**NRC INSPECTION MANUAL** NMSS/RII

INSPECTION PROCEDURE 88054

FIRE PROTECTION (TRIENNIAL)

PROGRAM APPLICABILITY: 2600

88054‑01 OBJECTIVE(S) (OR POLICY)

01.01 The objectives of this procedure are to evaluate the licensee or
certificate holder=s fire protection capability from a programmatic
design-based and risk-informed perspective to determine whether the
following meet license or certificate requirements and are adequate to
preclude or mitigate the consequences of a fire.

a\. Program for control of combustibles and ignition sources within the
plant;

b\. Program to ensure adequate fire detection and suppression
capability;

c\. Program to ensure that the material condition, design, and
qualification testing of passive fire protection features is adequate;

d\. Program to ensure that compensatory measures will be in place for
out-of-service, degraded or inoperable fire protection equipment,
systems or features;

e\. Program to ensure that feasible and reliable emergency operating
actions will be taken if required to mitigate the adverse affects of a
fire.

f\. Program to assure that maintenance and facility changes continue to
meet applicable codes and standards and license or certificate basis.

Inspection Procedure 88055, "Fire Protection (Annual)" complements the
triennial inspection by focusing on the design basis and operational
status of the fire protection program specifically in the areas of
active fire detection/suppression systems and passive fire confinement
features including the adequacy of their design, maintenance, and
operational performance. However, the inspector should consider the need
for additional evaluations in these areas based on previous inspections
and potential issues.

88054‑02 INSPECTION REQUIREMENTS

02.01 [Inspection Preparation.]{.underline} Fire protection requirements
for licensees vary greatly because of the significant differences in
operations, structures, and process materials at regulated facilities.
As a result, the inspector should, as part of inspection preparation,
review fire protection program documentation specific for the licensee
or certificate holder to be inspected. This review should include a
review of changes to the program since the last inspection. Specific
requirements are documented in the regulations, the license or
certificate, the Safety Analysis Report (SAR), the Integrated Safety
Analysis (ISA), and licensee or certificate holder policies and
procedures.

Select approximately three risk-significant fire areas containing safety
controls and items relied on for safety (IROFS) (for Part 70 licensees)
(not necessarily limited to the top few contributors to overall plant
fire risk) and conduct a risk-informed inspection of selected aspects of
the licensee=s fire protection program. The number of fire areas
inspected can be adjusted during the course of the inspection based on
the complexity of developing issues being inspected.

For each area, the selection process will consider but will not be
limited to the following from the ISA Summary or other documentation.
The review should focus on the programmatic aspects of the selected
areas:

a\. Review the Hazard and Operability (HAZOP) analysis or other analyses
for systems hardware and procedures as appropriate to determine which
safety controls are assumed to be capable and reliable based on the fire
protection associated with the controls.

b\. Potential ignition sources that could affect these controls.

c\. Configuration and characteristics of combustible materials in the
areas.

d\. Routing of circuits important to assure availability of safety
controls.

e\. Licensee=s or certificate holder=s fire protection and fire fighting
capability.

02.02 [Inspection Activities]{.underline}. The inspection is designed to
verify that the programs required to assure the availability and
reliability of fire protection features protecting safety controls are
adequate. The inspection should also verify that the licensee=s
engineering and licensing documents (e.g., license amendments, ISA,
exemptions, deviations) continue to support the selection of the fire
protection systems and equipment. The verification of fixed passive fire
confinement features and active fire protection systems including
installation, design, testing, and adequacy to control and/or suppress
fires associated with the hazards of each selected area will be done
against the code of record. Specific inspection requirements include:

a\. [Fire Hazard Analysis]{.underline}. Review changes in the facility
fire hazard analysis (if required by license condition) made since the
previous triennial fire protection inspection and determine if
appropriate changes have been made to the ISA and safety controls as a
result.

b\. [Pre-Fire Plans]{.underline}. Review changes in the facility
pre-fire plans for the selected areas (if required by license condition)
made since the previous triennial fire protection inspection and
determine if the changes are consistent with the fire hazard analysis.

c\. [Control of Transient Combustibles and Ignition
Sources]{.underline}. Determine whether programs and procedures remain
in place and are adequate to:

> 1\. Control transient combustible materials in accordance with the
> licensee=s or certificate holder=s procedures.
>
> 2\. Conduct hot work, welding, or cutting in accordance with the
> licensee=s or certificate holder=s procedures.
>
> 3\. Ensure that the facility work planning organization has an
> adequate familiarity of locations where changes in plant conditions
> have occurred in areas that require fire protection compensatory
> measures (e.g. for inoperability of fire detection or suppression
> systems) to allow adjustments in work planning to minimize the
> introduction of combustibles or ignition sources (that could increase
> the likelihood of a fire or increase fire severity) into those plant
> areas where degraded fire protection features system exist.
>
> 4\. Ensure that the work planning organization work control process
> accepts responsibility for storage and handling of pre‑staged work
> materials when issued, including flammable and hazardous materials
> that are included in the pre‑stage request.
>
> 5\. Ensure that the licensee maintains a process in place to assure
> that designated flammable/combustible liquid storage areas and floor
> drain systems (in selected plant areas in or adjacent to the areas
> selected for inspection) would not affect plant safety controls and
> IROFS process functions in the case of a fire in those areas.

d\. [Passive Fire Protection]{.underline}. Determine whether programs
and procedures remain in place and are adequate to:

> 1\. Assure that the fire ratings of fire area boundaries and equipment
> fire barriers are appropriate for the credible fire hazards in the
> area.
>
> 2\. Assure that material of an appropriate fire rating (equal to the
> overall rating of the barrier itself) has been used to fill openings
> and penetrations and that the installation meets engineering design.
>
> 3\. Assure whether material of an appropriate fire rating has been
> used as fire protection wraps and that the installation meets
> engineering design.
>
> 4\. Assure that fire test data are appropriate for unusual
> installation configurations and/or application of unusual materials.

e\. [Active Fire Protection]{.underline}. Assure that programs and
procedures remain in place and are adequate to:

> 1\. Ensure that the material condition, operational lineup,
> operational effectiveness, design for fire detection systems, fire
> water supply and distribution system, fire suppression system, manual
> fire fighting equipment, and fire brigade capabilities meet the code
> of record and/or the criteria of the ISA.
>
> 2\. Ensure that automatic and manual detection and suppression systems
> are installed, tested, and maintained in accordance with the code of
> record.
>
> 3\. Ensure that the design capability of gaseous suppression agent
> delivery systems meet the requirements of the fire hazards and code of
> record.

f\. [Protection From Damage From Fire Suppression
Activities]{.underline}. Assure that the licensee/certificate holder
maintains programs and procedures adequate to:

> 1\. Determine whether safety controls which are located in the same
> fire area are subject to damage from fire suppression activities or
> from the rupture or inadvertent operation of fire suppression systems.
>
> 2\. Determine if a fire in a single location could, indirectly,
> through the production of smoke, heat, or hot gases, cause activation
> of automatic fire suppression which could potentially damage other
> safety controls (e.g., sprinkler-caused flooding of other controls).
>
> 3\. Determine if adequate drainage and environmental protection is
> provided in areas protected by water suppression systems.

g\. [Undesired Consequences]{.underline}. Assure that the
licensee/certificate holder maintains programs and procedures adequate
to:

> 1\. Determine whether fire suppression agents (water or gaseous based)
> could impact nuclear criticality safety controls and whether controls
> to prohibit such impacts meet requirements and are adequate.
>
> 2\. Determine whether the potential consequence(s) of cable failures,
> as a result of the fire suppression activities, has been adequately
> considered for safety controls in the area including instrumentation
> and control cabling.

h\. [Environmental Issues and Water Based Suppression
Systems]{.underline}. Assure that the licensee/certificate holder
maintains programs and procedures adequate to:

> 1\. Preclude release of any hazardous effluents as a result of fire
> fighting efforts.

02.03 [Communications]{.underline}. Determine that the
licensee/certificate holder maintains programs and procedures adequate
to:

a\. Assure that portable radio communications and/or fixed emergency
communications systems are available, operable, adequate, and reliable
for their required performance in fire response activities.

b\. Assure that communication equipment such as repeaters, transmitters
etc. would not be affected by a credible fire in the selected areas.

02.04 [Emergency Lighting]{.underline}. Assure that the
licensee/certificate holder maintains programs and procedures adequate
to assure that emergency lighting would be available and operable when
needed by:

a\. Determining whether the power distribution system contains
protective devices so that a fire in the area will not cause loss of
emergency lighting in any unaffected area needing lighting.

b\. Determining whether battery power supplies are rated with the hour
capacity required by the code of record.

c\. Determining whether the operability testing and maintenance of the
lighting units follow licensee procedures and manufactures
recommendations.

d\. Determining whether sufficient illumination is provided to permit
access to and operation or verification of components for safety
controls.

e\. Determining whether emergency lighting unit batteries are being
maintained consistent with the manufacturer's recommendations.

02.05 [Fire Brigade Training and Offsite Fire Support
Orientation]{.underline}. Assure that the licensee/certificate holder
maintains programs and procedures adequate to maintain fire response
capabilities by:

a\. Determining whether the fire brigade qualifications and training
(including drills) meets the requirements of the license or certificate
and procedures.

b\. Determining whether offsite fire support organizations are offered
the opportunity for site orientation and if they have received such
orientation.

02.06 [Identification and Resolution of Problems]{.underline}. Assure
that the licensee/certificate holder maintains programs and procedures
adequate to maintain fire response capabilities by:

a\. Determining whether the licensee or certificate holder is
identifying safety control or IROFS fire protection problems at an
appropriate threshold and entering them into the corrective action
program.

b\. Determining, for selected licensee or certificate holder identified
items, whether effective corrective actions have been taken.

88054‑03 INSPECTION GUIDANCE

03.01 [Inspection Preparation]{.underline}. The inspector should review
the license, license condition(s), license application, or technical
safety requirements (TSRs) specific for fire protection at the licensee
or certificate holder to be inspected. In addition, the inspector should
review the parts of the ISA Summary applicable to fire safety as well as
the associated Fire Hazard Analysis (FHA). In preparing for the
inspection, the inspector should also discuss with the project inspector
and resident inspection staff, where applicable, any programmatic fire
protection equipment availability or reliability problems (such as
recurring failures or failures resulting in reportable events) the
licensee or certificate holder has experienced since the last annual
inspection.

The licensee or certificate holder should have a well developed and
documented fire protection program. The program should describe, as a
minimum, the following elements:

a\. Identification of the management person who is given the authority
to implement the program. Identification of a supervisory person
responsible for day to day implementation of the program.

b\. FHA and periodic reviews.

c\. Program for identification and resolutions of problems identified by
the FHA, periodic audit, and inspections.

d\. Fire protection equipment maintenance and testing program. Fire
protection equipment includes passive controls and automatic/manual
suppression systems.

e\. Program to control combustible/flammable materials and hot work
activities (i.e. welding, cutting, and grinding). Typically permits are
issued and a fire watch is maintained during such work.

f\. Fire brigade training program. Details, such as training subjects,
frequency of training classes and drills, and qualification standards.

03.02 [Inspection Activities]{.underline}.

a\. [Fire Hazard Analysis]{.underline}. The selections of changes to be
reviewed should be based on the risk‑significance of the modifications.
Consideration should be given to modifications which impact IROFS, as
well as systems not part of the ISA, but important to safety. The number
of modifications to be reviewed should be based on the number and
significance of modifications made by the licensee or certificate holder
since the last triennial inspection.

The purpose of the FHA is to assess the risk from fire within individual
fire areas in the facility. In the consideration of credible fire
scenarios, FHAs should include an evaluation (prediction) of all direct
and indirect effects of potential fires.

> The evaluation should consider:

1.  The effects of a fire on the structures, systems, and components
    (especially sensitive safety controls and IROFS components) within
    the fire area through thermal damage caused by direct flame
    impingement, indirect or secondary lower level thermal exposures,
    smoke, the interaction between smoke and moisture; and corrosive
    compounds generated during a fire.

    2\. During fire suppression activities ( i.e. sprinkler systems and
    hose streams), the analysis should be particularly cognizant of high
    humidity, water sprays, and flooding during suppression activities;
    and, to extremely low temperatures, high thermal gradients, high
    room pressures, and high static charge levels when gaseous flooding
    suppression systems are involved.

    3\. Malfunction of an automatic fire protection system (i.e.
    suppression system). If redundant systems are available in the area,
    only the system that causes the most vulnerable condition should be
    assumed to fail.

    4\. The effect of fire spread and the potential for spread of
    contamination or smoke through the facility ventilation system and
    malfunctioning passive fire system (i.e. dampers and doors).

    5\. The presence of transient combustible and flammable materials
    that could be present in the area associated with storage and
    maintenance activities.

    6\. Outside fire department and onsite fire brigade response
    including response time and resources.

    7\. Life safety considerations (i.e. personal evacuation and egress
    capability).

    b\. [Pre-Fire Plan]{.underline}. Sometimes the Pre-Fire plan is part
    of the general radiological emergency plan required by the license
    or certificate. However, the Pre-Fire plan is different from a
    Radiological Contingency Plan in that it requires information needed
    by fire-fighting personnel responding to an emergency. Often, the
    same team of employees is trained to respond to both fires and
    radiological emergencies. This is acceptable since a fire emergency
    may turn out to be a radiological emergency as well.

    The inspector should determine that the Pre‑Fire plans continue to
    include these elements:

    1\. The most favorable direction to attack a fire in each area, in
    view of the ventilation direction, access to hallways, stairs and
    doors which are most likely to be fire‑free, and the best station or
    elevation for fighting the fire.

    2\. Designation of plant systems that should have plans in place to
    reduce the damage potential from a local fire which could affect a
    greater area (e.g., any hydraulic or electrical systems in the area
    covered by the specific fire fighting procedure that could increase
    the hazards in the area because of over pressurization or electrical
    hazards).

    3\. Designation of vital heat‑sensitive \[safety controls and
    IROFS\] system components that should be kept cool while fighting a
    local fire. Critical equipment which contains particularly hazardous
    combustible material should be designated to receive cooling.

    4\. Identification of radiological and toxic hazards in fire zones.

    5\. Ventilation system operation that assures desired plant pressure
    distribution when the ventilation flow is modified for fire
    containment or smoke clearing operations.

    6\. Indication of the areas of concentration of combustibles,
    storage of flammable or combustibles liquids, and areas where the
    use of water for fire suppression is restricted due to criticality
    safety concerns.

    7\. Description of the offsite fire department\'s resources and
    estimated response time by the offsite fire department to provide
    assistance to the facility.

    8\. Identification of, preferably with the help of site plans and
    drawings, the location of fire fighting equipment such as portable
    extinguishers, automatic fire suppression systems, stand-pipes,
    hydrants, hoses, and manual pull stations for the fire alarm. In
    addition, passive features like fire walls and fire doors should be
    clearly indicated.

    9 Identification of evacuation routes and emergency lighting should
    be clearly identified.

    10\. Identification of fire suppression system and flammable gas
    isolation valves.

    c\. [Control of Transient Combustibles/Flammable Materials and
    Ignition Sources]{.underline}. During facilities tours and
    walkdowns, the inspector should assess whether or not
    combustible/flammable materials are controlled in accordance with
    the licensee=s or certificate holder=s procedures.

    Licensee=s or certificate holder=s procedures, as a minimum, should
    include:

    1\. Controls related to the quantity and handling of combustibles in
    and around the facility so that the potential for a significant,
    damaging fire is minimized.

    2\. Requirements that storage of combustible materials should not be
    allowed in locations where accumulation of combustible materials
    could occur, i.e. above suspended ceilings or below raised floors,
    under glove boxes or other process equipment, under stairs and/or in
    stairwells.

    3\. Requirements for handling of waste, scrap, rags, trash, and
    other combustible material resulting from work activity. These
    materials shall be disposed of in approved waste receptacles, or
    removed from the building at least once per day at the end of the
    work shift.

    4\. Controls for storage of materials susceptible to spontaneous
    ignition, such as oily rags. In addition, metals such as uranium and
    zirconium, are known to be combustible, especially when divided in a
    finely form.

    5\. Requirements that prevent the storage of unnecessary combustible
    materials near ducts and HEPA filters in housings/ducts of filter
    rooms that are in service.

    6\. Requirements to prevent accumulation of combustible materials in
    mechanical rooms, electrical rooms, or process areas.

    7\. Requirements to prevent blockage of access to active fire
    protection equipment and emergency exit paths from facilities.

    8\. Controls on the use of non‑combustible containers for storage of
    combustible trash.

    9\. Provisions to clean spills of flammable or combustible liquids.

    In addition, the program should require routine housekeeping and
    control of combustible materials inspections. The inspections should
    consist of a walkdown of the facility to identify all unnecessary
    combustible materials. Material identified during the inspection
    should be documented.

    d\. [Storage and Handling of Flammable and Combustible Liquids and
    Gases]{.underline}. The construction, installation, operation, and
    maintenance of combustible liquid storage and the related loading
    and dispensing systems should comply with National Fire Protection
    Agency (NFPA) 30, Flammable and Combustible Liquids Code. The
    construction, installation, operation, and maintenance of bulk gas
    (including liquefied gas) storage and the related loading and
    dispensing systems should comply with good industry practice and the
    relevant NFPA standards, as applicable, for example, NFPA 50, Bulk
    Oxygen Systems at Consumer Sites; NFPA 50B, Liquefied Hydrogen
    Systems at Consumer Sites; and NFPA 54, National Fuel Gas Code.

    Licensee=s or certificate holder=s procedures, as a minimum, should
    address:

    1\. The use of approved containers and tanks (NFPA 30) to store and
    handle flammable and combustible liquids.

    2\. Requirements to ensure that connections on drums and combustible
    liquid and gas piping are not leaking.

    3\. Proper storage practice to minimize the risk of fire, including
    spontaneous combustion.

    4\. Storage of flammable liquids in closed containers when not in
    use.

    5\. Grounding of bulk drums of flammable liquids during dispensing.

    6\. Use of fire-resistant barriers to separate fuel gas cylinders
    and oxygen cylinders while in storage.

    7\. Ventilation of storage tanks to prevent the development of
    excessive vacuum or pressure as a result of filling, emptying or
    atmosphere temperature changes.

    8\. Installation of combustible gas analyzers for enclosed spaces in
    which flammable mixtures of combustible gas could accumulate outside
    of the storage vessels, piping, and utilization equipment. The
    analyzer shall be set to alarm at a concentration no higher than 25
    percent of the lower explosive limit.

    9\. Installation of combustible gas analyzers for enclosed spaces in
    which flammable mixtures of vapors have the potential to accumulate
    outside of the storage vessels, piping, and utilization equipment.
    The analyzer shall be set to alarm at a concentration no higher than
    25 percent of the lower explosive limit.

    10\. Use of fire-resistant hydraulic fluid in presses or other
    hydraulic equipment.

    11\. Systems that do not allow uncontrolled release of vapors when
    flammable or combustible solvent are used.

    12 Operations involving metals, such as uranium and zirconium, to
    prevent combustible dust cloud formation and combustible scrap and
    swarf accumulation. Examples of these type of operations involve
    sawing, grinding, machining, and abrasive cutting.

    13\. Stationary Combustion Engines (i.e. emergency diesel
    generators) if located in part of a structure housing fuel
    process(es), the engine should be in an enclosure having a fire
    resistance of at least 1 hour. Fuel storage tanks, except for day
    tanks, should be located outside the room.

    e\. [Ignition Sources]{.underline}. The inspector should verify
    implementation and adequacy of the hot work program by observing any
    welding, grinding, brazing, or flame cutting being performed in any
    of the process areas. The licensee=s or certificate holder=s hot
    work program, as a minimum, should address the following precautions
    during hot work:

    1\. Hot work must not be permitted in flammable (explosive)
    atmospheres; near large quantities of exposed, readily ignitable
    materials; in areas not authorized by management; or on metal
    partitions, walls, or roofs with a combustible covering or with
    combustible sandwich-type panel construction.

    2\. Floor must be free of combustibles, such as wood shaving. If the
    floor is of combustible material, it must be kept wet or otherwise
    protected.

    3\. If combustibles are closer than 35 feet to the welding or
    cutting process and the work cannot be moved or the combustibles
    relocated at least 35 feet away, they must be protected with
    flame-resistant covers or metal guards or curtains. This also
    applies to walls, partitions, ceilings, or roofs of combustible
    construction.

    4\. Openings in walls, floors, or ducts must be covered if within 35
    feet of the work. Be alert for cutting conditions that could propel
    sparks overhead or downward, where combustibles are within a 35 foot
    sphere of the point of operation.

    5\. Cutting or welding on pipes or other metal in contact with
    combustible walls, partitions, ceilings, or roofs must not be
    performed if close enough to cause ignition by heat conduction.

    6\. Charged and operable fire extinguishers must be readily
    available. Trained fire watchers must be posted. In general, the
    posted fire watchers should not be engaged in any other activities
    and should remain posted for at least 30 minutes after the hot work
    is complete.

    f\. [Passive Fire Protection]{.underline}. The inspector should walk
    down passive fire protection features to determine whether
    inspection, testing, and maintenance (ITM) procedures and programs
    remain in place to ensure adequate performance of passive fire
    protection features.

    1\. [Fire Doors]{.underline}.

> \(a\) Fire door assemblies shall be inspected and tested not less than
> annually.
>
> \(b\) No open holes or breaks should exist in surfaces of either the
> door or frame.
>
> \(c\) Glazing, vision light frames, and glazing beads should be intact
> and securely fastened in place, if so equipped.
>
> \(d\) The door, frame, hinges, hardware, and noncombustible threshold
> should be secured, aligned, and in working order with no visible signs
> of damage.
>
> \(e\) Door clearances at the door edge to the frame, on the pull side
> of the door, should not exceed clearances listed in NFPA 80.
>
> \(f\) The self‑closing device is operational, that is, the active door
> completely closes when operated from the full open position.
>
> \(g\) If a coordinator is installed, the inactive leaf should closed
> before active leaf.
>
> \(h\) Latching hardware operates and secures the door when it is in
> the closed position \[Generally for the metal doors encountered during
> inspections, a 3 hour door needs a 5/8 inch latch throw, and a 1 hour
> door needs 12 inches. (Refer to NFPA 80 if an issue arises)\].
>
> \(i\) Slats, endlocks, bottom bar, guide assembly, curtain entry hood,
> and flame baffle should be correctly installed and intact.
>
> \(j\) Drop release arms and weights should not be blocked or wedged.
>
> \(k\) Fusible links, if equipped, are in the proper location; chain/
> cable, s‑hooks, eyes, and so forth, are in good condition (i.e., no
> kinked or pinched cable, no twisted or inflexible chain); and links
> are not painted or coated with dust or grease.
>
> \(l\) Inspection shall include an operational test for automatic
> closing doors to verify that the assembly will close under fire
> conditions. Assembly shall be reset after a successful test.
>
> \(m\) Door openings and the surrounding areas shall be kept clear of
> anything that could obstruct or interfere with the free operation of
> the door. In addition, blocking or wedging of doors in the open
> position shall be prohibited.
>
> \(n\) Doors normally held in the open position and equipped with
> automatic‑closing devices shall be operated at frequent intervals to
> ensure operation.

2\. [Fire Dampers]{.underline}.

\(a\) Dampers should be tested and inspected one year after
installation. The test and inspection frequency should then be every
four years.

\(b\) Full unobstructed access to the fire or combination fire/ smoke
damper should be verified and corrected as required.

\(c\) If the damper is equipped with a fusible link, the link should be
removed for testing to ensure full closure and lock‑in place if so
equipped. The fusible link shall be reinstalled after testing is
complete. If the link is damaged or painted, it should be replaced with
a link of the same size, temperature, and load rating.

\(d\) The operational test of the damper should verify that there is no
damper interference due to rusted, bent, misaligned, or damaged frame or
blades, or defective hinges or other moving parts. The damper frame
should not be penetrated by any foreign objects that would affect fire
damper operations.

\(e\) The damper should not be blocked from closure in any way.

3\. [Fire Walls, Ceilings, and Floor Barriers]{.underline}. All
through‑penetration protection systems should be tested and rated in
accordance with ASTM E 814, AStandard Test Method for Fire Tests of
Through‑Penetration Fire Stops@, or ANSI/UL 1479, "Fire Test of Through
Penetration Fire Stops."

During walkdown of fire walls, the inspector should verify that the
aggregate width of openings in each floor level does not exceed 25
percent of the wall length. The inspector should review installation or
repair records to determine whether or not material of an appropriate
fire rating (equal to the overall rating of the barrier itself) has been
used to fill openings and penetrations and that the installation meets
the fire hazard analysis and/or qualification test specifications.

g\. [Active Fire Protection]{.underline}. The inspector should walk down
systems, review ITM records, and procedures to determine whether or not
an adequate program remains in place.

1\. [Water Based Fire Suppression System]{.underline}. The licensee=s or
certificate holder=s ITM program should ensure that:

\(a\) Sprinklers do not show signs of leakage; are free of corrosion,
foreign materials, paint, and physical damage; and are installed in the
proper orientation (e.g., upright, pendent, or sidewall).

\(b\) There is a minimum clearance distance of 18 inches from the
sprinkler head to ensure adequate spray pattern development.

\(c\) Pipe and fittings are in good condition and free of mechanical
damage, leakage, corrosion, and misalignment.

\(d\) Hangers and seismic braces are not damaged or loose.

\(e\) Gauges on wet pipe sprinkler systems are in good condition and
that normal water supply pressure is being maintained. Gauges on dry,
preaction, and deluge systems are in good condition to ensure that
normal air and water pressures are being maintained.

\(f\) Water flow alarms are functional.

\(g\) There is not a major reduction in water flow to the system, such
as could be caused by a major obstruction, a dropped gate, a valve that
is almost fully closed, or a check valve clapper stuck to the valve
seat.

\(h\) System control valves are secured by means of a seal or a lock or
electrically supervised.

\(i\) The fire water supply and pumping capability is operable and
capable of supplying the designed water supply demand for the system.

\(j\) Functionality of the system during freezing weather.

2\. [Gaseous Fire Suppression System]{.underline}. The licensee=s or
certificate holder=s ITM program should ensure that:

\(a\) Discharge nozzles are free of corrosion, foreign materials, paint,
obstruction, and physical damage; and are installed in the proper
orientation such that gas dispersal could be significantly impacted.

\(b\) Suppression agent charge pressure is within the normal band as
required by the design basis, extinguishing agent control system
actuation supply valves are open, extinguishing agent main supply valves
are open, and the system is in the appropriate standby mode.

\(c\) Suppression agent storage containers are free of corrosion and the
containers are properly fastened and secured.

\(d\) For total flooding systems, the room enclosure=s ability to
maintain gas concentration is not degraded (e.g., worn‑out fire door
weather stripping, minimal penetration seal degradation C minor cracks,
no ventilation system isolation, removed or missing dampers), or more
leakage paths than originally tested.

3\. [Fire Detection System]{.underline}. The licensee=s or certificate
holder=s ITM program should ensure that:

\(a\) The main power supply is capable of supporting the design current
load during fire conditions. In addition, the secondary power supply
should be able to support the full current load of the fire alarm system
if the primary supply is lost.

\(b\) Batteries are fully charged and free of any terminal corrosion,
looseness in terminals connections, or electrolyte leakage. This
condition could cause an increase in the series resistance of the
battery set, thus depriving the fire alarm system of the necessary
operating potential under large current loads.

\(c\) Initiating devices (i.e., heat, smoke, and beam detectors) are
able to sense the condition for which they were designed. For example, a
smoke detector attains the alarm state at the smoke concentration for
which the detector was listed. In the case of manual fire alarm pull
stations, the actuation of the device should trigger the fire alarm.

\(d\) Heat detectors are free of any extraneous insulating material
(i.e., paint) that could retard or prevent response.

\(e\) Smoke detectors are free of any condition (i.e obstruction) that
could prevent smoke from enter the sensing chamber of the detector.

\(f\) All fire detection circuits are electronically supervised to
provide indication (trouble alarm) of any identified faulted condition.

\(g\) All functions of the fire alarm system are operational. These
functions include supervision of all signaling line circuits, initiating
devices circuits, notification appliances circuits, and signal
transmission circuits.

4\. [Protection From Damage From Fire Suppression
Activities]{.underline}. No specific guidance.

5\. [Undesired Consequences]{.underline}. No specific guidance provided.

6\. [Environmental Issues and Water Based Suppression
Systems]{.underline}. Facilities used for the storage and dispensing of
flammable and combustible liquids should have installed a containment
system to catch any hazardous effluent as a result of the system
activation and water runoff. When the sprinkler system activates, there
is the possibility that the water mixes with the hazardous substance in
the facility and if unchecked can flow into nearby bodies of water or
soak into nearby soil, threatening drinking water, etc. Depending on the
type of fire, the run‑off may be seriously contaminated, and threaten
nearby areas.

The problem of backflow to the city water source that the suppression
system draws its water from is also an issue. Pollutants can pass from
the system to the water supply through the normal backflow permitted by
check valves. The pollutants come from the water pumped into the system
through the fire department connection. If non‑potable water (for
example chemically‑treated water) used in the system backflows into the
drinking water supply there could be negative environmental and health
effects on the surrounding area.

Another area of concern is when water, which has been sitting for years
in a system and may contain microbes and corrosion products backflow
into the public water supply. This is a health concern in that the
stagnant water could cause illness if consumed. To safeguard this from
happening, the system should have backflow preventers on suppression
systems. This keeps the water in the system from going back into the
public water supply.

Another issue is chemical used in the systems such as antifreeze
solution. Antifreeze solutions are water solutions of ethylene glycol,
diethylene glycol, glycerine, or propylene glycol. Most of them are
hazardous to the environment and human health. When the system
activates, the water mixed with hazardous chemicals in antifreeze
solution can flow into the sewer system or to a water source (i.e.
river), if no proper containment systems is provided. This can cause
water pollution. It also can create land pollution if run‑off flows into
nearby soil. It might backflow into the water supply system and present
a serious issue.

Mold may result from water‑based fire protection equipment if not
properly maintained. Mold can grow inside system piping and, once
discharged these microbes can cause environmental and health problems.
If furniture and other items exposed to the water dousing are not dried
properly, mold and bacteria can fester and grow, especially in porous
materials such as flooring materials.

3.03 [Communications]{.underline}. Assess the capability of the
communication systems to support the operators in the conduct and
coordination of their required actions (e.g., consider ambient noise
levels, clarity of reception, reliability, and coverage patterns). If
specific issues arise relating to fire brigade and incident commander
communications adequacy, then, observe that a licensee or certificate
holder conducted communications tests in the subject plant area or areas
using a realistic scenario such as during audible alarm conditions.
Review the battery use characteristics and duration for the fire brigade
radios and verify that the batteries are at least one hour rated (full
charge) for Atalk@ and Areceive@ use. (If not the radio batteries may be
under-rated for use for normal fire brigade response (nominal 20 minutes
response time to place an effective fire suppression agent on simulated
fires) and during a severe long-duration event.)

03.04 [Emergency Lighting]{.underline}. Review emergency lighting
provided, either in fixed or portable form, to determine whether the
material condition of the equipment is being maintained and that any
changes are appropriately reviewed with respect to the consequences of
the change. Determine if battery-powered backup lighting units (ELUs)
are provided at the fire brigade storage locations and response assembly
areas and whether that lighting is adequate to support fire brigade
assembly and dress-out operations.

03.05 [Fire Brigade Training and Offsite Fire Support
Orientation]{.underline}. The inspector should determine if the
organization, training, qualifications, and equipment of the fire
brigade is adequate to respond to the credible fire scenarios identified
in the Radiological Contingency Emergency Plan, with assistance from
offsite fire departments.

NFPA 600, Standard on Industrial Fire Brigades, and NFPA 1081, Standard
for Industrial Fire Brigade Member Professional Qualifications describes
the requirements for the organization, training, and personal protective
equipment (PPE) of fire brigades whenever they are established by the
employer. NFPA 600 and 1081 should be used for guidance.

All members of the fire brigade should receive adequate training. The
inspector should review documentation of the meetings held, subjects
taught, examinations given, and names of the attendees. The training
should include:

a\. Use of thermal protective clothing during firefighting operations,
given thermal protective clothing, so that the clothing is correctly
donned, worn, and doffed.

b\. Use of self contained breathing apparatus (SCBA).

c\. Implementation of the site-specific Pre-Fire plan.

d\. Manual fire suppression activities.

e\. Forced entry into a structure or confined space.

f\. Overhaul of a fire scene, so that structural integrity is not
compromised, all hidden fires are discovered, fire cause evidence is
preserved, and the fire is extinguished.

g\. Exit of a hazardous area.

h\. Establishment of a water supply for fire‑fighting operations.

i\. Interface with offsite fire departments

j\. Emergency medical care.

k\. Search and rescue operations.

l\. Fire fighting techniques for different hazards that might be present
at the facility.

m\. Participation in a drill at least semiannually.

n\. Live fire training should be conducted at least annually. Live fire
training shall include props that are representative of and that
simulate as closely as possible the hazards and conditions that could be
encountered by the industrial fire brigade member.

03.06 [Identification and Resolution of Problems]{.underline}. Review
the results of fire protection internal audits and external reviews by
organizations such as insurance companies. Review selective corrective
actions from fire brigade drill critiques. Determine whether corrective
actions are being adequately prioritized and completed in a timely
manner.

88054‑04 INSPECTION RESOURCES

Approximately 68 hours of actual inspection time will be required to
perform this procedure. The normal frequency of inspection is triennial.

88054‑05 REFERENCES

05.01 [National Fire Protection Association (NFPA) Codes]{.underline}.

NFPA 10, "Portable Fire Extinguishers."

NFPA 11, "Low Expansion Foam and Combined Agent Systems."

NFPA 11A, "Medium‑ and High‑Expansion Foam Systems."

NFPA 12, "Carbon Dioxide Extinguishing Systems."

NFPA 12A, "Halon 1301 Fire Extinguishing Systems."

NFPA 12B, "Halon 1211 Fire Extinguishing Systems."

NFPA 13, "Sprinkler Systems."

NFPA 14, "Standpipe and Hose Systems."

NFPA 15, "Water Spray Fixed Systems for Fire Protection."

NFPA 16, "Deluge Foam‑Water Sprinkler and Foam‑Water Spray Systems."

NFPA 20, "Centrifugal Fire Pumps."

NFPA 24, "Private Fire Service Mains and Their Appurtenances."

NFPA 30, "Flammable and Combustible Liquids Code."

NFPA 31, "Oil Burning Equipment."

NFPA 37, "Stationary Combustion Engines and Gas Turbines."

NFPA 45, "Laboratories Using Chemicals."

NFPA 50, "Bulk Oxygen Systems at Consumer Sites."

NFPA 50B, "Liquified Hydrogen Systems at Consumer Sites."

NFPA 51B, "Fire Prevention in Use of Cutting and Welding Processes."

NFPA 54, "ANSI Z223.1‑1984, National Fuel Gas Code."

NFPA 69, "Explosion Prevention Systems."

NFPA 70, "National Electrical Code."

NFPA 70B, "Electrical Equipment Maintenance."

NFPA 70E, "Electrical Safety Requirements for Employee Workplaces."

NFPA 72D, "Proprietary Protective Signaling Systems."

NFPA 72E, "Automatic Fire Detectors."

NFPA 75, "Electronic Computer/Data Processing Equipment."

NFPA 77, "Static Electricity."

NFPA 78, "Lightning Protection Code."

NFPA 79, "Industrial Machinery."

NFPA 80, "Fire Doors and Windows."

NFPA 80A, "Protection of Buildings from Exterior Fire Exposures."

NFPA 85D, "Fuel Oil‑Fired Multiple Burner Boiler‑Furnaces."

NFPA 86C, "Industrial Furnaces Using a Special Processing Atmosphere."

NFPA 90A, "Air Conditioning and Ventilating Systems."

NFPA 90B, "Warm Air Heating and Air Conditioning Systems."

NFPA 101, "Life Safety Code."

NFPA 204M, "Smoke and Heat Venting."

NFPA 220, "Types of Building Construction."

NFPA 251, "Fire Tests of Building Construction and Materials."

NFPA 321, "Basic Classification of Flammable and Combustible Liquids."

NFPA 482, "Production, Processing, Handling and Storage of Zirconium."

NFPA 600, "Private Fire Brigades."

NFPA 801, "Facilities Handling Radioactive Materials."

NFPA 803, "Light Water‑Cooled Nuclear Reactors."

05.02 [U.S. Nuclear Regulatory Commission Documents]{.underline}.

U.S. Nuclear Regulatory Commission, "Standard Format and Content for
Emergency Plans for Fuel Cycle and Materials Facilities," NUREG 0762,
Rev. 1, November 1987.

U.S. Nuclear Regulatory Commission, Standard Review Plan 9.5.1,
"Guidelines for Fire Protection for Nuclear Power Plants," NUREG 0800,
Rev. 2, July 1981.

U.S. Nuclear Regulatory Commission, "Guidance on Management
Controls/Quality Assurance, Requirements for Operation, Chemical Safety,
and Fire Protection for Fuel Cycle Facilities," [Federal]{.underline}
[Register]{.underline}, Vol, 54, No. 53, March 1989.

05.03 [Other Documents]{.underline}.

American National Standards Institute, N665‑1985, "Facilities for
Fabricating Fuel for Light Water Reactors (LWR) ‑ Fire Protection."

American National Standards Institute/American Society of Heating,
Refrigeration, and Air Conditioning Engineers, ANSI/ASHRAE 15, "Safety
Code for Mechanical Refrigeration."

American Society for Testing and Materials, ASTM E‑84, "Surface Burning
Characteristics of Building Materials," 1976.

American Society for Testing and Materials, ASTM E‑119, "Fire Test of
Building Construction and Materials," 1976.

Factory Mutual System Approval Guide, "Equipment, Materials, Services
for Conservation of Property."

National Fire Protection Association, [Fire Protection
Handbook]{.underline}.

Underwriters Laboratories Standard UL 555, "Standard for Fire Dampers
and Ceiling Dampers."

Underwriters Laboratories Standard UL 586, (ANSI B 132.1),
"High‑Efficiency Air Filtration Units."

Underwriters Laboratories, [Building Materials Directory]{.underline}.

END

ATTACHMENT 1

[Revision History for IP 88054]{.underline}

+--------+--------+------------------------+-----+-------+-------------+
| Comm   | Issue  | Description of Change  | Tr  | Tra   | Comment     |
| itment | Date   |                        | ain | ining | Resolution  |
| Tr     |        |                        | ing | Compl | Accession   |
| acking |        |                        | Nee | etion | Number      |
| Number |        |                        | ded | Date  |             |
+--------+--------+------------------------+-----+-------+-------------+
| N/A    | 09     | Researched commitments | No  | N/A   | ML082330199 |
|        | /11/08 | for 4 years and found  |     |       |             |
|        |        | none.                  |     |       |             |
|        | CN     |                        |     |       |             |
|        | 08-026 | IP 88054 has been      |     |       |             |
|        |        | issued because of the  |     |       |             |
|        |        | need for a new         |     |       |             |
|        |        | Inspection Procedure   |     |       |             |
|        |        | for the Fire           |     |       |             |
|        |        | Protection Program.    |     |       |             |
+--------+--------+------------------------+-----+-------+-------------+
|        |        |                        |     |       |             |
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