Guidance for the Quality Assurance of

Fire Protection Systems

Prepared for:

Office of Energy Research

Office of Environment, Safety and Health Technical Support

Prepared by:

Roy F. Weston, Inc.

October 1994

Under Contract No. DE-AC02-93ER31192

DRAFT Quality Assurance of Fire Protection Systems

TABLE OF CONTENTS

PURPOSE .............................................................. 1

SCOPE 1

DOE Order 5700.6C, Quality Assurance ................................. 1

RISK ANALYSIS ........................................................ 2

GUIDANCE FOR THE QUALITY ASSURANCE OF FIRE PROTECTION SYSTEMS ........ 3

I. Establishment of a Fire Protection Systems Quality Assurance

Plan (QAP) ..................................................... 3

II. Qualifications and Training of the Fire Protection Personnel .. 3

III. Quality Improvement ............................................ 6

IV. Documents and Records .......................................... 7

V. Fire Protection Systems-Related Activities ..................... 8

VI. Design ......................................................... 10

VII. Procurement .................................................... 12

VIII. Inspection, Testing, and Maintenance ........................... 13

IX. Self-Assessment ................................................ 16

DRAFT Quality Assurance of Fire Protection Systems

PURPOSE

This quality assurance document is intended to provide guidance for the

DOE fire protection community in the continuing effort to ensure the
reliability of fire protection systems. This guidance document applies
the concepts of DOE Order 5700.6C, Quality Assurance, to the management
of fire protection systems. The recommendations of this document are
intended to supplement the management of a fire protection systems
program, the requirements of incorporated standards, and manufacturers'
recommendations.

SCOPE

This guidance recommends procedures and practices to implement while

designing, maintaining, and ensuring the proper operability of fire
protection systems at DOE sponsored facilities. The guidance can serve
as a basis for a new quality assurance program or the improvement of an
existing one. Fire protection systems under the purview of this
document include automatic water extinguishing systems, manual water
extinguishing systems, special extinguishing systems, water supply
systems, and fire detection and alarm systems.

DOE Order 5700.6C, Quality Assurance

DOE Order 5700.6C, Quality Assurance, establishes quality assurance

requirements for the DOE. The Order introduces DOE quality assurance
policy, defines related terms, establishes DOE objectives, and outlines
quality assurance criteria. The accompanying implementation guidance
incorporates ten quality assurance criteria which are grouped into three
functional categories:

Management
1. Program
2. Personnel Training and Qualification
3. Quality Improvement
4. Documents and Records

Performance
5. Work Processes
6. Design
7. Procurement
8. Inspection and Acceptance Testing

Assessment
9. Management Assessment
10. Independent Assessment

The guidance provided with DOE 5700.6C, Quality Assurance, states " that
all work is a process that can be planned, performed, assessed, and
improved" and "these quality assurance criteria reflect a comprehensive
way of doing business throughout the life cycle of DOE programs and

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projects." These criteria have been adapted for the management of fire
protection systems programs in this document.

RISK ANALYSIS

DOE Order 5480.7A, Fire Protection, incorporates the National Fire

Protection Association's (NFPA) National Fire Codes as the minimum
requirements for ensuring the reliability of fire protection systems. A
quality assurance program should ensure fire protection systems are
designed, accepted, inspected, tested, and maintained in accordance with
NFPA requirements.

Where fire protection systems protect high risk hazards requiring

minimum requirements to be exceeded, a Quality Assurance Plan should be
applied to the management of a fire protection systems commensurate with
the consequences of systems failure and complexity of the fire
protection systems.

QUALITY ASSURANCE OF FIRE PROTECTION SYSTEMS

I. Establishment of a Quality Assurance Plan

Management should develop and issue a written quality assurance policy

to establish a quality assurance plan (QAP). Acting on the policy, the
Fire Protection Manager 1 should develop a quality assurance plan
specifically for fire protection systems or incorporate fire protection
systems into a facility-wide quality assurance program.

a. Responsibilities. The fire protection system QAP should assign

responsibilities to the Fire Protection Manager, Fire Protection2,
and individuals such as engineers, specialists, and technicians.

1) The Fire Protection Manager is responsible for implementing

and maintaining the QAP, defining QAP responsibilities, and
translating the responsibilities into daily activities.

2) Fire Protection is responsible for achieving and maintaining

the quality of fire protection systems.

3) Individuals are responsible for achieving their assigned

objectives.

b. Definitions. The QAP should define:

1
Fire Protection Manager generically refers to the individual responsible
for planning, directing, and leading a facility's fire protection systems
program and the subordinate personnel assigned to it.
2
Fire Protection generically refers to any individual or group which
comprise an organizational unit responsible for developing, implementing, and
maintaining a fire protection systems program at a facility.

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1) Facility-specific QA and fire protection terminology.

2) Fire Protection organizational structure.
3) Functional responsibilities of Fire Protection related to
fire protection systems.
4) How Fire Protection interfaces with other organizational
units.

II. Qualifications and Training

All personnel involved in fire protection systems-related tasks should

be qualified to perform assigned work.

a. Engineering Tasks

1) An individual performing engineering tasks should possess one

of the credentials recommended by the DOE "Model" Fire
Protection Program, Section 2.D.

2) Individuals possessing a Bachelor Degree or Associate Degree,

within the discipline they are assigned; equivalent technical
work experience; or, a combination of education and
experience approved by management or the Fire Protection
Manager are qualified to perform engineering tasks.

b. Inspection, Testing, and Maintenance Activities

Individuals performing tasks associated with the inspection,

testing, and maintenance of fire protection systems should possess
the minimum credentials:

1) Meet the Field Inspection qualifications of NFPA 1031,

Professional Qualifications for Fire Inspector, 3-3.6, 4-3.5,
and 5-3.4.

2) Possess a working knowledge of the tools, instruments,

equipment, procedures, NFPA standards, and safe working
practices associated with the task assigned to them.

3) Demonstrate a competency to perform associated tasks based on

a combination of principles and education approved by
management or the Fire Protection Manager.

c. Training Plans. A training plan should be established to develop,

maintain, and improve the proficiency of personnel who perform fire
protection systems activities. An effective training plan includes
the following concepts:

1) Training plans are designed to accommodate individuals

assigned to every shift. Organized, on-the-job training is
acceptable for inclusion in the traiing plan.

2) Training accommodates the personnels' work schedules.

3) Training is provided to individuals where new systems,

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procedures, or processes are introduced to the facility.

4) Training is provided to individuals who need to maintain

certifications associated with fire protection systems
activities.

5) Fire Protection is given the opportunity to recommend

relevant training curricula.

d. Job-Instruction-Training. Job-Instruction Training (JIT) is used

for training new employees, introducing new skills to existing
employees, and providing refresher training utilizing a mentor-type
relationship.

This type of training allows the trainer to provide instruction

about fire protection systems and related activities under
realistic conditions while at the same time accomplishing an
assigned task. Most fire protection systems are not identical when
the hazards protected, design, and configuration are considered.
JIT allows a trainer who is already familiar with the different
fire protection systems to teach a trainee what is unique about
particular systems at a facility. Effective JIT includes:

1) Training Schedule. A training schedule for the trainee is

established with expected milestones. Detailed records of
progress on specific skills or tasks are be kept.

2) Selection of Trainer. Trainers are chosen based on

experience and interpersonal dynamics. An individual
assigned as a mentor is able to demonstrate a thorough
knowledge of the task and possess the necessary skills to
serve as a trainer. The trainer is capable of fostering a
one-on-one relationship with the trainee.

3) Preparation. The trainer makes the trainee feel comfortable

and assesses the trainee's current level of knowledge and
skills. The trainer also provides proper safety equipment
and explain the hazards related to the task.

4) Presentation. The trainer demonstrates the task step by step

allowing the trainee to observe them. The trainer stresses
principles, key points, and emphasizes safety precautions.

5) Performance. The trainee performs the task under the close

supervision of the trainer. The trainee explains each step
of the task to demonstrate his/her understanding. The
trainer observes weaknesses and reinforces proper practice by
coaching the trainee. The trainer constantly evaluates the
trainee. When the trainee is able to safely and proficiently
perform the task, the trainer will authorize the trainee to
perform that task.

6) Follow-up. The trainer follows-up on the trainee at a later

date to ensure continued proficiency and improvement in

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completing the task. 3

e. Review. The qualifications and training system should be reviewed

at least annually by the Fire Protection Manager to evaluate the
effectiveness of training. The review should consider:

1) The progress of individuals, as well as Fire Protection, to

ensure training schedules and objectives are being satisfied.

2) The effectiveness of the training plan and JIT program.

3) Future training needs.

f. The results of the review can be communicated to upper management

in the annual Fire Protection Summary Report.

III. Quality Improvement

While implementing a QAP, management should delegate the

responsibility of performing tasks, providing services, and
developing products that meet or exceed quality requirements to
individual employees. This assumes that management and the
individual understand the concept that the individual performing
the task is an expert at that task. Quality improvement efforts
should concentrate on the individual-task interface. Management
should, therefore, delegate authority to the individual to allow
him/her to ensure service and product requirements are being met.

a. Quality Improvement Principles

1) Management portrays a "no fault" attitude. This attitude

emphasizes the importance of correcting problems and
deficiencies at their respective sources instead of assessing
blame.

2) Personnel have the authority to suggest improvements,

identify problems, and recommend corrective actions.

3) The root cause of quality problems are analyzed, documented,

and later trended among a large population of root causes.
Studying the root causes over time is essential for
determining the reliability of fire protection systems.
Eliminating problems at their source also increases the
likelihood of reducing the variance of quality.

b. Personnel Performance Reviews. Performance reviews of Fire

Protection personnel should include an evaluation of the
individual's contribution to the quality assurance program. This
is the medium for holding individuals accountable for the quality
of their own work.

3
Accident Prevention Manual for Business and Industry, 10th ed., National Safety Council, Itasca,
Illinois,1992.

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c. Fire Protection Meetings. The Fire Protection staff should meet

regularly to identify, evaluate, and monitor the status of the
quality and performance of fire protection systems. This function
can be accomplished as part of a larger problem-solving group.
Recommended quality improvement activities are listed below:

1) Evaluate methods and procedures.

2) Conduct self-assessments.

3) Review risk analyses and other related documents.

4) Review training and work activity systems.

5) Analyze performance data.

6) Review the status of corrective actions.

7) Design reviews.

8) Procurement analyses/needs assessment.

IV. Documents and Records

a. Records should document the life cycle of the fire protection

systems at an appropriate level of detail. Documentation related
to the life cycle includes but is not limited to system
justification, code compliance, policies, procedures, safety
analyses, drawings, calculations, computer files, vendor receipts
and proposals, and inspection, testing, and maintenance results.

b. Review Process. All documents related to fire protection systems

which will become part of the permanent record or will be
distributed to sources beyond Fire Protection should be reviewed.
An effective review process incorporates the following concepts:

1) Documents are reviewed by someone other than the originator

who is technically competent in the subject area being
reviewed.

2) The review is documented.

3) The document is approved by the Fire Protection Manager prior

to use.

c. Document Control. Documents should be controlled when they are

determined to be technically complex or organizationally sensitive.

1) Management or the Fire Protection Manager determines the

complexity or sensitivity of a document.

2) Procedures outlining the preparation, review, approval,

issuance, and revision of controlled documents are developed.

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3) Controlled documents are distributed to only those

individuals who would be affected by the scope of the
document.

4) Individuals initial a document control form to verify their

receipt and review of controlled documents. The document
control form is stored for the life cycle of that document.

5) Approved revisions to controlled documents are distributed to

all personnel listed on the document control form.

d. Records Management. The Fire Protection Manager should document

the life cycle of fire protection systems. Effective documentation
includes the following concepts:

1) A records management system is established to store fire

protection system documentation in a central location.

2) Drawings and specifications are stored in a controlled and

central location.

V. Fire Protection Systems-Related Activities

Fire protection systems-related activities include but are not limited

to work processes such as inspection, testing, maintenance, acceptance
testing, calibration, and self-assessment.

a. Individuals should be qualified and trained to successfully

complete the work activities they are assigned.

b. Written Procedures. Written procedures for fire protection

systems-related activities should be developed and implemented for
every activity and work process. Nationally accepted good
practices can be recognized. Effective procedures include the
following concepts:

1) Procedures are prepared by individuals who possess a thorough

knowledge of the specific fire protection systems, the
hazard(s) the systems protect, and the associated risks.

2) Procedures incorporate the requirements and/or guidance of

NFPA standards or recommended practices, the DOE "Model" Fire
Protection Program, insurers, and manufacturers.

3) Organizations affected by the procedure have the opportunity

to review the procedures, changes to procedures, or revisions
and provide structured feedback.

4) Written procedures are verified for accuracy, useability, and

safety by a qualified individual other than the individual
who wrote the procedure.

5) Fire Protection approves the draft procedure after structured

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feedback has been incorporated.

6) The Fire Protection Manager implements the procedure into

practice with an effective date after the affected personnel
have been trained in the use of the new procedure.

7) Written procedures are distributed to each individual of Fire

Protection who has a responsibility in the procedure. In
addition, a manual of all written procedures are centrally
located and maintained for reference.

8) Management clearly communicates the responsibility of each

individual for ensuring the quality of their work while
following established procedures.

c. Identification and Control of Tangible Items. A method to account

for tangible items related to work activities should be developed
and implemented. Tangible items can include but are not limited to
consumables, tools, measuring equipment, and other materials needed
to complete a procedure. An effective method includes the
following concepts:

1) The marking or labeling items to identify that they belong to

Fire Protection. Items that cannot be physically scarred are
tagged.

2) The identification of a tangible item is maintained from the

time of initial receipt, or fabrication, up to and including
installation or end use.

3) Records documenting the service life of the item.

4) Hazardous items are controlled in accordance with

organizational and regulatory requirements including
provisions for the decontamination of items.

d. The Fire Protection Manager should identify applicable procedures

when he/she assign activities.

e. The Fire Protection Manager should develop and implement a work

activity planning system. An effective work activity planning
system incorporates the following concepts:

1) Prioritizes activities such that those involving fire

protection systems which protect the greatest risks are given
the highest priority for completion. (See Section 8.5 for
impairments).

2) Re-evaluates the prioritization of work activities as each

new request for a work activity is introduced into the
system.

f. A work activity completion report should be prepared upon the

accomplishment of an activity. Multiple activities of the same

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nature should be compiled in one report. An effective report

documents:

1) Date the activity was assigned.

2) Date the activity was completed.

3) Basis for activity.

4) Task performed/corrective action applied.

f) Degree of success.

g. Completion reports should be maintained in a central location.

VI. Design

A written design process should be developed and implemented for the

design of fire protection systems. An effective design process
includes:

a. Documentation. Each step of the design process is documented.

b. Design Input. During the planning phase of a fire protection

system design project, all input necessary for the design is
identified. Design input includes but is not limited to design
basis, reliability requirements, performance objectives, permits,
codes, and standards.

c. Fire protection system designers employ state-of-the-art equipment

that has been tested by a nationally recognized testing laboratory
for its intended use.

d. Conceptual Designs. Conceptual designs for new fire protection

systems and modifications to existing fire protection systems are
reviewed by qualified personnel familiar with the facility where
the system will be installed to ensure proposed designs will
sufficiently protect hazards.

e. Design input is correctly translated into the design output. The

individual or group ensuring that the design basis and technical
requirements are correctly represented in the design output (such
as specifications, drawings, procedures, and instructions) are
different from the individual or group responsible for the input,
where possible.

f. Design Transfer. The transfer of designs between Fire Protection

and groups within the organization, as well as other organizations
is controlled. Effective transfer procedures include:

1) A method of feedback to ensure designs were received.

2) Opening a channel of communication for further design input.

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3) Documenting the transfer of designs between parties.

4) Responsibilities for the individual providing the interface

is defined.

g. Design Verification. Design inputs, processes, calculations,

changes, and design outputs should be verified.

1) The verification process ensures the design is reliable, able

to be constructed, operable, and able to be maintained.

2) Qualified individuals or groups conduct the design

verification.

3) The individual or group verifying the design are different

then the individual or group that prepared the design.

4) The rigor of verification can be based on risk, complexity,

and uniqueness of design.

5) A tracking system for comments related to the design are

developed and implemented to ensure all comments are recorded
and reviewed.

6) Computer programs such as models and calculating tools are

validated.
h. Design Modifications. Changes or modifications to design outputs
should be justified, reviewed, and approved by the Fire Protection
Manager. Modifications should also be documented.

i. Configuration Management. A process for managing the configuration

of fire protection systems should be developed and implemented to
ensure the systems and their components conform to documented
design. An effective process includes the following:

1) Evaluation. An evaluation process identifies and examines

fire protection systems, components, and documents through
periodic assessments. The evaluation process measures the
effectiveness of modification and document control.

2) Design Basis. The design basis is updated when approved

modifications are made.

3) Modification Control. Modifications to fire protection

systems are correctly identified, evaluated, designed,
verified, and implemented. Fire protection system
modifications are documented throughout the life cycle of the
system.

4) Document Control. All documents that record the life cycle

of the fire protection systems are maintained and stored in a
central location. Individuals or groups outside of Fire
Protection are prohibited from removing documents from the
central location.

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VII. Procurement

Procurement Control. A procurement control system should be developed

and implemented to ensure purchased items such as system components and
service meet established requirements and perform as expected.

a. Identify Needs. The reason for procurement of a new fire

protection system or the replacement, modification, or repair of an
existing system is documented. An evaluation of safety factors
such as hazards and associated risks are discussed to justify the
procurement.

b. Acceptance Criteria. Applicable technical and administrative

requirements are documented. These include but are not limited to
codes, standards, regulations, tests, inspections, insurers'
recommendations, and other quality requirements.

c. Suitability. The procurement is reviewed by an individual other

than the individual who developed the documentation. The
justification and suitability of the item are examined.

d. Evaluate Suppliers. Potential suppliers are evaluated for the

reliability of their product or service and ensure they are
qualified to provide the item. An evaluation of reliability
includes analyzing a suppliers past performance, receipt inspection
process, frequency of use, established product trends, complexity
of procurement, and justification of quality through documentation.

e. Method of Acceptance. Procurement documentation defines the method

of verification that will be used to ensure the delivered product
or service complies to the acceptance criteria. The documentation
will also identify who will perform the verification and what
method will be used to document the acceptance of the product or
service.

f. Inspection. Fire protection systems should be inspected and tested

after they are installed, replaced, or repaired. Operability is
verified before the fire protection system is placed into service .

g. Performance Evaluation. Fire protection systems performance is

evaluated regularly after being placed in service. Routine
inspection and testing at frequencies defined by the NFPA standard
related to the type of system is required.

h. Information regarding the delivery of intentionally substandard

quality products or services must be forwarded to the DOE Office of
the Inspector General.

VIII. Inspection, Testing, and Maintenance

Fire protection systems should be maintained in an operable condition as

outlined in respective NFPA standards and the DOE "Model" Fire
Protection Program.

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a. Written procedures for inspection, testing, maintenance and

operations, should be developed and utilized.

b. The frequency of activities will be determined by the NFPA

standard, the NFPA recommended practice, manufacturer's
recommendation, or insurer's requirement related to the type of
fire protection system.

c. Inspection, testing, and maintenance activities should be planned

under the work activity system.

d. Where possible, equipment used during inspections, tests, and

maintenance activities should be properly calibrated.

1) Equipment is calibrated at regular intervals and before and

after use utilizing nationally recognized calibration
methods.

2) Equipment that cannot be successfully calibrated is tagged

and removed from service.

3) Calibration records are maintained and stored in a central

location.

e. Impairments to fire protection systems should be reported

immediately to the Fire Protection Manager and documented.

f. Impairments should be given greatest priority when ranking work

activities. When multiple impairments exist, they should be
prioritized using the scheme recommended by the DOE "Model" Fire
Protection Program:

1) First Priority. Assigned to an impairment that creates an

imminent hazard to employees, property, or the potential for
an environmental release in excess of allowed limits. First
priority impairments are considered an emergency.

2) Second Priority. Assigned to an impairment that reduces the

protection to employees, property, or the environment, but is
not an imminent hazard.

3) Third Priority. Assigned to an impairment that must be

corrected, but does not directly reduce the protection to
employees, property, or the environment.

g. The results of fire protection system inspections and tests should

be documented and stored. System performance, including trends,
should be summarized in the facility's annual Fire Protection
Summary Report.

h. Failures of fire protection systems or their components should be

documented.

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i. A root cause evaluation of the failure should be conducted and the

root cause documented. This evaluation determines which component
or feature of the system failed, how it failed, why it failed, and
the action required.

An effective root cause evaluation includes:

1) Confirmation of the failure.

2) Confirmation of the failure mode.

3) Confirmation of the failure mechanism.

4) Identification of the root cause.

5) Correction of the root cause by eliminating it.

6) Confirmation of the effectiveness of the corrective action.4

j. Root causes should be analyzed for trends.

k. A corrective action tracking system should be developed and

implemented as recommended by the DOE "Model" Fire Protection
Program. An effective corrective action tracking system includes:

1) A narrative of the finding including how the corrective

action was identified.

2) Structure/building affected.

3) Date of the finding.

4) Name of the individual who conducted the inspection or test.

5) Name of the person responsible for the corrective action.

6) Corrective action due date.

7). Interim compensatory measures required.

8). Priority level of the finding.

9) Closure date.

l. Corrective actions should be introduced to the work activity

planning system.

m. Acceptance testing should be conducted to demonstrate that fire

protection systems are capable of performing as they were designed.

4
Handbook for Nuclear Power Plant Self-Assessment Programs, Electric Power Research Institute, Palo
Alto, California, 1991.

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n. Written and approved acceptance testing procedures should be

followed.

o. Acceptance testing justification, criteria, and procedures should

be in accordance with the NFPA standard related to the type of fire
protection system.

p. Acceptance testing should be conducted after a deficiency is

corrected or the configuration of a fire protection system
changed.

q. The results of acceptance tests should be documented and stored in

a central location.

IX. Self-Assessment

Assessments shall be conducted by the Assistant Secretary for

Environment, Safety, and Health, Program Secretarial Officers,
Operations Offices, and contractors at intervals prescribed in DOE Order
5480.7A, Fire Protection. The Order also defines the scope of the fire
protection program evaluation, which includes fire protection systems.
Self-assessment is a continuous process and a management tool used to
monitor the effectiveness and quality of implemented programs. Self-
assessment is performed in addition to the external assessments
prescribed by DOE Order 5480.7A.

a. A comprehensive self-assessment of the management of fire

protection systems should be performed at least annually by the
Fire Protection Manager.

b. On-going self-assessment activities for fire protection systems

should be identified by the Fire Protection Manager. Self-
assessment activities should also be incorporated into the work
activity planning system. Self-assessment activities may include
but are not limited to:

1) Annual Summary Assessment Report

2) Review and analysis of incidents involving fire protection

systems.

3) Technical evaluation of fire protection system functional

performance and reliability.

4) Surveillance of fire protection system operability and

degradation.

5) Review of written procedures.

6) Design review of modifications.

7) Examination of fire protection system documentation.

8) Review of administrative systems.

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9) Quality improvement meetings.

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