formulating and/or verifying that
the fire protection QA program incorporates suitable requirements and is 
acceptable to the management responsible for fire protection and (2) 
verifying the effectiveness of the QA program for fire protection through 
review, surveillance, and audits. Performance of other QA program functions 
for meeting the fire protection program requirements may be performed by 
personnel outside of the QA organization. The QA program for fire protection
should be part of the overall plant QA program. These QA criteria apply to 
those items within the scope of the fire protection program, such as fire 
protection systems, emergency lighting, communication and emergency 
breathing apparatus as well as the fire protection requirements of 
applicable safety related equipment. 

Applicants/licensees can meet the fire protection quality assurance (QA) 
program criteria of Appendix. A to BTP 9.5-1 or Regulatory Guide 1.120 by 
either: 

1)   implementing those fire Protection QA criteria as part of their QA 
     program under 10 CFR Part 50 Appendix B. where such a commitment is 
     made, it is not necessary to submit a detailed description of the fire 
     protection QA program or its implementation for NRC review; or 

2)   providing for NRC review a description of the fire protection QA 
     program and the measures for implementing the program. Supplemental 
     guidance is provided below on acceptable measures for implementing each 
     of the fire protection QA program criteria of Appendix A to BTP 9.5-1 
     or Regulatory Guide 1.120. 

1.0  Design Control and Procurement Document Control - Measures should be 
     established to assure that the applicable guidelines of the Regulatory 
     Guide 1.120 or approved NRC alternatives are included in design and 
     procurement documents and that deviations therefrom are controlled. 
     These measures should assure that: 

     a.   Design and procurement document changes, including field changes 
          and design deviations are subject to the same level of controls, 
          reviews, and approvals that were applicable to the original 
          document. 
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                                      2  

     b.   Quality standards are specified in the design documents such as 
          appropriate fire protection codes and standards, and deviations 
          and changes from these quality standards are controlled. 

     c.   New designs and plant modifications, including fire protection 
          systems, are reviewed by qualified personnel to assure inclusion 
          of appropriate fire protection requirements. These reviews should 
          include items such as: 

          (1)  Design reviews to verify adequacy of wiring isolation and 
               cable separation criteria. 

          (2)  Design reviews to verify appropriate requirements for room 
               isolation (sealing penetrations, floors, and other fire 
               barriers). 

     d.   A review and concurrence of the adequacy of fire protection 
          requirements and quality requirements stated in procurement 
          documents are performed and documented by qualified personnel. 

          This review should determine that fire protection requirements and
          quality requirements are correctly stated, inspectable and 
          controllable; there are, adequate acceptance and rejection 
          criteria; and the procurement document has been prepared, 
          reviewed, and approved in accordance with QA program requirements. 

2.0  Instructions, Procedures, and Drawing - Inspections, tests, admin-
     istrative controls, fire drills, and training that govern the fire 
     protection program should be prescribed by documented instructions, 
     procedures or drawings and should be accomplished in accordance with 
     these documents. The following provisions should be included. 

     a.   Indoctrination and training programs for fire prevention and fire 
          fighting are implemented in accordance with documented procedures.

     b.   Activities such as design, installation, inspection, test, 
          maintenance, and modification of fire protection systems are 
          prescribed and accomplished in accordance with documented 
          instructions, procedures, and drawings. 

     c.   Instructions and procedures for design installation, inspection, 
          test, maintenance, modification and administrative controls are 
          reviewed to assure that proper inclusion of fire protection 
          requirements, such as precautions, control of ignition sources and
          combustibles, provisions for backup fire protection of the 
          activity requires disabling a fire protection system, and 
          restriction on material substitution unless specifically permitted 
          by design and confirmed by design review. 
.

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     d.   The installation or application of penetration seals and fire 
          retardant coatings is performed by trained personnel using 
          approved procedures. 

3.0  Control of Purchased Material, Equipment, and Services - Measures shall
     be established to assure that purchased material, equipment and 
     services conform to the procurement documents. These measures should 
     include: 

     a.   Provisions, as appropriate, for source evaluation and selection, 
          objective evidence of quality furnished by the contractor, 
          inspections at suppliers, or receiving inspections. 

     b.   Source or receiving inspection, as a minimum, for those items 
          whose quality cannot be verified after installation. 

4.0  Inspection - A program for independent inspection of activities 
     affecting fire protection should be established and executed by, or 
     for, the organization performing the activity to verify conformance to 
     documented installation drawings and test procedures for accomplishing 
     activities. This program should include: 

     a.   Inspections of (1) installation, maintenance and modification of 
          fire protection systems; and (2) emergency lighting and 
          communication equipment to assure conformance to design and 
          installation requirements. 

     b.   Inspection of penetration seals and fire retardant coating 
          installations to verify the activity is satisfactorily completed. 

     c.   Inspections of cable routing to verify conformance with design 
          requirements. 

     d.   Inspections to verify that appropriate requirements for room 
          isolation (sealing penetrations, floors, and other fire barriers) 
          are accomplished during construction. 

     e.   Measures to assure that inspection personnel are independent from 
          the individuals performing the activity being inspected and are 
          knowledgeable in the design and installation requirements for fire
          protection. 

     f.   Inspection procedures, instructions, and check lists which provide
          for the following: 

          (1)  Identification of characteristics and activities to be 
               inspected 

          (2)  Identification of the individuals or groups responsible for 
               performing the inspection operation 

          (3)  Acceptance and rejection criteria 
.

                                      4 

          (4)  A description of the method of inspection 

          (5)  Recording evidence of completing and verifying a 
               manufacturing, inspection or test operation 

          (6)  Recording inspector or data recorder and the results of the 
               inspection operation 

     g.   Periodic inspections of fire protection systems, emergency 
          breathing and auxiliary equipment, emergency lighting, and 
          communication equipment to assure the acceptable condition of 
          these items. 

     h.   Periodic inspection of materials subject to degradation such as 
          fire stops, seals, and fire retardant coatings to assure these 
          items have not deteriorated or been damaged. 

5.O  Test and Test Control - A test program should be established and 
     implemented to ensure that testing is performed and verified by 
     inspection and audit to demonstrate conformance with design and system 
     readiness requirements. The tests should be performed in accordance 
     with written test procedures; test results should be properly evaluated 
     and acted on. The test program should include the following: 

     a.   Installation Testing - Following construction, modification, 
          repair or replacement, sufficient testing is performed to 
          demonstrate that fire protection systems, emergency lighting and 
          communication equipment will perform satisfactorily in service and 
          that design criteria are met. Written test procedures for 
          installation tests incorporate the requirements and acceptance 
          limits contained in applicable design documents. 

     b.   Periodic testing - The schedules and methods for periodic testing 
          are developed and documented. Fire protection equipment, emergency
          lighting, and communication equipment are tested periodically to 
          assure that the equipment will properly function and continue to 
          meet the design criteria. 

     c.   Programs are established for QA/QC to verify-testing of fire 
          protection systems and to verify that test personnel are 
          effectively trained. 

     d.   Test results are documented, evaluated, and their acceptability 
          determined by a qualified responsible individual or group. 

6.0  Inspection, Test, and Operating Status - Measures should be established
     to provide for the identification of items that have satisfactorily 
     passed required tests and inspections. These measures should include 
     provisions for: 

     a.   Identification by means of tags, labels, or similar temporary 
          markings to indicate completion of required inspections and tests,
          and operating status. 
.

                                       5 

7.0  Nonconforming Items - Measures should be established to control items 
     that do not conform to specified requirements to prevent inadvertent 
     use of installation. These measures should include provisions to assure 
     that:  

     a.   Nonconforming, inoperative, or malfunctioning fire protection 
          systems, emergency lighting, and communication equipment are 
          appropriately tagged or labelled. 

     b.   The identification, documentation, segregation, review 
          disposition, and notification to the affected organization of 
          nonconforming materials, parts, components, or services are 
          procedurally controlled. 

     c.   Documentation identifies the nonconforming item, describes the 
          nonconformance and the disposition of the nonconforming item and 
          includes signature approval of the disposition. 

     d.   Provisions are established identifying those individuals or groups
          delegated the responsibility and authority for the disposition and
          approval of nonconforming items. 

8.0  Corrective Action - Measures shall be established to ensure that con-
     ditions adverse to fire protection such as failures, malfunctions, 
     deficiencies, deviations, defective components, uncontrolled 
     combustible material and nonconformances are promptly identified, 
     reported and corrected. These measures should assure: 

     a.   Procedures are established for evaluation of conditions adverse to
          fire protection (such as nonconformance, failures, malfunctions, 
          deficiencies, deviations, and defective material and equipment) to
          determine the necessary corrective action. 

     b.   In the case of significant or repetitive conditions adverse to 
          fire protection, including fire incidents, the cause of the 
          conditions is determined and analyzed, and prompt corrective 
          actions are taken to preclude recurrence. The cause of the 
          condition and the corrective action taken are promptly reported to 
          cognizant levels of management for review and assessment. 

9.0  Records - Records should be prepared and maintained to furnish evidence
     that the criteria enumerated above are being met for activities 
     affecting the fire protection program. The following provisions should 
     be included: 

     a.   Records are identifiable and retrievable and should demonstrate 
          conformance to fire protection requirements. The records should 
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          include results of inspections, tests, reviews, and audits; non-
          conformance and corrective action reports; construction, 
          maintenance and modification records; and certified manufacturers'
          data. 

     b.   Record retention requirements are established. 

10.0 Audits - Audits should be conducted and documented to verify compliance
     with the fire protection program, including design and procurement 
     documents, instructions, procedures, and drawings, and inspection and 
     test activities. The following provisions should be included: 

     a.   Audits are periodically performed to verify compliance with the 
          administrative controls and implementation of quality assurance 
          criteria including design and procurement, instructions, 
          procedures and drawings and inspection and test activities. These 
          audits are performed by QA personnel in accordance with 
          preestablished written procedures or check lists and conducted by 
          trained personnel not having direct responsibilities in the areas 
          being audited. 

     b.   Audit results are documented and then reviewed with management 
          having responsibility in the area audited. 

     c.   Followup action is taken by responsible management to correct the 
          deficiencies revealed by the audit. 

     d.   Audits are annually performed to provide an overall assessment  of
          conformance to fire protection requirements. 
.

                                ENCLOSURE 3 

             Minimum Elements That Should Be Incorporated in 
                Annual and Triennial Fire Protection Audits 

A.   Purpose - The purpose of these audits is to assess the plant fire 
     protection equipment and program implementation to verify that a level 
     of safety consistent with NRC guidelines continues to be provided. 

B.   Scope - Each audit should verify that the commitments of the SAR and 
     that the requirements of the Technical Specifications and license 
     conditions have been met and that modifications to systems and 
     structures or changes in operating procedures have not decreased the 
     level of safety in the plant. The audit should include inspection of 
     all plant areas for which fire protection is provided and, in 
     particular, examination of fire barriers, fire detection systems, and 
     fire extinguishing systems provided for safety-related equipment. The 
     audit should verify that: 

     1.   The installed fire protection systems and barriers are appropriate
          for the objects protected by comparing them to NRC guidelines of 
          SER approved alternatives and noting any deviations. 

     2.   The fire loading in each fire area has not increased above that 
          which was specified in the SAR. 

     3.   Regularly scheduled maintenance is performed on plant fire 
          protection systems. 

     4.   Identified deficiencies have been promptly and adequately 
          corrected. 

     5.   Special permit procedures (hot work, valve positioning) are being 
          followed. 

     6.   Plant personnel are receiving appropriate training in fire 
          prevention and fire fighting procedures and that the training 
          program is consistent with approved standards. (The audit team 
          should witness a typical training session.) 

     7.   Plant response to fire emergencies is adequate by analyzing 
          incident records and witnessing and unplanned fire drill. 

     8.   Administrative controls are limiting transient combustibles in 
          safety-related areas. 

     9.   Problem areas identified in previous audits have been corrected. 

     The audit should analyze all problem areas identified by the audit and 
     recommend appropriate fire protection measures to provide a level of 
     safety consistent with NRC guidelines. 
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