NRC Generic Letter 82-21, Fire Protection Audits

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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 statedEnclosure 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

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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.