NRC Generic Letter 1977-02
| ML031280293 | |
| Person / Time | |
|---|---|
| Issue date: | 08/04/1977 |
| From: | Reid R W Office of Nuclear Reactor Regulation |
| To: | Cahill W J Consolidated Edison Co of New York |
| References | |
| GL-77-002 | |
| Download: ML031280293 (23) | |
WAugust 4, 1977Dockets Nos.: 50-350-247and 50-286DISTRIBUTION:Docket File (3NRC PDR (3)L PDR (3)RReidRIngramPEricksonTCarterTWambachAttorney, OELDOI&E (5)DEisenhutTBAbernathyJRBuchananACRS (16)Gray File (3)Consolidated Edison Companyof New York, Inc.ATTN: Mr. William 3. Cahill, Jr.Vice President4 Irving PlaceNew York, flew York 10003Gentlemen:RE: INDIAN POINT UNITS NOS. 1, 2. AND 3We are enclosing for your infonaation and use a copy of*Nuclear Plant Fire Protection Functional Responsibilities,Administrative Controls and Quality Assurance.* This document ispresently being used by the HRC as supplemental guidance for thereview of the organizational and adfvninistrative aspects of the fireprotection evaluation of your facility.By letter dated July 15, 1977, you indicated your intention todevelop no fire protection Technical Specifications for IndianPoint Unit No. I because it was shutdown and defueled. Ie, there-fore, request that you propose fire protection Technical Specifi-cations for Indian Point Unit No. 1 appropriate to Its presentshutdown defueled condition. A fire originating in Unit No. 1could have serious consequences at the operating units because oftheir close proximity to Unit No. 1.Sincerely,Robert W. Reid, ChiefOperating Reactors Branch #4Division of Operating ReactorsEnclosuresNuclear Plant Fire ProtectionFunctional Responsibilities,Administrative Controlsand Quality Assurancef1'u1Abpva~- jORB#4:DOMJORB#l ~~ >3TO*URNAMK.. Prickso m(?Wnbach~ ...--- ---*qkR OM318 (9-76) XRCMv 0240 *U:9. OVxNMUKNT rpRtip.NO OFFICEZ 1676-626424AT*j 8/i/7~J /k 781)T7_ ___________I_____.>
Consolidated Edison Companyof New York, Inc.cc: Mrs. Kay Winter, LibrarianHendrick Hudson Free Library31 Albany Post RoadMontrose, New York 10548Leonard M. Trosten, EsquireLeBoeuf, Lamb, Leiby & MacRae1757 N Street, N. W.Washington, D. C. 20036Anthony Z. RoismanBerlin Roisman &1025 lAth Street,Washington, D. C., EsquireKesslerN.W., 5th Floor20005Paul S. Shemrin, Esq.Assistant Attorney GeneralState of New YorkDepartment of LawTwo World Trade CenterNew York, New York 10047Sarah Chasis, Esq.Richard M. Hall, Esquire15 West 44th StreetNew York, New York 10036Director, Technical DevelopmentProgramsState of New York Energy OfficeAgency Building 2Empire State PlazaAlbany, New York 12223Admiral Paul EarlyPower Authority ofof New York10 Columbus CircleNew York, New York(IP-3)the State10019 I *:~ .-NUCLEAR PLANT FIRE PROTECTION FUNCTIONAL RESPONSIBILITIES, ADMINISTRATIVECONTROLS AND QUALITY ASSURANCEThe functional responsibilities, administrative controls, and qualityassurance related to nuclear power plant fire protection programs have asignificant role in preventing and fighting fires. Because these controlsrepresent a significant portion of the licensee's fire protection programand are subject to periodic reviews by NRC inspectors, it is necessary tohave a common understanding between applicant/licensees, NRC reviewers,and NRC inspectors as to what constitutes adequate delineation of respon-sibilities, administrative controls and quality assurance and how theseresponsibilities and activities should be conducted. Therefore, supple-mentary guidance on these controls is desirable.Appendix A to Branch Technical Position 9.5-1 and Regulatory Guide 1.120provide overall guidance related to functional responsibilities, admin-istrative controls, and quality assurance. The discussion in the Attach-ments provides supplemental guidance on specific functional responsibilities,administrative controls, and quality assurance necessary to assure aneffective fire protection program. The table below correlates each subjectfor which supplemental guidance is provided with the respective section(s)of Appendix A and Regulatory Guide 1.120.REGULATORYSUBJECT APPENDIX A GUIDE 1.1201. Fire Protection A.1, B, C C.1, C.2, C.3Organization2. Fire Brigade A.l(d), B.5 C.1(4), C.2eTraining3. Control of B.2, B.3(c) C.2.b, C.2.c(3)Combustibles4. Control of Ignition B.3(a) C.2.c(1)Sources5. Fire Fighting A.l(d), B.1, 4, 5 C.la(4), (5),Procedures C.2.a, d, e.6. Quality AssuranceC.C.3 I-2-This supplementary guidance is to be given to utilities and is beingdistributed to NRC fire protection program reviewers and NRC Officeof Inspection and Enforcement.The licensee should provide the description of fire protection functionalresponsibilities and administrative controls in a fire protection planwhich describes his organization and its qualifications, fire brigadetraining, the controls over combustibles and ignition sources, methodsfor assuring the availability of the fire protection systems and equip-ment; procedures for fighting fires, fire watch, and quality assuranceprovisions for the fire protection program. The plan should alsoidentify the plant procedures that implement the plan. The plan will befiled with the Nuclear Regulatory Commission and the plant proceduresshould be available to NRC Inspectors and at the plant site.
Attachment No. 1FIRE PROTECTION ORGANIZATION1.0 The organizational responsibilities and lines of communication per-taining to fire protection should be defined between the variouspositions through the use of organizational charts and functionaldescriptions of each position's responsibilities. As a minimum thepositions/organizations responsible for the following should bedesignated:a. The upper level offsite management position which has managementresponsibility for the formulation, implementation, and assess-ment of the effectiveness of the nuclear plant fire protectionprogram.b. The offsite management position(s) directly responsible for(1) formulating, implemenring, and periodically assessing theeffectiveness of the fire protection program for the licensee'snuclear power plant including fire drills and training con-ducted by the fire brigade and plant personnel. The resultsof these assessments should be reported to the upper levelmanagement position responsible for fire protection withrecommendations for improvements or corrective actions asdeemed necessary.(2) Using the following NFPA Publications for guidance to dev-elop the fire protection program:No. 4 -"Organization for Fire Services"No. 4A -'Organization of a Fire Department"No. 6 -"Industrial Fire Loss Prevention"No. 7 -"Management of Fire Emergencies"No. 8 -"Management Responsibilities for Effects ofFire on Operations"No. 27 -"Private Fire Brigades"c. The onsite management position responsible for the overalladministration of the plant operations and emergency plans whichinclude the fire protection and prevention program and whichprovides a single point of control and contact for all contingencies.
' -2d. The onsite position(s) which:(1) implements periodic inspections to: minimize the amountof combustibles in safety related areas; determine theeffectiveness of housekeeping practices; assure the avail-ability and acceptable condition of all fire protectionsystems/equipment, emergency breathing apparatus, emergencylighting, communication equipment, fire stops, penetrationseals and fire retardant coatings; and assures prompt andeffective corrective actions are taken to correct conditionsadverse to fire protection and preclude their recurrence.(2) is responsible for the fire fighting training for operatingplant personnel and the plant's fire brigade; design andselection of equipment; periodic inspection and testing offire protection systems and equipment in accordance withestablished procedures and evaluate test results and deter-mine the acceptability of the systems under test.(3) assists in the critique of all fire drills to determinehow well the training objectives have been met.(4) reviews and evaluates proposed work activities to identifypotential transient fire loads.(5) implements a program for indoctrination of all plantcontractor personnel in appropriate administrative pro-cedures which implement the fire protection program, .and the emergency procedures relative to fire protection.(6) implements a program for instruction of personnel on theproper handling of accidental events such as leaks orspills of flammable materials that are related to fireprotection.e. The onsite position responsible for fire protection qualityassurance.This position should be responsible for assuring the effectiveimplementation of the fire protection program by planned in-spections and scheduled audits. He should assure and verifythat results of these inspections or audits are promptly re-ported to cognizant management personnel.
3f. The positions which are part of the plant fire brigade(1) The plant fire brigade positions should be responsible forfighting fires. The authority and responsibility of eachfire brigade position relative to fire protection shouldbe clearly defined.(2) The responsibilities of each fire brigade position shouldcorrespond with the actions required by the fire fightingprocedures.(3) The responsibilities of the fire brigade members undernormal plant conditions, should not conflict with theirresponsibilities during a fire emergency.(4) The minimum number of trained fire brigade members avail-able onsite for each operating shift should be consistentwith the activities required to combat the most significantfire. The size of 'te fire brigade should be based uponthe functions required to fight fires with adequate allow-ance for injuries.(5) The recommendations for organization, training, and equip-ment of "PRIVATE FIRE BRIGADES" as specified in NFPANo. 27-1975, including the applicable NFPA publicationslisted in the Appendix to NFPA No. 27, are consideredappropriate criteria for organizing, training, and operatinga plant fire brigade.2.0 Qualificationsa. The position responsible for formulation and implementationof the Fire Protection Program should have, within his organ-ization, or as a consultant, a Fire Protection Engineer who is agraduate of an engineering curriculum of accepted standing and whoshall have completed not-less than six years of engineeringattainment indicative of growth in engineering competency andachievement, three of which shall have been in responsiblecharge of fire protection engineering work. These requirementsare the eligibility requirements as a Member in the Societyof Fire Protection Engineers.
4b. The fire brigade members qualifications should include satis-factory completion of a physical examination for performingstrenuous activity, and of the fire brigade traininadescribed inAttachment No. 2.c. The personnel responsible for the maintenance and testing of theFire Protection Systems should be qualified by training andexperience for such work.d. The personnel responsible for the training of the fire brigadeshould be qualified by training and experience for such work.
ALs.'hment No. 2FIRE BRIGADi TRAININGThe training program should assure that the capability to fight potentialfires is established and maintained. The program should consist of aninitial classroom instruction program followed by periodic classroomretraining , practice in fire fighting and fire drills:1.0 Classroom Instructiona. The initial classroom instruction should include:(1) Identification of the fire hazards and associated typesof fires that could occur in the plant, and an identi-fication of the location of such hazards.(2) Identification of the location of fire fighting equip-ment for each fire area, and familiarization with layoutof the plant including access and egress routes to-eacharea.(3) The proper use of available fire fighting equipment, andthe correct method of fighting each type of fire. Thetypes of fires covered should include electrical fires,fires in cables and cable trays, hydrogen fires, flam-mable liquid, waste/debris fires, and record file fires.(4) Indoctrination of the plant fire fighting plan withspecific coverage of each individual's responsibilities.(5) The proper use of communication, lighting, ventilationand emergency breathing equipment.(6) The direction and coordination of the fire fightingactivities (fire brigade leaders only).(7) The toxic characteristics of expected products ofcombustion.(8) The proper method for fighting fires inside buildingsand tunnels.(9) Detailed review of fire fighting procedures and procedurechanges.(10) Review of latest plant modifications and changes in firefighting plans.
- 2b. The instruction should be provided by qualified individualsknowledgeable, experienced, and suitably trained in fightingthe types of fires that could occur in the plant and in usingthe types of equipment available in the nuclear power plant.Members of the "Fire Protection Staff" and Fire Brigade Leadersmay conduct this training.c. Instruction should be provided to all fire brigade membersand fire brigade leaders.d. Regular planned meetings held every 3 months should repeatthe classroom instruction program over a two year period.2.0 PracticePractice sessions should be held for fire brigade members on theproper method of fighting various types of fires of similar mag-nitude, complexity, and difficulty as those which could occur ina nuclear power plant. These session
- should provide brigade memberswith experience in actual fire extinguishment and the use of em-ergency breathing apparatus under strenuous conditions. Thesepractice sessions should be provided at regular intervals but notto exceed 1 year for each fire brigade member.3.0 Drills that thefire brigade drills should be performed in tne Plait%. -- .fire brigade can practice as a team. Drills should include thefollowing:a. Assessment of fire alarm effectiveness, time required to notifyand assembly fire brigade, and selection, placement and use ofequipment.b. Assess each brigade member's knowledge of his role in the firefighting strategy for the area assumed to contain the fire.Assess the brigade members conformance with established plantfire fighting procedures and use of fire fighting equipment,including self-contained emergency breathing apparatus, communi-cation equipment, and ventilation equipment, to the extentpracticable.
3c. The simulated use of fire fighting equipment required to copewith the situation and type of fire selected for the drill.The area and type of fire chosen for the drill should be variedsuch that brigade members are trained in fighting fires in allsafety related areas containing significant fire hazards. Thesituation selected should simulate the size and arrangementof a fire which could reasonably occur in the area selected,allowing for fire development due to the time required to re-spond, to obtain equipment, and organize for the fire, assumingloss of automatic suppression capability.d. Assessment of brigade leader's direction of the fire fightingeffort, as to thoroughness, accuracy, and effectiveness.e. The drills should be performed at regular intervals but notto exceed 3 months for each fire brigade. At least one drillper year should be performed on a "back shift" for each firebrigade. A sufficient number of these drills, not less than onefor each fire brigade per year, shall be unannounced, to de-termine the fire readiness of the plant fire brigade leader,brigade, fire protection systems and equipment.f. The drills should be pre-planned to establish the trainingobjectives of the drill. The drills should be critiqued todetermine how well the training objectives have been met.Unannounced drills should have their critiques performed bymembers of the management staff responsible for plant safetyand security. At three year intervals, drills should be critiquedby qualified individuals independent of the utility's staff.4.0 Records, Records of training provided to each fire brigade member includingdrill critiques should be maintained to assure that each memberreceives training in all parts of the training program. Theserecords of training should be available for review.
" Attachment No. 3CONTROL OF CU;IBUSTIBLESAdministrative controls should be established to minimize the amount ofcombustibles that a safety related area may be exposed to. These con-trols should be established to govern:a. the handling of and limitation on the use of combustibles,flammable and explosive hazards such as flammable gases andliquids, HEPA and charcoal filters, dry unused ion exchangeresins or other combustible supplies in safety related areas,and to assure that these items are not stored in safety relatedareas.b. the transient fire loads during maintenance and modificationssuch as combustible and flammable liquids, wood and plasticproducts, spilled oil, oil drums, and other combustible mater-ials in buildings containing safety related systems or equip-ment. This control should require an in-plant review of pro-posed work activities to identify potential transient fireloads. The onsite staff member designated the responsibilityfor reviewing work activities for potential transient fireloads should specify the required additional fire protectionin the work activity procedure.When the transient fire load causes the total fire load toexceed the capabilities of existing suppression systems andequipment, additional portable suppression equipment shouldbe brought into the area.c. the removal of all waste, debris, scrap, rags, oil spills, orother combustibles resulting from the work activity, in thearea following completion of the activity, or at the end ofeach work shift, whichever is sooner.d. periodic inspection for accumulation of combustibles.e. all wood used in safety related areas to assure that itis treated with flame retardant.
Attachment No. 4CONTROL OF IGNITION SOURCES1.0 Administrative ControlsAdministrative controls should be instituted to protect safety-related equipment.from fire damage or loss resulting from workinvolving ignition sources, such as welding, cutting, grinding, oropen flame work; administrative controls should prohibit the use ofopen flame or combustion smoke for leak testing and controlsshould prohibit smoking and other ignition sources in certainareas.2.0 Control of Weldina, Cutting, Grinding, and Open Flame Worka. Al' cutting, welding, grinding or open-flame work shouldoe authorized by the responsible foreman or supervisorthrough a work pernmiL. The responsible foreman or supervisorshould have received a basic industrial fire fighting and fireprevention course covering anticipated fires, such as elec-trical fires, fires in cables and cable trays, hydrogen fires,hydrocarbon fires, solvent fires, waste/debris fires, and re-cord file fires.b. Before issuing the permit, the responsible foreman or super-visor should physically survey the area where the work is tobe performed and establish that the following precautions havebeen accomplished:(1) All moveable combustible material below and within a 35foot radius of the cutting, welding, grinding, or openflame work has been removed. (See NFPA 518)(2) All immovable combustible material below and within a 35foot radius has been thoroughly protected by asbestoscurtains, metal guards, or flameproof covers, and fireextinguishers, hose, or other firefighting equipment areprovided at the work site. (See NFPA 518)(3) A fire watch trained and equipped to prevent and combatfires is present throughout any operations in which thereis potential for fire Jtat mign t ge mfiff safety.related equipment. A ire watcn s ou be proided wherecutting, welding, grinding or open flame is performedabove or within a radius of 35 feet of any open cables,flammable liquids, scaffold boards, paper, rags, orother objects on the same elevation of the work or ifcombustible materials are below the work area whereopenings exist. A fire watch should be provided for all
"-I2cutting, welding, grinding, and open flame work in theControl Room, Cable Spreading Room, Diesel GeneratorRooms, and other safety related areas that contain sig-nificant amount of cable or flammable liquids. (SeeNFPA 51B)The fire watch sould remain on the work site while workis performed and remain in the area for at least 30 min-utes after the work is completed to check for smolderingfires.(4) All equipment to be used is in a safe, working condition.Oxyacetylene equipment is checked for leaks before beingmoved to the work area.c. The signature concurrence of a member of the plant's managementor a quality control inspector certified to make this concurrenceshould be obtained whenever the supervisor or foreman determinesthat a fire watch is not required.3.0 Leak TestingAdministrative procedures should be established to prohibit the useof open flame or combustion smoke for leak testing. Work ordersfor leak testing should require the concurrence of the shift engineerto verify that the leak test method is acceptable and would notpresent a potential ignition source.4.0 Smoking and Ignition Source RestrictionSmoking should be prohibited in safety related areas, except where"smoking permitted" areas have been specifically designated by aresponsible member of plant management and in areas containing flammableor potentially explosive materials or atmospheres that present ahazard to safety related equipment. These areas should be identi-fied with "No Smoking" signs.
.Attachment No. 5FIRE FIGHTING PROCEDURESfire fighting procedures should be established to cover such items asnotification of a fire, fire emergency procedures, and coordination offire fighting activities with Ofprocedureidentify_ing pa. Actions to be taken by individual discovering the fire, suchas, notification of control room, attempt to extinguish fire,and actuation of local fire suppression systems.b. Actions to be taken by the control room operator and the needfor brigade assistance upon report of a fire or receipt ofalarm on control room annunciator panel, such as: announcinglocation of fire over PA system, sounding fire alarms andnotifying the shift supervisor and the fire brigade leader ofthe type, size, and location of the fire.c. Actions to be taken by the fire brigade after notification bythe control room operator of a fire, including: location toassemble; directions given by fire brigade leader; and responsi-bilities of brigade members such as selection of fire fightingequipment and transportation to fire location, selection ofprotective equipment, use of fire suppression systems operatinginstructions, and use of preplanned strategies for fightingfires in specific areas.d. The strategies established for fighting fires in all safety-related areas and areas presenting a hazard to safety-relatedequipment. As a minimum the following subjects should becovered:(1) Identification of combustibles in each plant zone coveredby the specific fire fighting procedures.(2) Fire extinguishants best suited for controlling the firesassociated with the combustible loadings in that zone andthe nearest location of these extinguishants.(3) Most favorable direction from which to attack a fire ineach area, in view of the ventilation direction, accesshallways, stairs and doors which are most likely to befire-free, and the best station or elevation for fightingthe fire. A specific identification system shall designateall hallways, stairs, doors, fire equipment and systemcontrol locations, and other items described in the firefighting procedures. This identification should be used
2in the procedures and the corresponding plant items shouldbe prominently marked so that they can be recognized indim light. All access and egress routes that involvelocked doors should be specifically identified in theprocedure with the appropriate precautions and methodsfor access specified.(4) Designation of plant systems that should be managed toreduce the damage potential during a local fire; locationof local and remote-controls for such management (e.g.,any hydraulic or electrical systems in the zone coveredby the specific fire fighting procedure that couldincrease the hazards in the area because of overpres-surization or electrical hazards).(5) Designation of vital heat-sensitive system componentsthat should be kept cool while fighting a local fire.Critical equipment which are particularly hazardouscombustible sources should be designated to receivecooling.(6) Organization of fire fighting brigades and the assignmentof special duties according to job title so that all firefighting functions are covered by any complete shift per-sonnel complement. These duties should include commandcontrol of the brigade, fire hose laying, applying theextinguishant to the fire, advancing support supplies tothe fire scene, communication with the control room,coordination with outside fire departments.(7) Identification radiological and toxic hazards in firezones.(8) Ventilation system operation that assures desired plantpressure distribution when the ventilation flow ismodified for fire containment or smoke clearing operations.(9) Operations requiring control room and shift engineercoordination or authorization.(10) Instructions for plant operators and general plant per-sonnel during fire.e. The validity of the preplanning strategies should be tested byappropriate full-dress drills to check the logic of thestrategy, the adequacy of the equipment, personnel under-standing, and to uncover unforeseen problems.
If. Actions to be taken by Plant Superintendent and his staff, andSecurity Guards after notification of a fire.g. Actions to be taken that will coordinate fire fighting activitieswith offsite fire departments, including: identification ofindividual responsible for assessing situation and calling inoutside fire department assistance when needed; identificationof individual who will direct fire fighting activities whenaided by offsite fire fighting assistance; provisions forincluding offsite fire fighting organizations in fire brigadedrills at least once per year; and provisions for trainingoffsite fire department personnel in basic radiation principles,typical radiation hazards, and precautions to be taken in afire involving radioactive materials in the plant. The pro-cedures should also describe the offsite fire department'sresources and estimated response time by the offsite firedepartment to provide assistance to the station.
Attachment No. 6QUALITY 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, arndaudits. Performance of other QA program functions for meeting the fireprotection program requirements may be performed by personnel outside ofthe 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 Regulatdry 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 commitmentis 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 on 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 originaldocument.
2b. 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, ,nd 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, inspec-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 review.I~iVF
3d. 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 conformances.o 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 designrequirements.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
4(4) A description of the method of inspection(5) Recording evidence of completing and verifying a manu-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.i Periodic inspection of materials subject to degradation such as firestops, seals, and fire retardant coatings to assure these items 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 byinspectioa 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 QA/QC 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 gro4p.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 status.
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 itemand 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 leveis 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.lo.0Audits -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 thedeficiencies revealed by the audit.d. Audits are annually performed to provide an overall assessmentof conformance to fire protection requirements.