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HomeMy WebLinkAbout#5253_2021_0630_TLH_FINAL September 3, 2021 5253 Ms. Regina Danison RDU Airport Authority P.O. Box 80001 RDU Airport, NC 27623 Subject: North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW LC) Maintenance Inspection Dear Ms. Danison: Enclosed is a report for the inspection performed on June 30, 2021 by Thomas Halvosa. I apologize for the delay in getting this report to you. 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 2H .0800. A copy of the laboratory’s Certified Parameter List at the time of the audit is attached. This list will 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. 259. Sincerely, Beth Swanson Technical Assistance & Compliance Specialist Division of Water Resources Attachment cc: Todd Crawford, Thomas Halvosa, File #5253 On-Site Inspection Report LABORATORY NAME: RDU Airport Authority NC GENERAL PERMIT #: NCS000588 ADDRESS: 1000 Trade Drive RDU Airport, NC 27623 CERTIFICATE #: 5253 DATE OF INSPECTION: June 30, 2021 TYPE OF INSPECTION: Field Municipal Maintenance AUDITOR: Tom Halvosa LOCAL PERSON CONTACTED: Regina Danison 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 was forthcoming and responded well to suggestions from the auditor. All required Proficiency Testing (PT) Samples have been analyzed and the laboratory has fulfilled its PT requirements for the 2021 PT Calendar Year. Contracted analyses are performed by Environmental Conservation Laboratories, Inc. - Cary (Certification # 591). The Approved Procedure documents for the analysis of the facility’s currently certified Field Parameters were provided at the time of the inspection. The laboratory submitted their Standard Operating Procedure (SOP) documents in advance of the inspection. These documents were reviewed and deemed acceptable. The laboratory is reminded that any time changes are made to laboratory procedures, the laboratory must update the QA/SOP document(s) and inform relevant staff. Any changes made in response to the pre-audit review or to Findings, Recommendations or Comments listed in this report must be incorporated to insure the method is 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 Page 2 # 5253 RDU Airport Authority instances, the laboratory may need to create an SOP to document how new functions or policies will be implemented. The laboratory is also reminded that SOPs are required to be reviewed at least every two years and 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”. III. FINDINGS, REQUIREMENTS, COMMENTS AND RECOMMENDATIONS: Documentation Comment: The laboratory benchsheet for Dissolved Oxygen (DO) describes the post-analysis calibration verification as a Post-Sample/End-of-day Buffer check. It is recommended that the laboratory rename this the Post-Analysis Calibration Verification. A. Finding: The laboratory benchsheets for DO and pH are lacking required documentation: the proper units of measure. Requirement: All laboratories shall use printable laboratory benchsheets. Certified Data shall be traceable to the associated sample analyses and shall consist of: proper units of measure. 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) (L). Comment: The DO benchsheet is missing % for the Drift Check result and the pH benchsheet is missing Standard Units (S.U.) for all results. B. Finding: The laboratory benchsheets for DO, pH and Temperature are lacking required documentation: the method or Standard Operating Procedure. 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. 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) (A). C. Finding: The laboratory is not documenting traceability information for purchased materials, reagents and standards. Requirement: 15A NCAC 02H .0805 (a)(7)(K) and (g)(7) requires laboratories to have a documented system of traceability for the purchase, preparation, and use of all chemicals, reagents, standards, and consumables. That system must include documentation of the following information: Date received, Date Opened (in use), Vendor, Lot Number, and Expiration Date (where specified). 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 primary standards, chemicals, reagents, and materials used for a period of five years. Consumable materials such as pH buffers, lots of pre-made standards and/or media, solids and bacteria filters, etc. are included in this requirement. Ref: NC WW/GW LCB Policy. Page 3 # 5253 RDU Airport Authority Comment: The laboratory was provided with an example receipt log to use for documenting traceability information for purchased materials, reagents and standards. D. Finding: Error corrections are not 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: The June 5, 2020 PT had an incorrect error correction for the Sample ID. The March 16, 2021 DO benchsheet had an incorrect error correction for the Pre-Sample Calibration value. In both cases, the corrected result was written over the original result and did not have an initial or date. E. Finding: The pH laboratory benchsheet is lacking required documentation: value obtained for the check standard buffer. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: The following must be documented in indelible ink whenever sample analysis is performed. Value obtained for the check standard buffer. Ref: NC WW/GW LCB Approved Procedure for the Analysis of pH. Comment: The laboratory writes a check mark for the check standard buffer result instead of the actual value obtained. Proficiency Testing F. Finding: Additional QC beyond what is routine for Compliance Samples is being analyzed with PT Samples. Requirement: Laboratories are required to analyze an appropriate PT Sample by each parameter method on the laboratory’s CPL. The same PT Sample may be analyzed by one or more methods. Laboratories shall conduct the analyses in accordance with their routine testing, calibration and reporting procedures, unless otherwise specified in the instructions supplied by the Accredited PT Sample Provider. This means that they are to be logged in and analyzed using the same staff, sample tracking systems, standard operating procedures including the same equipment, reagents, calibration techniques, analytical methods, preparatory techniques (e.g., digestions, distillations and extractions) and the same quality control acceptance criteria. PT Samples shall not be analyzed with additional quality control. They are not to be replicated beyond what is routine for Compliance Sample analysis. Although, it may be routine to spike Compliance Samples, it is neither required, nor recommended, for PT Samples. PT sample results from multiple analyses (when this is the routine procedure) must be calculated in the same manner as routine Compliance Samples. Ref: Proficiency Testing Requirements, February 19, 2020, Revision 5, Section 3.6. Comment: The laboratory analyzes the previous years’ PT as a known standard. Laboratories must not analyze additional standards with known concentrations along with PT Samples with unknown concentrations, as this is not the routine testing protocol for Compliance Samples. This is not to say that they cannot be used for troubleshooting Page 4 # 5253 RDU Airport Authority purposes before analyzing a remedial PT Sample. This would be considered part of the corrective action plan. G.Finding: PT Samples are not being analyzed in the same manner as routine Compliance Samples. Requirement: Laboratories are required to analyze an appropriate PT Sample by each parameter method on the laboratory’s CPL. The same PT Sample may be analyzed by one or more methods. Laboratories shall conduct the analyses in accordance with their routine testing, calibration and reporting procedures, unless otherwise specified in the instructions supplied by the Accredited PT Sample Provider. This means that they are to be logged in and analyzed using the same staff, sample tracking systems, standard operating procedures including the same equipment, reagents, calibration techniques, analytical methods, preparatory techniques (e.g., digestions, distillations and extractions) and the same quality control acceptance criteria. PT Samples shall not be analyzed with additional quality control. They are not to be replicated beyond what is routine for Compliance Sample analysis. Although, it may be routine to spike Compliance Samples, it is neither required, nor recommended, for PT Samples. PT sample results from multiple analyses (when this is the routine procedure) must be calculated in the same manner as routine Compliance Samples. Ref: Proficiency Testing Requirements, February 19, 2020, Revision 5, Section 3.6. Comment: The laboratory analyzes the PT Sample in duplicate and reports one result. The laboratory does not analyze Compliance Samples in duplicate. Dissolved Oxygen – Standard Methods, 4500 O G-2011 (Aqueous) H.Finding: The laboratory does not take corrective action when the Post-Analysis Calibration Verification is outside of acceptable limits. Requirement: If quality control results fall outside established limits or indicate an analytical problem, the laboratory shall identify the Root Cause of the failure. The problem shall be resolved through corrective action, the corrective action process documented, and any samples involved shall be reanalyzed, if possible. If the sample cannot be reanalyzed, or if the quality control results continue to fall outside established limits or indicate an analytical problem, the results shall be qualified as such. Ref: 15A NCAC 02H .0805 (g) (8).. Requirement: A post-check verification can be performed with the initial calibration value in mind. If, for instance, you calibrate your instrument to 98% and then conduct your DO testing, you can place the sensor back into the same calibration environment and it should read +/- 2% (+/- 1% on optical) of 98% once stable. Ref: YSI, Dissolved Oxygen Meters Q&A | The Ultimate List Patrick Higgins | Jan 31, 2017. Requirement: Calibration: Follow manufacturer’s calibration procedure exactly to obtain guaranteed precision and accuracy. Ref: Standard Methods, 4500 O G-2011. (3) (a). Comment: The laboratory performs the calibration and post-analysis calibration verifications on the DO meter using % saturation. The initial calibration values frequently show results around 80% saturation. The post-analysis calibration verifications are usually much higher (~98% saturation). The laboratory must investigate causes for the initial calibration value to vary widely from the post-analysis calibration verification value. Page 5 # 5253 RDU Airport Authority Temperature – Standard Methods, 2550 B-2010 (Aqueous) I. Finding: The annual temperature-measuring device check procedure is not performed correctly. 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 National Institute of Standards and Technology (NIST) traceable temperature-measuring device and record all four readings. The readings from both devices must agree within 0.5 ºC. Ref: NC WW/GW LCB Approved Procedure for the Analysis of Temperature. Comment: The laboratory could not provide sufficient documentation that a comparison of the compliance temperature-measuring device and a NIST thermometer was correctly performed. Documentation contained a result of 70.1 ºF which could not be determined if it was the compliance temperature-measuring device or the NIST thermometer. J. Finding: Documentation of the compliance temperature-measuring device calibration verification does not include the stated accuracy of the National Institute of Standards and Technology (NIST) traceable temperature-measuring device that was used in the comparison. This is considered pertinent data. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: All compliance temperature-measuring devices without a valid NIST certificate must be checked initially and every 12 months against an NIST traceable temperature-measuring device and the process documented. Documentation must include the serial number of the device being checked. The serial number, stated accuracy and expiration date of the NIST traceable temperature-measuring device used in the comparison must also be documented. Verification data must be kept on file and be available for inspection for 5 years. (NOTE: Vendors or other Certified laboratories may provide assistance in meeting this requirement. When a vendor or other Certified laboratory provides this assistance, they must provide a copy of their NIST Certificate or the serial number, accuracy and calibration expiration date.) Ref: NC WW/GW LCB Approved Procedure for the Analysis of Temperature. Requirement: All NIST traceable temperature-measuring devices must have a stated accuracy of at least ± 0.5°C and be within their expiration date. Ref: NC WW/GW LCB Approved Procedure for the Analysis of Temperature. 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 RDU Airport Authority (NC General Permit # NCS000588) for March 2017, January 2021 and March 2021. No transcription errors were observed. The facility appears to be doing a good job of accurately transcribing data. Page 6 # 5253 RDU Airport Authority 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: Tom Halvosa Date: July 21, 2021 Report reviewed by: Tonja Springer Date: July 26, 2021 Certificate Number:5253 Effective Date:1/1/2021 Expiration Date:12/31/2021 Lab Name:RDU Airport Authority Address:1000 Trade Drive RDU Airport, NC 27623 North Carolina Wastewater/Groundwater Laboratory Certification Certified Parameters Listing Date of Last Amendment: 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 DISSOLVED OXYGEN SM 4500 O G-2011 (Aqueous) 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.