NRC Generic Letter 1982-21: Difference between revisions
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J 061982* 2 JTO ALL LICENSEES AND APPLICANTS OF NUCLEAR POWER REACTORSGentlemen:
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 preventioninspection and audit utilizing either qualifiedoffsite licensee personnel or an outside fireprotection firm:(b) a biennial audit of the Fire Protection Programand implementing procedures; and(c) a triennial fire protection and loss preventioninspection and audit utilizing an outside qualifiedfire consultant.We have received inquiries about the differences between these threeaudits, both as to the scope of the audits and the make-up and qualifi-cations of the inspectors and auditors. We have, therefore, preparedthe enclosed guidance which is what we believe would be a comprehensiveand conscientious audit program. Such a program would be responsive tothe overall programatic requirements contained in 10 CFR 50.48(a) andguideline positions in BTP 9.5-1.Enclosure 1 discusses the general scope of the three audits and thecomposition and qualifications of the audit teams. Section 10 ofEnclosure 2 provides additional information with regard to the 24 monthaudit. Enclosure 2 is excerpted from a document entitled "Nuclear PlantFire Protection Functional Responsibilities, Administrative Controls andQuality Assurance" which was sent to all licensees and applicants in1977. Enclosure 3 describes elements that should be included in theannual and triennial audits.This guidance is provided for your information. Ndo written response isrequired.
Sincerely,Original signed byDarrell G. Eisenhut8210070019 Darrell G. Eisenhut, Director {Division of Licensing
Enclosures:
$1As stat.dOFFICE~J .. .............. ..............D.............. ....R.........SURNAMEIP 2 2 Af ~ .f... en hu .. ....... ...... .. ...... ........DATE & ~~~~~./.e. .X2../.l. G .i..2...... .................. ...... ..................... ...... ..................... ...... ..................... ...... ........................DATENRClet. /82 ..... F .................. .................... I...........E.C.O.R.DNRC FORM 318 (10-80) NRCM 0240 OFFICIAL RECOR D C OPY USGPO: 1981-335-960 Enclosure 1General Scope of Fire Protection Audits andComposition and Qualifications of Auditors24-Month AuditItem 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 requirementsfor design, procurement, fabrication, installation, testing, maintenance,and adminsitrative controls for the respective programs continue to beincluded in the plant QA program for fire protection and meet the criteriaof 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 programbeing audited. These audits would noirally encompass an evaluation ofexisting programmatic documents to verify continued adherence to NRC require-ments. Additional information is contained in Enclosure 2. "Nuclear PlantFire Protection Functional Responsibilities, Administrative Controls andQuality Assurance," August 29, 1977.Annual and 3 year AuditsItems i and j of Section 6.5.2.8of Standard Technical SpecificationsThe purpose of the audits required by items i and j of Section 6.5.2.8 isto assess the plant fire protection equipment and program implementationin 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 shouldbe included in these audits are described in Enclosure 3. These audits arebasically the same; the difference lies in the source of the auditorts).The annual item i audits may be performed by qualified utility personnelwho are not directly responsible for the site fire protection program orby an outside independent fire protection consultant. The three-yearitem j audit must be performed by an outside independent fire protectionconsultant. 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 integrityof fire barriers, and witnessing of procedures to verify that the fire pro-tection program has been fully implemented and is adequate for the objectsprotected. Duplicate audits are not required, i.e., the three-year item jaudit 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 theinsurance company has already agreed to insure the licensee's program as itis being implemented. Insurance company inspections are generally limitedto checking systems and materials for proper condition and maintenance, andevaluating hazardous conditions related to property protection and lifesafety, 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 performingthese audits in conjunction with a lead auditor from the licensee's QAorganization.Our recommended approach for the fire protection audits is to have each auditperformed by a qualified audit team. The team should include at least alead auditor from the licensee's QA organization, a systems engineer, anda fire protection engineer. The lead auditor should be qualified per ANSIN45.2.23 as endorsed by Regulatory Guide 1.146. The systems engineer shouldbe knowledgeable in safety systems, operating procedures, and emergency pro-cedures. The fire protection engineer f(or engineering consultant) shouldhave the qualifications for membership in the Society of Fire ProtectionEngineers at the grade of member. The fire protection engineer can be alicensee employee who is not directly responsible for the site fire protec-tion program for two of three years, but must be an outside independent fireprotection consultant every third year. This audit team approach will assure..that the technical requirements as well as the QA requirements are adequatelyaudite ENCLOSURE 2QUALITY ASSURANCEThe quality assurance (QA) program should assure that the requirementsfor design, procurement, installation, testing, and administrativecontrols for the fire protection program for safety related areasapproved by NRC are satisfied. The Quality Assurance provisions forfire protection should apply to activities performed after the effectivedate of the adoption of said provisions. The QA program should be underthe management control of the QA organization. This control consists of(1) formulating and/or verifying that the fire protection QA programincorporates suitable requirements and is acceptable to the managementresponsible for fire protection and (2) verifying the effectiveness ofthe QA program for fire protection through review. surveillance, and* audits. Performance of-other 1QA program funct ons forrneetifig the fireprotection program requirements may oe perTormea Cy personnel outsiae orthe QA organization. The QA program for fire protection should be partof the overall plant QA program. These QA criteria apply to those itemswithin the scope of the fire protection program, such as fire protectionsystems, emergency lighting, communication and emergency breathingapparatus as well as the fire protection requirements of applicablesafety related equipment.Applicants/licensees can meet the fire protection quality assurance (QA)program criteria of Appendix A to BTP 9.5-1 or Regulat6ry Guide 1.120by either:1) implementing those fire protection QA criteria as part of their QAprogram under 10 CFR Part 50 Appendix B. where such a committmentis made, it is not necessary to submit a detailed description of thefire protection QA program or its implementation for NRC review; or2) providing for NRC review a description of the fire protection QAprogram and the measures for implementing the program. Supplementalguidance is provided below 6n acceptable measures.for implementingeach of the fire protection QA program criteria of Appendix A toBTP 9.5-1 or Regulatory Guide 1.120.1.0 Design Control and Procurement Document Control -Measures shouldbe established to assure that the applicable guidelines of theRegulatory Guide 1.120 or approved NRC alternatives are included indesign and procurement documents and that deviations therefrom arecontrolled. These measures should assure that:..* a. Design and procurement document changes, including field changesand design deviations are subject to the same level of controls,reviews, and approvals that were applicable to the originaldocumen b. Quality standards are specified in the design documents such asappropriate fire-protection codes and standards, and deviationsand changes from these quality standards are controlled.c. New designs and plant modifications, including fire protectionsystems, are reviewed by qualified personnel to assure inclusionof appropriate fire protection requirements. These reviewsshould include items such as:(1) Design reviews to verify adequacy of wiring isolation andcable separation criteria.(2) Design reviews to verify appropriate requirements for roomisolation (sealing penetrations, floors, and other firebarriers).d.. A review and concurrence of the adequacy of fire protectionrequirements and quality requirements stated in procurementdocuments are performed and documented by qualified personnel.This review should determine that fire protection requirementsand quality requirements are correctly stated, inspectable andcontrollable; there are adequate acceptance and rejectioncriteria; 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 fireprotection program should be prescribed by documented instructions,procedures or drawings and should be accomplished in accordancewith these documents. The following provisions should be included.a. Indoctrination and training programs for fire prevention andfire fighting are implemented in accordance with documentedprocedures.b. Activities such as design, installation, inspection, test,maintenance, and modification of fire protection systems areprescribed 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 controlsare reviewed to assure that proper inclusion of fire protectionrequirements, such as precautions, control of ignition sourcesand combustibles, provisions for backup fire protection of theactivity requires disabling a fire protection system, and re-striction on material substitution unless specifically permittedby design and confirmed-by design revie d. The installation or application of penetration seals and fireretardant coatings is performed by trained personnel usingapproved procedures.3.0 Control of Purchased Material, Equipment, and Services -Measuresshall be established to assure that purchased material, equipmentand services conform to the procurement documents. These measuresshould 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 itemswhose quality cannot be verified after installation.4.0 Inspection -A program for independent inspection of activitiesaffecting fire protection should be established and executed by, orfor, the organization performing the activity to verify conformanceto documented installation drawings and test procedures foraccomplishing activities. This program should include:a. Inspections of (1) installation, maintenance and modification offire protection systems; and (2) emergency lighting and communica-tion equipment to assure conformance to design and installationrequirements.b. Inspection of penetration seals and fire retardant coatinginstallations to verify the activity is satisfactorily completed.c. Inspections of cable routing to verify conformance with designrequi rements.d. Inspections to verify that appropriate requirements for roomisolation (sealing penetrations, floors, and other fire barriers)are accomplished during construction.e. Measures to assure that inspection personnel are independent fromthe individuals performing the activity being inspected and areknowledgeable in the design and installation requirements for fireprotection.f. Inspection procedures, instructions, and check lists which providefor the following:(1) Identification of characteristics and activities to beinspected(2) Identification of the individuals or groups responsible forperforming 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 ofthe inspection operationg. Periodic inspections of fire protection systems, emergency breathingand 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 firestops, seals, and fire retardant coatings to assure these itemfs havenot deteriorated or'been damaged.5.0 Test and Test Control -A test program should be established andimplemented to ensure that testing is performed and verified byinspection and audit to demonstrate conformance with design andsystem readiness requirements. The tests should be performed inaccordance with written test procedures; test results should beproperly evaluated and acted on. The test program should includethe following:a. Installation Testing -Following construction, modification, repairor replacement, sufficient testing is performed to demonstrate thatfire protection systems, emergency lighting and communication equip-ment will perform satisfactorily in service and that design criteriaare met. Written test procedures for installation tests incorporatethe requirements and acceptance limits contained in applicabledesign documents.b. Periodic testing -The schedules and methods for periodic testingare developed and documented. Fire protection equipment, emergencylighting, and communication equipment are tested periodically toassure that the equipment will properly function and continue tomeet the design criteria.c. Programs are established for QAIQC to verify'testing of fireprotection systems and to verify that test personnel are effectivelytrained.d. Test results are documented, evaluated, and their acceptabilitydetermined by a qualified responsible individual or group.6.0 Inspection, Test, and Operating Status -Measures should be establishedto provide for the identification of items that have satisfactorilypassed required tests and inspections. These measures should includeprovisions for:a. Identification by means of tags, labels, or similar temporarymarkings to indicate completion of required inspections andtests, and operating statu J .'&57.0 Nonconforming Items -Measures should be established to control itemsthat do not conform to specified requirements to prevent inadvertentuse of installation. These measures should include provisions toassure that:a. Nonconforming, inoperative, or malfunctioning fire protectionsystems, emergency lighting, and communication equipment areappropriately tagged or labelled.b. The identification, documentation, segregation, review dis-position, and notification to the affected organization ofnonconforming materials, parts, components, or services areprocedurally controlled.* c. Documentation identifies the nonconforming item, describes thenonconformance and the disposition of the nonconforming item* and includes signature approval of the disposition.d. Provisions are established identifying those individuals orgroups delegated the responsibility and authority for thedisposition 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 combus-tible material and nonconformances are promptly identified, reportedand corrected. These measures should assure:a. Procedures are established for evaluation of conditions adverseto fire protection (such as nonconformance, failures, mal-functions, deficiencies, deviations, and defective materialand equipment) to determine the necessary corrective action.b. In the case of significant or repetitive conditions adverseto fire protection, including fire incidents, the cause ofthe conditions is determined and analyzed, and prompt correctiveactions are taken to preclude recurrence. The cause of thecondition and the corrective action taken are promptly reportedto-cognizant levels of management for review and assessment.9.0 Records -Records should be prepared and maintained to furnishevidence that the criteria enumerated above are being met foractivities affecting the fire protection program. The followingprovisions should be included:a. Records are identifiable and retrievable and should demonstrateconformance to fire protection requirements. The records should 6include results of inspections, tests, reviews, and audits; non-conformance and corrective action reports; construction, maintenanceand modification records; and certified manufacturers' data.b. Record retention requirements are established.10.0 Audits -Audits should be conducted and documented to verify compliancewith the fire protection program, including design and procurementdocuments, instructions, procedures, and drawings, and inspection andtest activities. The following provisions should be included:a. Audits are periodically performed to verify compliance with theadministrative controls and implementation of quality assurancecriteria including design and procurement, instructions, proceduresand drawings and inspection and test activities. These audits areperformed by QA personnel in accordance with preestablished writtenprocedures or check lists and conducted by trained personnel nothaving direct responsibilities in the areas being audited.b. Audit results are documented and then reviewed with managementhaving 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 assessmentof conformance to fire protection requirement v ,s..-- ':-..*- .a_- v .-_. .-_ -_~. _Minimum Elements That Should Be Incorporated in -, -*. ._.X... nnual'.'nd Triennia FeProtection AuditsA. -
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 safetyconsistent with NRC guidelines continues to be provided.B. Scope Each audit should verify .that the commitments of the SAR and thatthe req.irements of the Technical Specifications and license conditionshave been met and that modifications to systems and structures or changesin 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, firedetection systems, and fire extinguishing systems provided for safety-related.Sequipment.. The auditshbuld verify: that:e c o th .a ta1. The installed fire protection systems and barriersfor the objects protected by comparing them to NRCapproved alternatives and noting any deviations.are appropriateguidelines or SER2. The fire loading in each fire area has not increased above that whichwas 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 being6. 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 teamshould 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 andrecommend appropriate fire protection measures to provide a level ofsafety consistent with NRC guidelines.