NRC Generic Letter 1982-21
J 061982
- 2J
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 qualifi- cations 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 programatic 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. Ndo written response is required.
Sincerely, Original signed by Darrell G. Eisenhut
8210070019 Darrell G. Eisenhut, Director {
Division of Licensing Enclosures: $1 As stat.d OFFICE~J D..............
R......... .. .............. .............. ....
SURNAMEIP 2 2enAfhu .f..........
~ .. .............. ........
DATE G .i..2......
& ~~~~~./.e..X2../.l. .................. ...... ..................... ...... ..................... ...... ..................... ...... ........................
DATENRClet. /82 ..... F I...........E.C.O.R.D
.................. ....................
NRC FORM 318 (10-80) NRCM 0240 OFFICIAL RECOR D C OPY USGPO: 1981-335-960
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 imple- menting procedures required by item h is to assure that the requirements for design, procurement, fabrication, installation, testing, maintenance, and adminsitrative 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 licen- see's QA orgainization who do not have direct responsibility for the program being audited. These audits would noirally encompass an evaluation of existing programmatic documents to verify continued adherence to NRC require- ments. 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 auditorts).
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 exist- ing documents (other than those addressed under item U) plus an inspec- tion of fire protection system operability, and inspection of the integrity of fire barriers, and witnessing of procedures to verify that the fire pro- tection 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 ant of the Tech- nical Specification audit requirements because they do not evaluate plant
.fire protection programs against NRC requirements. %Insurance company inspec-
.tions 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 evaluating hazardous conditions related to property protection and life safety, 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, ye 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 pro- cedures. The fire protection engineer f(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 protec- tion 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 requirements The quality assurance (QA) program should assure thatadministrative for design, procurement, installation, testing, and safety related areas controls for the fire protection program for Assurance The Quality provisions for approved by NRC are satisfied. after the effective fire protection should apply to activities performed program should be under date of the adoption of said provisions. The QA This control consists of the management control of the QA organization. protection QA program
(1) formulating and/or verifying that the fire to the management incorporates suitable requirements and is acceptable effectiveness of responsible for fire protection and (2)verifying the surveillance, and the QA program for fire protection through review. forrneetifig the fire
- audits. Performance of-other 1QAmay program funct ons protection program requirements oe perTormea Cy personnel outsiae or should be part the QA organization. The QA program for fire protection apply to those items of the overall plant QA program. These QA criteria as fire protection within the scope of the fire protection program, such breathing systems, emergency lighting, communication and emergency of applicable apparatus as well as the fire protection requirements safety related equipment.
assurance (QA)
Applicants/licensees can meet the fire protection quality Guide 1.120
program criteria of Appendix A to BTP 9.5-1 or Regulat6ry by either:
part of their QA
1) implementing those fire protection QA criteria as a committment program under 10 CFR Part 50 Appendix B. where such description of the is made, it is not necessary to submit a detailed review; or for NRC
fire protection QA program or its implementation protection QA
2) providing for NRC review a description of the fire Supplemental program and the measures for implementing the program.
measures.for implementing guidance is provided below 6n acceptable A to each of the fire protection QA program criteria of Appendix BTP 9.5-1 or Regulatory Guide 1.120.
should
1.0 Design Control and Procurement Document Control - Measures of the be established to assure that the applicable guidelines NRC alternatives are included in Regulatory Guide 1.120 or approved are design and procurement documents and that deviations therefrom controlled. These measures should assure that:
changes
. .* a. Design and procurement document changes, including fieldcontrols, and design deviations are subject to the same level of reviews, and approvals that were applicable to the original document.
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, re- viewed, 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 in- structions, procedures, and drawings.
c. Instructions and procedures for design installation, inspect- tion, 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 re- striction on material substitution unless specifically permitted by design and confirmed-by design review.
3 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 communica- tion 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 requi rements.
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
- - -.0-
4
(4) A description of the method of inspection
(5) Recording evidence of completing and verifying a nanu- facturing, 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 equip- ment 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 itemfs have not deteriorated or'been damaged.
5.0 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 equip- ment 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 QAIQC 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.
J .'&
5 items
7.0 Nonconforming Items - Measures should be established to control inadvertent that do not conform to specified requirements to prevent to use of installation. These measures should include provisions assure that:
a. Nonconforming, inoperative, or malfunctioning fire protection are systems, emergency lighting, and communication equipment appropriately tagged or labelled.
dis- b. The identification, documentation, segregation, review of position, and notification to the affected organization nonconforming materials, parts, components, or services are procedurally controlled.
the
- c. Documentation identifies the nonconforming item, describes item nonconformance and the disposition of the nonconforming
- and includes signature approval of the disposition.
or d. Provisions are established identifying those individuals for the groups delegated the responsibility and authority disposition and approval of nonconforming items.
ensure that con-
8.0 Corrective Action - Measures shall be established tomalfunctions, ditions adverse to fire protection such as failures, combus- deficiencies, deviations, defective components, uncontrolled reported tible material and nonconformances are promptly identified, and corrected. These measures should assure:
adverse a. Procedures are established for evaluation of conditionsmal- to fire protection (such as nonconformance, failures, functions, 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 and analyzed, and prompt corrective the conditions is determined of the actions are taken to preclude recurrence. The cause action taken are promptly reported condition and the corrective to-cognizant levels of management for review and assessment.
to furnish
9.0 Records - Records should be prepared and maintained met for evidence that the criteria enumerated above are being following activities affecting the fire protection program. The provisions should be included:
a. Records are identifiable and retrievable and should demonstrate should conformance to fire protection requirements. The records
6 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.
v ,s..-- ':-..*- . a_- v . -_. . - _ -_~.
_
Minimum Elements That Should Be Incorporated in -, - *.
. _
.X... nnual'.'nd Triennia FeProtection Audits A. -
Purpose
- Th e purpose of these audits is to assess the plant fire protec- tion 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 req.irements 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 pro- tection is provided and, in particular, examination of fire barriers, fire detection systems, and fire extinguishing systems provided for safety-related
. Sequipment.. The auditshbuld verify:that:e c o th a ta .
1. The installed fire protection systems and barriers are appropriate for the objects protected by comparing them to NRC guidelines or 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 pro- tection systems.
4. Identified deficiencies have been promptly and adequately corrected.
5I. Special permit procedures (hot work,_ alve positioning) are being
6. Plant personnel are receiving appropriate training in fire pre- vention and fire fighting procedures and that the training pro- gram is consistent with approved standards. (The audit team should witness a typical training session.)
7. Plant response to fire emergencies is adequate by analyzing inci- dent records and witnessing an 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.