NC0048577_Lab Inspection_20121016

INSPECTION REPORT ROUTING SHEET
To be attached to all inspection reports in-house only.
Laboratory Cert. #: #515 (changed to #5628, effective 9/26/2012)
Laboratory Name: Robeson County WTP Laboratory
Inspection Type: Municipal Maintenance
Inspector Name(s): Jeffrey R. Adams, Dana Satterwhite, Gary Francies, & Tonja Springer
Inspection Date: July 31, 2012 & (Follow-up) on September 13, 2012
Date Report Completed: October 16, 2012
Date Forwarded to Reviewer: October 16, 2012
Reviewed by: Dana Satterwhite
Date Review Completed: November 5, 2012
Cover Letter to use: ❑ Insp. Initial ® Insp. Reg.
❑ Insp. No Finding ❑ Insp. CP
❑ Corrected
Unit Supervisor: Dana Satterwhite
Date Received: October 16, 2012
Date Forwarded to Linda: November 8, 2012
Date Mailed: November 8, 2012
Linda — please mail a separate copy to both Ms. Debbie Locklear's and Mr. Myron Neville's attention. Also,
please file copies under both certification numbers: #515 and #5628.
Tonia — please notify the regional office of our findings and the actions taken so far.
Attach Instructions for DMR reporting and calculations.
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On -Site Inspection Report
LABORATORY NAME: Robeson County Water Department
NPDES PERMIT # NC0048577; NC0086894; NC0084204; NC0085685; NC0086991
ADDRESS: 265 McGirt Road
Maxton, NC 28364
CERTIFICATE #: 515 (changed to field lab #5628, effective 9/26/2012)
DATE/TYPE OF INSPECTION: July 31, 2012 - Municipal Maintenance Inspection
September 13, 2012 — Compliance Enforcement Investigation
AUDITOR(S):
July 31, 2012 — Jeffrey R. Adams
September 13, 2012 - Jeffrey R. Adams, Gary Francies, Dana
Satterwhite and Tonja Springer
LOCAL PERSON(S) CONTACTED: July 31, 2012 - Katie Radford, Debbie Locklear and Myron Neville
September 13, 2012 - Debbie Locklear and Myron Neville
I. INTRODUCTION:
This laboratory was inspected by a representative of the North Carolina Wastewater/Groundwater
Laboratory Certification (NC WW/GW LC) program to verify its compliance with the requirements of 15A
NCAC 2H ..0800 for the analysis of environmental samples.
II. GENERAL COMMENTS:
The laboratory was clean and well organized. The facility has all the equipment necessary to perform the
analyses.
During a routine municipal maintenance laboratory inspection on July 31, 2012, evidence of fraudulent
activities was discovered. Laboratory fraud may be defined as the deliberate falsification of analytical and
quality assurance results. As a result, a -Compliance Enforcement Investigation was performed on
September 13, 2012 by the NC WW/GW LC Compliance Officer, Mr. Gary Francies, accompanied by Ms.
Dana Satterwhite, Mr. Jeff Adams and Ms. Tonja Springer. During this visit, Mr. Myron Neville, the plant
Operator in Responsible Charge (ORC) and laboratory manager, immediately acknowledged that actions
taken by Ms. Katie Radford were unacceptable and that falsification did occur. Those actions are detailed
in Section III of this report.
On September 26, 2012 the laboratory's certificate attachment was amended to delete Total Suspended
Residue and certification status was changed from a Municipal Laboratory to a Field Laboratory. The
laboratory is currently certified to analyze the following field parameters: pH and Total Residual Chlorine.
Contracted analyses are performed by Environment One, Inc. (Certification #10)

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#515 Robeson County Water Dept.
III. FINDINGS, REQUIREMENTS, COMMENTS AND RECOMMENDATIONS:
Documentation
Comment: The laboratory submitted falsified benchsheets to the inspector. The North Carolina
Administrative Code, 15A NCAC 2H .0807 (c) (7) (K) states: A laboratory that submits falsified data or
other information may be decertified for all, parameters for up to two years. During the Compliance
Enforcement Investigation on September 13, 2012, Mr. Myron Neville stated that the analyst
responsible for submitting falsified information (i.e., Ms. Katie Radford) would have no involvement with
the generation of compliance data including, but not limited to, sample preparation, monitoring of
support equipment, instrument maintenance and calibration, quality control procedures, sample
analysis, calculation of results, transcription of data, and reporting data. Ms. Debbie Locklear was
designated as the Laboratory Supervisor on September 26, 2012. No further response is necessary
for this finding.
Recommendation: It is recommended that measures be taken to detect and deter fraudulent practices in
the future. These measures may include implementing a technical data peer review system, developing a
clearly defined and well communicated quality assurance document and/or standard operating procedures
and implementing a personnel training program in laboratory procedures, as well as, laboratory ethics.
Comment: The North Carolina Administrative Code, 15A NCAC 2H .0805 (a) (3) (C) prescribes the
following: The supervisor shall provide personal and direct supervision of the technical personnel and be
held responsible for the proper performance and reporting of all analyses made for these Rules. The
supervisor must work in the laboratory or visit the laboratory once each day of normal operations.
A. Finding: All original records are not retained.
Requirement: Supporting records shall be maintained as evidence that these practices are
being effectively carried out. All analytical records must be available for a period of five years.
Ref: 15A NCAC 2H .0805 (a) (7) and (a) (7) (G).
Requirement: Data pertinent to each analysis must be maintained for five years. Certified Data
must consist of date collected, time collected, sample site, sample collector, and sample
analysis time. The field benchsheets must provide a space for the signature or initials of the
analyst, and proper units of measure for all analyses. Ref: 15A NCAC 2H .0805 (g) (1).
Comment: During the initial municipal maintenance inspection performed on July 31, 2012, the
laboratory field analyst, Ms. Debbie Locklear, provided records of her original observations for field
analyses to the auditor for review. The inspector reviewed field data benchsheets for pH and
Total Residual Chlorine on July 2 and July 3, 2012 for all five discharge monitoring locations. It
was noted at that time, that this analyst was not performing required quality assurance. During the
Paper Trail Investigation, it was found that the laboratory Supervisor, Ms. Katie Radford, was
constructing secondary field sheets with the field data transcribed from Ms. Locklear's records and
with the addition of fabricated sample duplicate and quality control sample data. The original field
data sheets, completed by Ms. Locklear, could not be found for any days other than the July 2nd
and 3`d data that Ms. Locklear provided during the audit. The environmental compliance data
reported for these two days were transcribed accurately to the DMR. Further investigation and
subsequent attestation by Ms. Locklear also revealed that Ms. Locklear's signature was forged on
these secondary data sheets.
B. Finding: Several instances of writing over a number and the use of a correction fluid as a
means of error correction were observed.

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#515 Robeson County Water Dept.
Requirement: All documentation errors must be corrected by drawing a single line through the
error so that the original entry remains legible. Entries shall not be obliterated by erasures or
markings. Wite-Out®, correction tape or similar products designed to obliterate documentation
are not to be used. Write the correction adjacent to the error. The correction must be initialed by
the responsible individual and the date of change documented. All data and log entries must be
written in indelible ink. Pencil entries are not acceptable. Ref: Quality Assurance Policies for
Field Laboratories.
Traceability
Comment: The laboratory needs to increase the documentation of purchased materials and reagents,
as well as documentation of standards and reagents prepared in the laboratory. The Quality Assurance
Policies for Field Laboratories document states: All chemicals, reagents, standards and consumables
used by the laboratory must have the following information documented: Date Received, Date Opened
(in use), Vendor, Lot Number, and Expiration Date. A system (e.g., traceable identifiers) must be in
place that links standard/reagent preparation information to analytical batches in which the solutions
are used. Documentation of solution preparation must include the analyst's initials, date of preparation,
the volume or weight of standard(s) used, the solvent and final volume of the solution. This information
as well as the vendor and/or manufacturer, lot number, and expiration date must be retained for
chemicals, reagents, standards and consumables used for a period of five years. Consumable
materials such as pH buffers and lots of pre -made standards are included in this requirement. During
the Compliance Enforcement Investigation on September 13, 2012, Ms. Tonja Springer designed
benchsheets that included spaces to enter the required traceability information for pH and Total
Residual Chlorine. The laboratory implemented these benchsheets on September 14, 2012. No further
response is necessary for this finding.
— Standard Methods, 4500 H+ B — 2000
Comment: The laboratory is not analyzing a check buffer on each analysis day. The NC WW/GW LC
Approved Procedure for Field Analysis of pH document states: If compliance samples are analyzed
throughout the day, a post calibration check (e.g., 7 buffer) must be analyzed mid -day and at the end of
the run (i.e., roughly every 4 hours based on an eight hour day). For routine work, use a pH meter
accurate and reproducible to 0.1 pH unit with a range of 0 to 14, equipped with a temperature
compensation device. Follow all manufacturers' recommendations for the calibration of the meter each
analysis day. The meter must be calibrated with at least two buffers. In addition to the calibration
standards, the meter must be verified with a third calibration standard. The calibration and check
standard buffers must bracket the range of the samples being analyzed. The check standard buffer
must read within a range of ± 0.1 pH units to be acceptable. During the Compliance Enforcement
Investigation on September 13, 2012, it was observed that the laboratory had implemented analysis of a
daily check buffer. No further response is necessary for this finding.
Comment: The laboratory reported unacceptable results on two consecutive proficiency testing (PT)
samples for the 2012 proficiency testing calendar year. In addition, it was found that the laboratory.
supervisor, rather than the analyst that regularly performs analysis of environmental samples, analyzed the
PTs. The North Carolina Administrative Code, 15A NCAC 2H .0807 (b) (1) states: A laboratory may
receive a parameter decertification for failing to: Obtain acceptable results on two consecutive blind or
announced performance evaluation samples submitted by an EPA accredited vendor or the State
Laboratory. The Proficiency Testing Requirements, February 20, 2012, Revision 1.2 document states: All
PT samples are to be analyzed and the results reported in a manner consistent with the routine analysis
and reporting requirements of compliance samples and any other samples analyzed according to the
requirements of 15A NCAC 2H .0800. In lieu of issuing a parameter decertification, it was agreed (during
the Compliance Enforcement investigation on September 13, 2012) that if the laboratory analyst, who
analyzes the environmental compliance samples, obtained acceptable results on two consecutive PTs,

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#515 Robeson County Water Dept.
decertification would not be issued. The laboratory submitted acceptable results for two consecutive PTs
(i.e., ERA WP-208 received on 9/4/2012 and ERA 091912L 2009 TNI received on 9/24/2012) which were
analyzed by the analyst responsible for generating environmental compliance data. No further response
if necessary for these findings.
Total Residual Chlorine — Standard Methods, 4500 CI G — 2000
Comment: The laboratory is not documenting the proper units of measure on the laboratory
benchsheets. The secondary benchsheets, created by Ms. Radford, list "mg/L" and "ug/L" in the column
headers with the same sample data values recorded in each. In addition, "ug" were recorded with the
sample value in the individual results spaces. The permit requires reporting in "pg/L". The North
Carolina Administrative Code, 15A NCAC 2H .0805 (g) (1) states: Data pertinent to each analysis must
be maintained for five years. Certified Data must consist of date collected, time collected, sample site,
sample collector, and sample analysis time. The field benchsheets must provide a space for the
signature or initials of the analyst, and proper units of measure for all analyses. During the Compliance
Enforcement Investigation on September 13, 2012, Ms. Tonja Springer designed benchsheets that
included proper units of measure for Total Residual Chlorine results. The laboratory implemented these
benchsheets on September 14, 2012. No further response is necessary for this finding.
Comment: The laboratory is not analyzing a daily midrange check standard. The NC WW/GW LC
Approved Procedure for Field Analysis of Total Residual Chlorine document states: If compliance samples
are analyzed throughout the day, a post calibration check (mid -range) must be analyzed mid -day and at
the end of the run (i.e., roughly every 4 hours based on an eight hour day). The check standard
concentration must be at mid range and recovery must be within 10% of the known value. It was observed
during the Compliance Enforcement Investigation on September 13, 2012, that the laboratory had
implemented analyzing a daily midrange check standard. No further response is necessary for this
finding.
C. Finding: The laboratory is reporting Total Residual Chlorine values below the lowest calibration
verification standard concentration.
Requirement: For analytical procedures requiring analysis of a series of standards, the.
concentrations of those standards must bracket the concentration of the samples analyzed: One of
the standards must have a concentration equal to the laboratory's lower reporting concentration for
the parameter involved. Ref: NC WW/GW LC Approved Procedure for Field Analysis of Total
Residual Chlorine. Please submit a copy of the Total Residual Chlorine meter calibration
verification with the response to this report.
Comment: The laboratory was reporting "0 pg/L" on the Discharge Monitoring Reports (DMRs)
and the lowest calibration verification standard is 20 pg/L. The laboratory analyzes- samples
from 5 different locations. Four of the 5 facilities have permit limits of 17 pg/L.
Recommendation: It is recommended that the laboratory verify the internal calibration using
the concentrations: 15, 30, 50, 200 and 400 pg/L and report "less than" values as "<15 pg/L" in
the daily cells of the DMRs. This will verify the analytical range used to measure Proficiency
Testing (PT) samples as well as environmental samples.
Comment: When calculating an arithmetic mean, you may consider a "less than" value as
equal to zero. Therefore, if all monthly values are "less than" values, the monthly arithmetic
average would be "zero". When calculating a geometric mean, you may consider a "less than"
value as equal to one. Therefore, if all monthly values are "less than" values, the monthly
geometric average would be "one". This procedure pertains only to the calculation of an
average. You must report individual data values on the DMR exactly as reported to you by your

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#515 Robeson County Water Dept.
laboratory and with the "less than" sigh. Please see the attached documents (i.e., NC DWQ
NPDES Permitting Guidance for DMR Calculations and Directions for Completing Monthly
Discharge Monitoring Reports) for additional guidance.
Comment: During the Compliance Enforcement Investigation, it was observed that the laboratory
had obtained a new stock standard solution to verify the meter's factory -set calibration.
D. Finding: The annual calibration curve verification does not always bracket the concentration of
the annual Proficiency Testing (PT) samples.
Requirement: For analytical procedures requiring analysis of a series of standards, the
concentrations of those standards must bracket the concentration of the samples analyzed. Ref:
NC WW/GW LC Approved Procedure for Field Analysis of Total Residual Chlorine.
IV. PAPER TRAIL INVESTIGATION:
The paper trail consisted of comparing laboratory benchsheets and contract lab reports to Discharge
Monitoring Reports (DMRs) submitted to the North Carolina Division of Water Quality. Data were
reviewed for the Maxton WTP Laboratory (NPDES permit #NC0048577), Raemon Well WTP (NPDES
permit #NC0086894), Kenric Road WTP-I-95 (NPDES permit #NC0084204), Lumber Bridge (NPDES
permit #NC0085685) and Sanchez Drive (NPDES permit #NC0086991) for April, May, June and July,
2012. Apart from the falsification issues noted in Section III of this report, it appears that the laboratory
accurately transcribed the July 2 and July 3, 2012 data (which were the only original observations
retained) and was accurately transcribing contract laboratory data.
V. CONCLUSIONS:
Ms. Locklear's candor during the initial audit and subsequent investigation, her swift attention to corrective
actions and Mr. Neville's immediate action to remove Ms. Radford from any duties associated with
generating compliance data have all contributed to the decision of this office not to take any enforcement
action at this time.
Correcting the above -cited findings and implementing the recommendations will help this lab to produce
quality data and meet certification requirements. The inspector would like to thank the staff for its
assistance during the inspection, data review process and Compliance Enforcement Investigation.
Please respond to all findings.
Report prepared by: Jeffrey R. Adams Date: October 16, 2012
Report reviewed by: Dana Satterwhite Date: November 5, 2012

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FEB 1 2013
DWO
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Pat McCrory Charles Wakild, P. E. John E. Skvarla, Ill
Governor Director Secretary
February 5, 2013
5628
Ms. Debbie Locklear
Robeson County Water Dept.
265 McGirt Road
Maxton, NC 28364-
Subject: Inspection Report Corrective Action
Dear Ms. Locklear:
Your correspondence, received November 26, 2012, concerning corrective actions taken in response to
the laboratory inspection performed on July 31 and September 13, 2012 has been reviewed. The quality
control measures, taken in reference to the Findings cited in the November 8, 2012, inspection report are
acceptable with the following exceptions and comments:
D. Finding: The annual calibration curve verification does not always bracket the concentration of
the annual Proficiency Testing (PT) samples.
Requirement: , For analytical -procedures requiring analysis of a series of standards, the
concentrations of those standards must bracket the concentration of the samples analyzed. Ref: NC
WW/GW LC Approved Procedure for Field Analysis of Total Residual Chlorine.
Laboratory Response: No written response for this finding was noted by the laboratory in its
response to the inspection report.
Auditor Response: The laboratory did not state this finding in its response to the inspection
report, but did include the requested calibration curve which does address the finding. The
calibration curve concentrations for Total Residual Chlorine does bracket the Proficiency Testing
(PT) samples. No further response is necessary.
Please continue to follow all approved methods, rules and regulations.
Thank you again for your cooperation during the inspection. Contact us at (919)
733 — 3908 Ext.249 if you have any questions or need additional information regarding our
requirements.
Sincerely,
Jeffrey R. Adams
Certification Auditor
Laboratory Section
cc: Dana Satterwhite
Fayetteville Regional Office
DENR DWQ Laboratory Section NC WastewaterffGroundwater Laboratory Certification Branch
1623 Mail Service Center, Raleigh, North Carolina 27699-1623
Location: 4405 Reedy Creek Road. Raleigh. North Carolina 27607-6445
Phone: [phone] FAX: [phone]
Internet www.dwolab.oro
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