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HomeMy WebLinkAbout#5383_2021_0524_MC_FINAL August 27, 2021 5383 Ms. Austin Blackmon P.W. Swann Water Treatment Plant 2800 River Ridge Road Pfafftown, NC 27040- Subject: North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW LC) Maintenance Inspection Dear Ms. Blackmon: Enclosed is a report for the inspection performed on June 10, 2021 by Michael Cumbus. 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, Michael Cumbus, #5383 On-Site Inspection Report LABORATORY NAME: P.W. Swann Water Treatment Plant NC GENERAL PERMIT #: NCG590003 ADDRESS: 2800 River Ridge Road Pfafftown, NC 27040 CERTIFICATE #: 5383 DATE OF INSPECTION: June 10, 2021 TYPE OF INSPECTION: Field Municipal Maintenance AUDITOR: Michael Cumbus LOCAL PERSON(S) CONTACTED: Austin Blackmon and Chris Triplett 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 02H .0800 for the analysis of compliance monitoring samples. II. GENERAL COMMENTS: The inspection was performed remotely due to the coronavirus pandemic. The laboratory submitted requested documentation and pictures of their consumables and instruments electronically. The inspection was performed via teleconference on June 10, 2021. All required Proficiency Testing (PT) Samples for the 2021 PT Calendar Year have not yet been analyzed. The laboratory is reminded that results must be received by this office directly from the vendor by September 30, 2021. The laboratory submitted their Quality Assurance (QA) and/or Standard Operating Procedure (SOP) document(s) in advance of the inspection. These documents were reviewed, and editorial and substantive revision requirements and recommendations were made by this program outside of this formal report process. Although subsequent revisions were not requested to be submitted, they must be completed by December 31, 2021. 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 instances, the laboratory may need to create an SOP to document how new functions or policies will be implemented. Page 3 #5383 P.W. Swann Water Treatment Plant 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”. Contracted analyses are performed by Environment 1, Inc. (Certification #10). Approved Procedure documents for the analysis of the facility’s currently certified Field Parameters were provided at the time of the inspection. III. FINDINGS, REQUIREMENTS, COMMENTS AND RECOMMENDATIONS: Documentation A. Finding: The laboratory is not consistently documenting all 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 LC Policy. Comment: The Phenylarsine Oxide Standard (Hach Lot# A0112) was lacking the date received. The Phenylarsine Oxide Standard received on March 11, 2020 was lacking the vendor and lot number. Comment: The Phenylarsine Oxide Standard (Hach Lot# A9156) was recorded as being received on July 29, 2020 and opened on February 12, 2020, with an expiration date of July 31, 2020. When asked for an explanation of how the system works, the laboratory commented that when chemicals arrive each container has the date received written on it and the chemicals are placed in a common stockroom. When operators need a chemical, the required information, including date received, is entered into the log at that time. The log is therefore in chronological order of date opened, not date received. The date received for the Phenylarsine Oxide Standard appears to have been a transcription error when copying the Date Received from the container to the log at the time that the standard was opened. Comment: The pH 4.0 S.U. buffer (Hach lot #A0141), the pH 7.0 S.U. buffers (Hach lot #A1012 and Fisher lot #200388) and the pH 10.0 S.U. buffer (Hach lot #A1012) are not listed on the laboratory’s traceability log. The DPD indicator and Ultra Low Range Chlorine Buffer (both Hach lot #A0203) were also not found on the traceability log. B. 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 Page 4 #5383 P.W. Swann Water Treatment Plant 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 laboratory worksheets for September 14, 2020 and November 9 and 16, 2020 include instances where the error was obliterated by overwriting, rather than crossing out and writing the correct information adjacent to the error. Comment: There were several instances where the correction lacked the date of change and the initials of the responsible individual. For example, data on the laboratory worksheet for November 9 and 16, 2020 lacked the date of the change. Entries on the laboratory worksheet for April 25, 2020 lacked the date of change and the initials of the responsible individual. C. Finding: The laboratory benchsheet is lacking required documentation. Requirement: All laboratories shall use printable laboratory benchsheets. Certified Data shall be traceable to the associated sample analyses and shall consist of: the laboratory identification; the time of sample analyses (when required to document a required holding time or when time-critical steps are imposed by the method, a federal regulation, or this Rule); the 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) (2) (B) (H) and (L). Comment: The pH calibration log is lacking the proper units of measure. Comment: The Total Residual Chlorine (TRC) Daily Check Standard Log is lacking units of measure, time of analysis, the laboratory identification (name or permit number). D. Finding: The laboratory benchsheet is lacking required documentation: date of most recent calibration curve generation or calibration curve verification. Requirement: The following must be documented in indelible ink whenever sample analysis is performed: Date of most recent calibration curve generation or calibration curve verification. Ref: NC WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine (DPD Colorimetric by SM 4500 Cl G-2011). E. Finding: The preparation of standards is not documented in such a way as to provide traceability from preparation to analysis. 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 LC Policy. Page 5 #5383 P.W. Swann Water Treatment Plant Comment: The laboratory is not documenting the in-house preparation of the standards used to verify the factory set calibration curve for TRC. Proficiency Testing F. Finding: The laboratory is not documenting the preparation of PT Samples. Requirement: PT Samples received as ampules are diluted according to the Accredited PT Sample Provider’s instructions. It is important to remember to document the preparation of PT Samples in a traceable log or other traceable format. The diluted PT Sample then becomes a routine Compliance Sample and is added to a routine sample batch for analysis. No documentation is needed for whole volume PT Samples which require no preparation, however the instructions must be maintained. Ref: Proficiency Testing Requirements, February 19, 2020, Revision 5, Section 3.6. Comment: Dating and initialing the instruction sheet for each prepared PT Sample would satisfy the documentation requirement. G. Finding: The laboratory PT benchsheet is lacking required documentation. 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 report environmental analytical results; therefore, PT samples must be analyzed and the process documented in the same manner as environmental samples. Ref: NC WW/GW LC Policy. Comment: The PT benchsheet for pH is lacking the method reference, time analyzed, the laboratory identification (name or permit number), the instrument identification (serial number preferred), sample identification (listed on the benchsheet as “pH 1”), the proper units of measure (listed on the benchsheet as “units” instead of “Standard Units” or “S.U.”) and the acceptance criterion for the check standard buffer. Comment: The PT benchsheet for TRC is lacking the method reference, the laboratory identification (name or permit number), the instrument identification (serial number preferred), the time of analysis for the calibration standards and the PT sample, acceptance criteria for the daily check standard, and the readings for the daily check standard. Comment: The laboratory uses different benchsheets for PT Samples than it does for daily compliance samples. QA/QC Page 6 #5383 P.W. Swann Water Treatment Plant H. Finding: SOPs are not being reviewed every two years. 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). Comment: The revision date for the pH SOP is listed as February 7, 2014. The revision date for the TRC SOP is listed as October 22, 2018. I. Finding: The laboratory is not properly calibrating the mechanical volumetric liquid-dispensing devices used for critical measurements. Requirement: To demonstrate compliance with these requirements, each liquid- dispensing device must meet the manufacturer’s statement of accuracy. For variable volume devices used at more than one setting, check the accuracy at the maximum, middle and minimum values. Testing at more than three volumes is optional. When a device capable of variable settings is dedicated to dispensing a single specific volume, calibration is required at that setting only. Ref: NC WW/GW LC Policy. Comment: The laboratory is calibrating a variable-setting pipet (serial number 4822616, with a capacity of 100-1000 µL) at a volume of 600 µL. Another variable setting pipet (serial number NH42082, with a capacity of 1-10 mL) is calibrated at a volume of 10 mL. Neither of these single-point calibrations meet the requirement of calibrating at the routine volume dispensed (i.e., 1000 µL) as noted in the TRC SOP. If the pipets will be used at multiple settings, then the calibration must be performed at the maximum, middle and minimum volume settings. J. Finding: The holding time for TRC and pH analyses is sometimes exceeded. Requirement: Analyze within 15 minutes. Ref: Code of Federal Regulations, Title 40, Part 136; Federal Register Vol. 82, No. 165, August 28, 2017; Table II. Comment: Samples collected for pH analysis on the following dates exceeded the holding time: April 22, 27, 28, and September 8, 16, 2020. Samples collected for TRC analysis on the following dates exceeded the holding time: September 21 and November 2, 16, 2020. Reporting K. Finding: The laboratory does not report results of all tests on the characteristics of the effluent. Requirement: The results of all tests on the characteristics of the effluent, including but not limited to NPDES permit monitoring requirements, shall be reported on the monthly report forms. Ref: 15A NCAC 2B .0506 (b) (3) (J). Comment: The laboratory is currently analyzing the effluent for Settleable Residue and Turbidity for process control purposes; these results are not reported on the DMR. The laboratory collects an additional sample for Turbidity that is analyzed by a contract lab and reported on the DMR for compliance with the permit. The laboratory must report the results of Page 7 #5383 P.W. Swann Water Treatment Plant in-house Turbidity and Settleable Residue analyses in the comments box of the DMR and note that this is uncertified data. Recommendation: It is recommended that the laboratory change the sampling point if they wish to keep analyzing these parameters. L. Finding: Data that does not meet all QC requirements or is associated with holding time exceedances is not qualified on the Discharge Monitoring Report. Requirement: Reported data associated with quality control failures, improper sample collection, holding time exceedances, or improper preservation shall be qualified as such. Ref: 15A NCAC 02H .0805 (e) (5). Comment: The following data were not qualified on the DMR for holding time exceedances: pH samples collected on April 22, 27, 28, and September 8, 16, 2020, and TRC samples collected on September 21 and November 2, 16, 2020. Chlorine, Total Residual – Standard Methods, 4500 Cl G-2011 (Aqueous) M. Finding: The true value of the gel-type standard is not determined properly. Requirement: All analytical records, including original observations and information necessary to facilitate historical reconstruction of the calculated results, shall be maintained for five years. All analytical data and records pertinent to each certified analysis shall be available for inspection upon request. Ref: 15A NCAC 02H .0805 (g) (1). Requirement: Purchased “gel-type” or sealed liquid standards may be used only for daily calibration curve verifications. These standards must have a true value assigned initially and with each subsequent calibration curve generation/verification thereafter. Ref: NC WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine (DPD Colorimetric by SM 4500 Cl G-2011). Please submit a copy of the gel verification with the report reply. Requirement: To assign a true value to the gel-type or sealed liquid standard: 1. Zero the instrument with the calibration blank. 2. Read and record gel standard values. 3. Repeat steps 1 and 2 at least two more times. 4. Assign the average value as the true value. Ref: NC WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine (DPD Colorimetric by SM 4500 Cl G-2011). Comment: The gel-type standard currently in use by the laboratory was assigned a true value initially in 2019 and subsequently in 2020 based on a single reading. N. Finding: The laboratory is not analyzing a Method Blank when using laboratory prepared standards. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: Method Blanks would be required when using laboratory-prepared standards [including PT Samples] and anytime sample dilutions are performed. Ref: NC WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine (DPD Colorimetric by SM 4500 Cl G-2011). Requirement: The Method Blank is deionized or distilled water from the same source used to prepare the calibration verification standards or the PT Sample, and is analyzed like a Page 8 #5383 P.W. Swann Water Treatment Plant sample (i.e., with DPD/buffer added). The concentration of the Method Blank must not exceed 50% of the reporting limit (i.e., the lowest calibration verification standard concentration) or corrective action must be taken. Ref: NC WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine (DPD Colorimetric by SM 4500 Cl G-2011). O. Finding: The laboratory is not verifying the instrument’s Factory-set Calibration Curve every 12 months. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: Annual Factory-set Calibration Curve Verification: This type of calibration curve verification must be performed initially, at least every 12 months and any time the instrument optics are serviced. Zero the instrument with a Calibration Blank and then analyze a Method Blank and a series of five standards (do not use gel or sealed liquid standards for this purpose). The calibration standard values obtained must not vary by more than ±10% from the known value for standard concentrations greater than or equal to 50 μg/L and must not vary by more than ±25% from the known value for standard concentrations less than 50 μg/L. Ref: NC WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine (DPD Colorimetric by SM 4500 Cl G-2011). Comment: The laboratory is performing the annual verification on the same day that PT analysis is performed. The curve was verified on August 7, 2020 and July 25, 2019. pH – Standard Methods, 4500 H+ B-2011 (Aqueous) Comment: The laboratory is currently calibrating the pH meter with three buffer standards and then analyzing a check standard. Unless the manufacturer’s directions state otherwise, the laboratory may choose to standardize with two of the three buffer standards and analyze the third as a calibration check. Recommendation: It is recommended that the laboratory analyze a check standard buffer immediately before or after analyzing the compliance sample(s), since calibration is performed at the beginning of every eight-hour shift but sample analysis is performed near the end of the same shift. P. Finding: The acceptance criterion for the check standard buffer is not being assessed. Requirement: All laboratories shall use printable laboratory benchsheets. Certified Data shall be traceable to the associated sample analyses and shall consist of: the quality control assessments. Ref: 15A NCAC 02H .0805 (g) (2) (O). Requirement: All check standard buffers must read within ±0.1 S.U. to be acceptable. If the meter verification does not read within ±0.1 S.U., corrective actions must be taken before any samples are analyzed. Ref: NC WW/GW LC Approved Procedure for the Analysis of pH. Comment: The laboratory has a log documenting the calibration and check standard verification. Notation on the cover of the log stating the true value and acceptance criteria for the check standard buffer would meet this requirement. IV. PAPER TRAIL INVESTIGATION: The paper trail consisted of comparing original records (e.g., laboratory benchsheets, logbooks, etc.) and contract laboratory reports to DMRs submitted to the North Carolina Division of Water Resources. Data were reviewed for P.W. Swann Water Treatment Plant (North Carolina General permit # NCG590003) for Page 9 #5383 P.W. Swann Water Treatment Plant April, September and November 2020. 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 and implementing the Recommendations 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: Michael Cumbus Date: June 18, 2021 Report reviewed by: Tom Halvosa Date: June 30, 2021 Certificate Number:5383 Effective Date:1/1/2021 Expiration Date:12/31/2021 Lab Name:P.W. Swann Water Treatment Plant Address:2800 River Ridge Road Pfafftown, NC 27040- 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 CHLORINE, TOTAL RESIDUAL SM 4500 Cl G-2011 (Aqueous) pH SM 4500 H+B-2011 (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.