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
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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.
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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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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
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(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.
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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.
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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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