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HomeMy WebLinkAbout#5152_2022_1018_JMS_FINAL NC Department of Environmental Quality | Division of Water Resources | Laboratory Certification Branch 4405 Reedy Creek Road | 1623 Mail Service Center | Raleigh, North Carolina 27699-1623 919-733-3908 November 22, 2022 5152 Mr. Garrett R. Hutchings Duke Power Company LLC d/b/a Duke Energy Carolinas LLC - Cliffside 13339 Hagers Ferry Road Mailcode: MG02A3 Huntersville, NC 28078- Subject: North Carolina Wastewater/Groundwater Laboratory Certification Branch (NC WW/GW LCB) Maintenance Inspection Dear Mr. Hutchings: Enclosed is a report for the inspection performed on October 18, 2022 by Jason Smith. Where Finding(s) are cited in this report, a response is required. Within thirty days, please supply this office with a written item for item description of how these Finding(s) were corrected. Please describe the steps taken to prevent recurrence and include an implementation date for each corrective action. If the Finding(s) cited in the enclosed report are not corrected, enforcement actions may be recommended. For Certification maintenance, your laboratory must continue to carry out the requirements set forth in 15A NCAC 02H .0800. A copy of the laboratory’s Certified Parameter List at the time of the audit is attached. This list will not reflect any changes made during the audit. Copies of the checklists completed during the inspection may be requested from this office. Thank you for your cooperation during the inspection. If you have questions or need additional information, please contact me at (919) 733- 3908 Ext. 251. Sincerely, Anna Ostendorff Technical Assistance & Compliance Specialist Division of Water Resources Attachment cc: Todd Crawford, Jason Smith, Master File # 5152 On-Site Inspection Report LABORATORY NAME: Duke Power Company LLC d/b/a Duke Energy Carolinas LLC - Cliffside NPDES PERMIT #: NC0005088 ADDRESS: 573 Duke Power Road Mooresboro, NC 28114 CERTIFICATE #: 5152 DATE OF INSPECTION: October 18, 2022 TYPE OF INSPECTION: Field Industrial Maintenance AUDITOR(S): Jason Smith LOCAL PERSON(S) CONTACTED: Steve Hodges and Joe Hall I. INTRODUCTION: This laboratory was inspected by a representative of the North Carolina Wastewater/Groundwater Laboratory Certification Branch (NC WW/GW LCB) to verify its compliance with the requirements of 15A NCAC 02H .0800 for the analysis of compliance monitoring samples. II. GENERAL COMMENTS: The facility is neat and well organized and has all the equipment necessary to perform the analyses. Staff were forthcoming and responded well to suggestions from the auditor. All required Proficiency Testing (PT) Samples have been analyzed for the 2022 PT Calendar Year and the graded results were 100% acceptable. Any time changes are made to laboratory procedures, QA/SOP document(s) must be updated and relevant staff retrained. Staff must acknowledge that they have read and understand the changes as part of the documented training program. The same requirements apply when changes are made in response to Findings, Recommendations or Comments listed in this report, to ensure the methods are being performed as stated, references to methods are accurate, and the QA and/or SOP document(s) is in agreement with each approved practice, test, analysis, measurement, monitoring procedure or regulatory requirement being used in the laboratory. In some instances, the laboratory may need to create an SOP to document how new functions or policies will be implemented. Revisions to the SOPs, based on the Findings, Comments and Recommendations within this report must be submitted to this office by May 31, 2023. The laboratory is reminded that SOPs are intended to describe procedures exactly as they are to be performed. Use of the word “should” is not appropriate when describing requirements (e.g., Quality Control (QC) frequency, acceptance criteria, etc.). Evaluate all SOPs for the proper use of the word “should”. Contracted analyses are performed by Duke Power Company LLC d/b/a Duke Energy Carolinas LLC (Certification #248) and Pace Analytical Services LLC - Asheville NC (Certification #40). Approved Procedure documents for the analysis of the facility’s currently certified Field Parameters were provided at the time of the inspection. Page 2 #5152 – Duke Power Company LLC d/b/a Duke Energy Carolinas LLC - Cliffside III. FINDINGS, REQUIREMENTS, COMMENTS AND RECOMMENDATIONS: Documentation A. Finding: All original records are not being maintained for five years. Requirement: All analytical records, including original observations and information necessary to facilitate historical reconstruction of the calculated results, shall be maintained for five years. Ref: 15A NCAC 02H .0805 (g) (1). Comment: The testing data is initially written on a piece of paper, transported back to the laboratory, and transferred to the benchsheet. This original paperwork is then discarded. B. Finding: Error corrections are not always properly performed. Requirement: All documentation errors shall 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; instead the correction shall be written adjacent to the error. The correction shall be initialed by the responsible individual and the date of change documented. Ref: 15A NCAC 02H .0805 (g) (1). Comment: Some instances of overwriting and crossing out with multiple lines so the original entry is not clearly legible were observed. C. Finding: The laboratory benchsheet is lacking required documentation: the method or Standard Operating Procedure reference; the instrument identification. Requirement: All laboratories shall use printable laboratory benchsheets. Certified Data shall be traceable to the associated sample analyses and shall consist of: the method or Standard Operating Procedure; the instrument identification. Each item shall be recorded each time samples are analyzed. Analyses shall conform to methodologies found in Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (2) (A) and (C). Proficiency Testing D. Finding: The laboratory is not documenting PT Sample analyses in the same manner as routine Compliance Samples. Requirement: All PT Sample analyses must be recorded in the daily analysis records as for any Compliance Sample. This serves as the permanent laboratory record. Ref: Proficiency Testing Requirements, February 19, 2020, Revision 5, Section 3.6. Requirement: The laboratory shall retain all records necessary to facilitate historical reconstruction of the analysis and reporting of analytical results for PT Samples. This means the laboratory must have available and retain for five years [pursuant to 15A NCAC 02H .0805 (a) (7) (E) and (g) (1)] all of the raw data, including benchsheets, instrument printouts and calibration data, for all PT Sample analyses and the associated QC analyses conducted by all parameter methods. Ref: Proficiency Testing Requirements, February 19, 2020, Revision 5, Section 4.0. Requirement: The analysis of Proficiency Testing (PT) Samples is designed to evaluate the entire process used to routinely analyze and report Compliance Sample results. PT Samples Page 3 #5152 – Duke Power Company LLC d/b/a Duke Energy Carolinas LLC - Cliffside must be analyzed the same as Compliance Samples. Also, documentation must be made on the same benchsheets used for Compliance Samples. Ref: NC WW/GW LCB Proficiency Testing Samples Analyzed and Documented Same as Compliance Samples Policy. Comment: The laboratory properly documents and maintains the calibration record when analyzing PT Samples but does not document the analysis on the benchsheet. E. Finding: The laboratory does not have a documented plan for PT procedures. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. A copy of each analytical method or Approved Procedure and Standard Operating Procedure shall be available to each analyst and available for review upon request by the State Laboratory. Standard Operating Procedure documentation shall state the effective date of the document and shall be reviewed every two years and updated if changes in procedures are made. Each laboratory shall have a formal process to track and document review dates and any revisions made in all Standard Operating Procedure documents. Supporting Records shall be maintained as evidence that these practices are implemented. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: Laboratories must have a documented plan [this is usually detailed in the laboratory’s Quality Assurance Manual or may be a separate Standard Operating Procedure (SOP)] of how they intend to cover the applicable program requirements for Proficiency Testing per their scope of accreditation. This plan shall cover any commercially available PT Samples and any inter-laboratory organized studies, as applicable. The laboratory must also be able to explain when PT Sample analysis is not possible for certain methods and provide a description of what the laboratory is doing in lieu of Proficiency Testing. This shall be detailed in the plan. The plan must also address the laboratory’s process for submission of PT Sample results and related Corrective Action Reports (CARs). Ref: Proficiency Testing Requirements, February 19, 2020, Revision 5, Section 3.0. Temperature – Standard Methods, 2550 B-2010 (Aqueous) F. Finding: The compliance temperature-measuring device is not checked at two temperatures that bracket the range of observed compliance sample temperatures. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: To check a compliance temperature-measuring device, compare readings at two temperatures that bracket the range of compliance samples routinely analyzed against a Reference Temperature-Measuring Device and record all four readings. The readings from both devices must agree within 0.5ºC. If they do not, the device may not be used for temperature compliance monitoring. Ref: NC WW/GW LCB Approved Procedure for the Analysis of Temperature. G. Finding: The Reference Temperature-Measuring Device is sometimes used to measure the Temperature of samples. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: A Reference Temperature-Measuring Device is an NIST traceable temperature-measuring device used only to verify the calibration of other temperature- Page 4 #5152 – Duke Power Company LLC d/b/a Duke Energy Carolinas LLC - Cliffside measuring devices. Ref: NC WW/GW LCB Approved Procedure for the Analysis of Temperature. H. Finding for Immediate Response: Temperature sensor check readings for devices used for compliance monitoring varied more than 0.5 °C (0.9 °F) from the Reference Temperature- Measuring Device reading. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: To check a compliance temperature-measuring device, compare readings at two temperatures that bracket the range of compliance samples routinely analyzed against a Reference Temperature-Measuring Device and record all four readings. The readings from both devices must agree within 0.5 ºC. If they do not, the device may not be used for temperature compliance monitoring. Ref: NC WW/GW LCB Approved Procedure for the Analysis of Temperature. Comment: The permit requires that Temperature be reported in degrees Fahrenheit. In order to meet the requirements, the readings must be within 0.9 ºF of each other. Comment: A NOFIR was issued during the inspection so that the Finding would be corrected more quickly than the normal inspection report process allows, since compliance data results are being directly affected. Comment: The laboratory agreed to use their NIST traceable thermometer referenced in Finding G for Temperature measurements until an acceptable verification is performed and submitted for review. This thermometer is within its calibration date and the accuracy is acceptable for reporting Temperature. Since it has been used for analyzing samples, it will need to be recalibrated or replaced before doing the next thermometer verification. Comment: The laboratory submitted an acceptable verification of the pH meter on October 20, 2022 and may resume using it for Temperature analyses. IV. PAPER TRAIL INVESTIGATION: The paper trail consisted of comparing original records (e.g., laboratory benchsheets, logbooks, etc.) and contract laboratory reports to Discharge Monitoring Reports (DMRs) submitted to the North Carolina Division of Water Resources. Data were reviewed for Duke Power Company LLC d/b/a Duke Energy Carolinas LLC - Cliffside (NPDES permit # NC0005088) for March, June and August 2022. No transcription errors were observed. The facility appears to be doing a good job of accurately transcribing data. V. CONCLUSIONS: Correcting the above-cited Findings will help this laboratory to produce quality data and meet Certification requirements. The inspector would like to thank the staff for their assistance during the inspection and data review process. Please respond to all Findings and include supporting documentation, implementation dates and steps taken to prevent recurrence for each corrective action. Report prepared by: Jason Smith Date: November 2, 2022 Report reviewed by: Michael Cumbus Date: November 4, 2022 Certificate Number:5152 Effective Date:1/1/2022 Expiration Date:12/31/2022 Lab Name:Duke Power Company LLC d/b/a Duke Energy Carolinas LLC - Cliffside Address:573 Duke Power Road Mooresboro, NC 28114 North Carolina Wastewater/Groundwater Laboratory Certification Certified Parameters Listing Date of Last Amendment:5/15/2015 The above named laboratory, having duly met the requirements of 15A NCAC 2H.0800, is hereby certified for the measurement of the parameters listed below. CERTIFIED PARAMETERS INORGANIC pH SM 4500 H+B-2011 (Aqueous) TEMPERATURE SM 2550 B-2010 (Aqueous) This certification requires maintance of an acceptable quality assurance program, use of approved methodology, and satisfactory performance on evaluation samples. Laboratories are subject to civil penalties and/or decertification for infractions as set forth in 15A NCAC 2H.0807.