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HomeMy WebLinkAbout#5085_0429_finalTS_2015_ INSPECTION REPORT ROUTING SHEET To be attached to all inspection reports in-house only. Laboratory Cert. #: 5085 Laboratory Name: Laurinburg-Maxton Airport Inspection Type: Field Maintenance Inspector Name(s): Tonja Springer & Beth Swanson Inspection Date: April 29, 2015 & May 6, 2015 Date Report Completed: May 28, 2015 Date Forwarded to Reviewer: May 29, 2015 Reviewed by: Beth Swanson Date Review Completed: June 3, 2015 Cover Letter to use: Insp. Initial Insp. Reg. Insp. No Finding Insp. CP Corrected Insp. Reg. Delay Unit Supervisor/Chemist III: Dana Satterwhite Date Received: June 3, 2015 Date Forwarded to Linda: June 5, 2015 Date Mailed: June 8, 2015 _____________________________________________________________________ On-Site Inspection Report LABORATORY NAME: Laurinburg-Maxton Airport ADDRESS: 16701 Airport Rd. Maxton, NC 28364 NPDES PERMIT # NC0044725, NC0005479 CERTIFICATE #: 5085 DATE OF INSPECTION: April 29, 2015 and May 6, 2015 TYPE OF INSPECTION: Field Maintenance AUDITOR(S): Tonja Springer and Beth Swanson LOCAL PERSON(S) CONTACTED: James Croke 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 facility has all the equipment necessary to perform the analyses. Proficiency Testing (PT) samples for the 2015 proficiency testing calendar year have not yet been analyzed. The laboratory is reminded that these results must be submitted to this office directly from the vendor by September 30, 2015. Contracted analyses are performed by TBL Environmental Laboratory, Inc. (Certification #37) and Meritech, Inc. (Certification #165). Current quality assurance policies for Field Laboratories, an example benchsheet and approved procedures for the analysis of the facility’s currently certified parameters were provided at the time of the inspection. The requirements associated with Findings E, K, L, and M have been implemented by our program since the last inspection. III. FINDINGS, REQUIREMENTS, COMMENTS AND RECOMMENDATIONS: Documentation Comment: The laboratory needs to increase the documentation of purchased pH buffers and Total Residual Chlorine reagents and standards. Dates received and opened were written on the top of the bottle lid for the DPD powder packets. While this can provide a traceability link to analyses by looking at the dates that the chemicals were in use, that link is lost once the bottles are discarded. The Quality Assurance Policies for Field Laboratories document states: All chemicals, reagents, standards and Page 2 #5085 Laurinburg-Maxton Airport 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. 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. This is a new required that was implemented since the last inspection. Demonstration of acceptable corrective action (i.e., an updated benchsheet that included all the required traceability information with an implementation date of 05/05/2015) was observed on the second day of inspection conducted on 05/06/2015. No further response is necessary for this finding. Comment: As a reminder, whenever changes occur (such as new reagents are purchased, a new TRC curve is verified, etc.) information will need to be updated on the original benchsheet template in the computer and an updated benchsheet printed. A. Finding: Several instances of writing over a number as a means of error correction were observed. Error corrections were not initialed or dated. 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. B. Finding: Numbers ending with a “5” are not properly rounded. Requirement: Round off by dropping digits that are not significant. If the digit 6, 7, 8, or 9 is dropped, increase preceding digit by one unit; if the digit 0, 1, 2, 3, or 4 is dropped, do not alter preceding digit. If the digit 5 is dropped, round off preceding digit to the nearest even number: thus 2.25 becomes 2.2 and 2.35 becomes 2.4. Ref: Standard Methods, 1050 B-2006. (2). Comment: If the digit 5 is dropped, the laboratory is not rounding off the preceding digit to the nearest even number. For example, 8.55 is being reported as 8.5 by the laboratory and not 8.6. Quality Control C. Finding: Data from the contract lab reports that does not meet all quality control requirements is not qualified on the Discharge Monitoring Report (DMR). Requirement: When quality control (QC) failures occur, the laboratory must attempt to determine the source of the problem and must apply corrective action. Part of the corrective action is notification to the end user. If data qualifiers are used to qualify samples not meeting QC requirements, the data may not be useable for the intended purposes. It is the responsibility of the laboratory to provide the client or end-user of the data with sufficient information to determine the usability of the qualified data. Where applicable, a notation must be made on the Discharge Monitoring Report (DMR) form or Electronic Discharge Monitoring Report (eDMR), in the comment section or on a separate sheet attached to the DMR form, when any required sample quality control does not meet specified criteria and another sample cannot be obtained. Ref: Quality Assurance Policies for Field Laboratories. Page 3 #5085 Laurinburg-Maxton Airport Comment: On 01/06/2015 the BOD qualifier “E” which states the glucose/glutamic acid standard exceeded the range of 198 +/- 30.5 mg/L, was not documented on the DMR for the Effluent and Influent results for NPDES # NC0044725. Total Residual Chlorine – Standard Methods, 4500 Cl G-2000 pH – Standard Methods, 4500 H+ B-2000 Dissolved Oxygen – Standard Methods, 4500 O G-2001 Temperature – Standard Methods, 2550 B-2000 Comment: The laboratory benchsheets for pH, Dissolved Oxygen, Temperature and Total Residual Chlorine (TRC) were lacking pertinent data: Instrument identification. The NC WW/GW LC Approved Procedure for the Analysis of pH, NC WW/GW LC Approved Procedure for the Analysis of DO, NC WW/GW LC Approved Procedure for the Analysis of Temperature, and NC WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine documents state: The following must be documented in indelible ink whenever sample analysis is performed: Instrument identification. This requirement is a new policy that has been implemented by our program since the last inspection. Demonstration of acceptable corrective action (i.e., an updated completed benchsheet with instrument identification and an implementation date of 05/05/2015) was observed on the second day of inspection conducted on 05/06/2015. No further response is necessary for this finding. Total Residual Chlorine – Standard Methods, 4500 Cl G-2000 Comment: The laboratory is not verifying the instrument’s factory set curve every 12 months. The last curve verification was performed on 03/05/2013. The NC WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine states: Analyze a calibration blank to zero the instrument and then analyze a series of five standards (do not use gel or sealed liquid standards for this purpose). The curve verification must check 5 concentrations (not counting the blank) that bracket the range of the sample concentrations to be analyzed. This type of standard curve verification must be performed at least every 12 months. The values obtained must not vary by more than 10% of the known value for standard concentrations greater than or equal to 50 g/L and must not vary by more than 25% of the known value for standard concentrations less than 50 g/L. The overall correlation coefficient of the curve must be ≥0.995. Demonstration of acceptable corrective action (i.e., a curve verification that was performed on 04/28/2015 by Leith Creek WWTP Lab (Certification #133)) was observed at the time of the inspection on 04/29/2015. No further response is necessary for this finding. Recommendation: It is recommended that when the annual verification curve is analyzed next year with a permit limit of 28 µg/L, the laboratory verify the internal calibration using the following concentrations: 20 (or 25), 30, 50, 200 and 400 µg/L. This will verify the analytical range used to measure Proficiency Testing (PT) samples, gel standards; as well as, environmental samples. Comment: The Gel® standard is not verified every 12 months. The last verification was done on 03/05/2013. At the time of the inspection the analyst tried to obtain a true value by reading the gel standard 3 times and using the average. The gel standard readings were erratic and a true value could not be established. The gel standard also appeared to have scratches etched on the sides of the vial. The erratic readings may indicate a problem with either the gel standard or the meter. The NC WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine document states: Purchased “Gel-type” or sealed liquid ampoule standards may be used for daily standard curve verification only. These standards must be verified initially and every 12 months thereafter, with the standard curve. When this is done, these standards may be used after the manufacturer’s expiration date. It is only necessary to verify the gel or sealed liquid standard which falls within the concentration range of the curve used to measure sample concentrations. Demonstration of acceptable corrective action (i.e., on 5/1/2015 a gel standard was borrowed from City of Hamlet WWTP (Certification #5114) Page 4 #5085 Laurinburg-Maxton Airport and read on program (86) 3 times and the average taken to obtain a true value of 179 µg/L which was recorded on an updated completed benchsheet with an implementation date of 05/1/2015) was observed on the second day of the inspection on 5/6/2015. It was determined that the problem was with the original gel standard and not the meter. An additional notification of acceptable corrective action (i.e., new gel standards were purchased and read on program (86) 3 times and the average taken to obtain a true value of 224 µg/L which was included on an updated completed benchsheet with an implementation date of 5/5/2015) was observed on the second day of the inspection on 5/6/2015. No further response is necessary for this finding. Recommendation: The DR 2700 spectrophotometer that the laboratory is currently using is obsolete and can no longer be serviced according to the manufacturer. The analyst also indicated that sometimes the buttons do not work on the meter and a pencil or pen has to be used to press the buttons. It is recommended that the laboratory budget for the purchase a new spectrophotometer. Comment: If a new spectrophotometer is purchased, the meter’s internal calibration must be verified and a true value must be determined and assigned to the gel standard prior to analyzing samples. D. Finding: Values are not reported on the DMR as less than the lowest calibration verification standard. Requirement: The concentrations of the calibration standards must bracket the concentrations of the samples analyzed. One of the standards must have a concentration equal to or below the lower reporting concentration for Total Residual Chlorine. The lower reporting limit must be less than or equal to the permit limit. Ref: NC WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine. Comment: The laboratory established a lower reporting limit on 04/28/2015 of 10 µg/L. Values with concentrations less than that must be reported as <10 µg/L on the DMR. The laboratory has continued reporting <25 µg/L on the DMR beyond 4/28/2015 based on the established lower reporting limit of the 03/05/2013 annual verification curve. Please provide an implementation date with your corrective actions response. E. Finding: The meter calibration time is not being documented. Requirement: The following must be documented in indelible ink whenever sample analysis is performed: Meter calibration time. Ref: NC WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine. Please submit 5 weeks of updated completed benchsheets that include sample results with the response to this report. F. Finding: The sample cuvette appeared discolored and the inside of the meter appeared dirty. Requirement: A best effort must be made to perform analyses in a manner where possible sources of contamination or error will not be introduced. For example: Dirty interior work area, unclean cuvettes. Ref: Quality Assurance Policies for Field Laboratories. Requirement: Clean the enclosure, sample cell compartments and all accessories with a soft damp cloth. A mild soap solution can also be used. Do not get excess water in the sample cell compartments. Do not insert a brush or sharp object into Cell Compartment #1 to avoid damaging the mechanical components. • Dry the cleaned parts carefully with a soft cotton cloth. 7.1.3 Sample cells CAUTION Potential Chemical/ Biological Exposure Hazards. Use proper laboratory practices whenever there is a risk of chemical exposure. 1. After performing a procedure, clean glass sample cells with cleaning agents. 2. Afterwards, rinse the sample cells Page 5 #5085 Laurinburg-Maxton Airport several times with tap water and then thoroughly with deionized water. Ref: Hach DR 2700 User Manual Sections 7.11 and 7.13. Comment: During the inspection the analyst discovered that he had a new sample cuvette that had never been used. At the time of the inspection, Mr. Croke indicated he would begin using the new cuvette the next time he did the analysis. Please include an implementation with your corrective actions response. pH – Standard Methods, 4500 H+ B-2000 Comment: The pH meter is required to have Automatic Temperature Compensation (ATC) built in but the (ATC) check is no longer required. G. Finding: Sample results are reported to two decimal places. Requirement: By careful use of a laboratory pH meter with good electrodes, a precision of ±0.02 unit and an accuracy of ±0.05 unit can be achieved. However, ± 0.1 pH unit represents the limit of accuracy under normal conditions, especially for measurement of water and poorly buffered solutions. For this reason, report pH values to the nearest 0.1 pH unit. Ref: Standard Methods, 4500 H+ B-2000. (6). Dissolved Oxygen – Standard Methods, 4500-O G-2001 Comment: The laboratory’s National Institute of Standards and Technology (NIST) traceable mercury thermometer was recalibrated by TBL Environmental Laboratory, Inc. (#37) on 05/05/2015. Since no recalibration date is given for the laboratory’s NIST traceable thermometer, it must be recalibrated every 5 years. This thermometer can be used to verify the temperature sensor of the DO meter. Comment: The meter was not being calibrated according the manufacturer’s instructions. A moist sponge was not being kept in the calibration chamber. The analyst was unable to get the meter to stabilize at the time of the inspection. The YSI 550A Operator’s Manual states: Ensure that the sponge inside the instrument's calibration chamber is moist. Insert the probe into the calibration chamber. Membranes last longer if properly installed and regularly maintained. Erratic readings can result from loose, wrinkled, damaged, or fouled membranes, large (more than 1/8" diameter) air bubbles in the electrolyte reservoir, or membrane coating by oxygen consuming (e.g. bacteria) or oxygen producing (e.g. algae) organisms. If unstable readings or membrane damage occurs, replace both the membrane cap and electrolyte solution. Demonstration of acceptable corrective action (i.e., the analyst found a backup meter that had been repaired and a moist sponge was placed in the calibration chamber and a calibration was performed) was observed at the time of the inspection. No further response is necessary for this finding. H. Finding: The meter’s calibration is being performed but it is not documented each analysis day. Requirement: The following must be documented in indelible ink whenever sample analysis is performed. Meter calibration. Ref: NC WW/GW LC Approved Procedure for the Analysis of Dissolved Oxygen (DO). Requirement: Instruments are to be calibrated according to the manufacturer’s calibration procedure prior to analysis of samples each day compliance monitoring is performed. Ref: NC WW/GW LC Approved Procedure for the Analysis of Dissolved Oxygen (DO). Please submit 5 weeks of completed benchsheets with the response to this report. Page 6 #5085 Laurinburg-Maxton Airport Requirement: The laboratory must document each time that a calibration is performed. Calibration documentation must include the following, where applicable to the instrument used and the type of calibration performed: elevation, temperature, barometric pressure (in mmHg), salinity, slope, or %efficiency. Simply recording a final reading (in mg/L) for instruments that auto calibrate (e.g., LDO sensors and Membrane Electrodes that AUTOCAL) is also acceptable. Ref: NC WW/GW LC Approved Procedure for the Analysis of Dissolved Oxygen (DO). Comment: There is a column labelled as “Adjusted Air Calibration” on the updated benchsheet for DO but the analyst is simply writing “mg/L” in the space below the header. The value obtained when the meter is calibrated is the value that must be written in this space. Temperature – Standard Methods, 2550 B-2000 I. Finding: The temperature sensor on the Dissolved Oxygen meter used to obtain reported temperature values has not been checked against a NIST traceable thermometer in the last 12 months. Requirement: Thermometers and temperature measuring devices, used to measure temperature for compliance monitoring, must be checked every 12 months against a NIST traceable thermometer. The thermometer/meter readings must be less than or equal to 1ºC from the NIST traceable thermometer reading. The documentation must include the serial number of the NIST traceable thermometer that was used in the comparison. Document any correction that applies on both the thermometer/meter and on a separate sheet to be filed. Ref: NC WW/GW LC Approved Procedure for the Analysis of Temperature. Please submit a copy of the temperature sensor verification with the response to this report. J. Finding: The laboratory is not documenting the following information for compliance Temperature measurements: time of analysis, collection time, and method reference. Requirement: The following must be documented in indelible ink whenever sample analysis is performed: Date and time of sample collection, date and time of sample analysis. Alternatively, one time may be documented for collection and analysis with the notation that samples are measured in situ or immediately at the sample site. Ref: The NC WW/GW LC Approved Procedure for the Analysis of Temperature. Please submit 5 weeks of updated completed benchsheets that include sample results with the response to this report. Comment: The reported temperature readings are recorded on the daily log and not the benchsheet. The daily log does not have time of analysis, collection time, and method reference documented. Comment: An updated benchsheet that merges the daily log information and the benchsheet was provided to the laboratory by email on 05/27/2015. There is space provided on this benchsheet to document Temperature and the required supporting information. Proficiency Testing K. Finding: The preparation of TRC Proficiency Testing (PT) samples is not documented. Requirement: PT samples received as ampules must be diluted according to the PT provider’s instructions. The preparation of PT samples must be documented in a traceable log or other Page 7 #5085 Laurinburg-Maxton Airport traceable format. The diluted PT sample becomes a routine environmental sample and is added to a routine sample batch for analysis. Ref: Proficiency Testing Requirements, February 20, 2012, Revision 1.2. Comment: Dating and initialing the instruction sheet for the preparation of the TRC PT would satisfy the documentation requirement. L. Finding: The laboratory is not documenting PT sample analyses in the same manner as environmental samples. Requirement: All PT sample analyses must be recorded in the daily analysis records as for any environmental sample. This serves as the permanent laboratory record. Ref: Proficiency Testing Requirements, February 20, 2012, Revision 1.2. Comment: PT samples are not being documented on the benchsheets. Results were only documented on the vendor reporting form then submitted to the vendor by fax and the form is retained and kept of file. M. Finding: The laboratory is not analyzing PT samples in the same manner as environmental samples. Requirement: 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. Ref: Proficiency Testing Requirements, February 20, 2012, Revision 1.2. Comment: The laboratory’s common practice was to analyze a known standard along with the PT sample as additional quality control. Since this is not performed with all environmental samples, it is considered additional quality control. However, known samples are recommended when analyzing remedial PT samples as part of the troubleshooting and corrective action process. IV. PAPER TRAIL INVESTIGATION: The paper trail consisted of comparing original records (e.g., laboratory benchsheets, logbooks, etc.) and contract lab reports to Discharge Monitoring Reports (DMRs) submitted to th e North Carolina Division of Water Resources. Data were reviewed for Laurinburg-Maxton Airport (NPDES #NC0044725), and Laurel Hill WWTP (NPDES #NC0005479) for January and February, 2015. The following errors were noted. Date Parameter Location Sample Type Value on Benchsheet Value on DMR 1/6/2015 DO Laurel Hill NC0005479 Effluent No value documented 5.99 mg/L 1/21/2015 Temperature Laurel Hill NC0005479 Upstream 8.55 ºC 8.5 ºC 1/21/2015 Temperature Laurel Hill NC0005479 Effluent *9 ºC 7 ºC 2/2/2015 BOD Laurel Hill NC0005479 Influent ● 38.0 mg/L 39 mg/L 2/16/2015 Fecal Coliform Laurel Hill NC0005479 Effluent ●<1 col/100 mL No result Page 8 #5085 Laurinburg-Maxton Airport Date Parameter Location Sample Type Value on Benchsheet Value on DMR 2/2/2015 DO Laurinburg-Maxton Airport NC0044725 Effluent 9.11 mg/L 8.37 mg/L 2/2/2015 Temperature Laurinburg-Maxton Airport NC0044725 Effluent 16.3 ºC 14.2 ºC 2/3/2015 DO Laurinburg-Maxton Airport NC0044725 Effluent 10.56 mg/L 9.12 mg/L 2/3/2015 Temperature Laurinburg-Maxton Airport NC0044725 Effluent 10.4 ºC 12.9 ºC 2/4/2015 DO Laurinburg-Maxton Airport NC0044725 Effluent 9.61 mg/L 7.95 mg/L 2/4/2015 Temperature Laurinburg-Maxton Airport NC0044725 Effluent 11.9 ºC 12.7 ºC 2/9/2015 DO Laurinburg-Maxton Airport NC0044725 Effluent 9.16 mg/L 7.90 mg/L 2/9/2015 Temperature Laurinburg-Maxton Airport NC0044725 Effluent 14.4 ºC 14.3 ºC 2/11/2015 Temperature Laurinburg-Maxton Airport NC0044725 Effluent 11.1 ºC 13.3 ºC 2/11/2015 DO Laurinburg-Maxton Airport NC0044725 Effluent 9.45 mg/L 8.14 mg/L 2/12/2015 Temperature Laurinburg-Maxton Airport NC0044725 Effluent 12.7 ºC 13.3 ºC 2/12/2015 DO Laurinburg-Maxton Airport NC0044725 Effluent 9.45 mg/L 7.87 mg/L 2/16/2015 Temperature Laurinburg-Maxton Airport NC0044725 Effluent 9.7 ºC 11.0 ºC 2/16/2015 DO Laurinburg-Maxton Airport NC0044725 Effluent 9.54 mg/L 9.0 mg/L 2/17/2015 Temperature Laurinburg-Maxton Airport NC0044725 Effluent 9.2 ºC 11.0 ºC 2/17/2015 DO Laurinburg-Maxton Airport NC0044725 Effluent 9.54 mg/L 8.44 mg/L 2/18/2015 Temperature Laurinburg-Maxton Airport NC0044725 Effluent 11.4 ºC 12.4 ºC 2/18/2015 DO Laurinburg-Maxton Airport NC0044725 Effluent 9.30 mg/L 8.23 mg/L 2/23/2015 DO Laurinburg-Maxton Airport NC0044725 Effluent 8.9 mg/L 8.27 mg/L Page 9 #5085 Laurinburg-Maxton Airport 2/23/2015 Temperature Laurinburg-Maxton Airport NC0044725 Effluent 13.8 ºC 12.9 ºC 2/24/2015 DO Laurinburg-Maxton Airport NC0044725 Effluent 9.41 mg/L 8.75 mg/L *Matched the value recorded on the benchsheet. ●Result is from Contract lab report Recommendation: The laboratory is recording the results on both the daily log and the benchsheet. This may have contributed to the errors noted above. It is recommended that sample results be documented on one sheet instead of two. A revised benchsheet that merges the benchsheet and the daily log was provided to the laboratory on 6/1/2015. Recommendation: Due to the number of errors noted in the paper trail investigation, it is recommended that a system of checking the data entered on the DMR be implemented. It would be beneficial to have a second person review the accuracy of data transcription to the DMR. At a minimum, the person entering the data should review the transcriptions to the DMR after some time has passed from the original data entry. In order to avoid a possible monitoring frequency violation and questions of legality it is recommended that you contact the appropriate Regional Office for guidance as to whether amended Discharge Monitoring Reports will be required. A copy of this report will be made available to the Regional Office. V. CONCLUSIONS: 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 and data review process. Please respond to all findings and include an implementation date for each corrective action. Report prepared by: Tonja Springer Date: May 28, 2015 Report reviewed by: Beth Swanson Date: June 3, 2015