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HomeMy WebLinkAbout#5101_0513finalTS_2015_0 HOENR North Carolina Department of Environment and Natural Resources Pat McCrary Donald R, van der Vaart Governor Secretary August 17, 2015 5101 Duke Energy Carolinas — Cape Fear Plant Henry G. Gales 500 CP&L Road Moncure, NC 27559 Subject: North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW LC) Maintenance Inspection Dear Mr. Gales: Enclosed is a report for the inspection performed on May 13, 2015 by Tonja Springer. 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 of receipt, please supply this office with a written item for item description of how these finding(s) were corrected 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. Copies of the checklists completed during the inspection may be requested from this office. Thank you for your cooperation during the inspection. If you wish to obtain an electronic copy of this report by email or if you have questions or need additional information, please contact us at (919) 733-3908. Attachment cc: Tonja Springer Dana Satterwhite Sincerely, Dana Satterwhite, Environmental Program Supervisor Division of Water Resources Water Sciences Section NC Wastewater/Groundwater Laboratory Certification Branch 1623 Mail Service Center, Raleigh, North Carolina 27699-1623 Location: 4405 Reedy Creek Road, Raleigh, North Carolina 27607 Phone: 919-733-39081 FAX: 919-733-6241 Internet: www,dM[ab.org An Equal Opportunityk Affirmative Action Employer INSPECTION REPORT ROUTING SHEET To be attached to all inspection reports in-house only. Laboratory Cert. #: Laboratory Name: Inspection Type: Inspector Name(s): Inspection Date: Date Report Completed: Date Forwarded to Reviewer: Reviewed by: Date Review Completed: Cover Letter to use: Unit Supervisor/Chemist III: Date Received: Date Forwarded to Linda: Date Mailed: 5101 Duke Energy Carolinas -Cape Fear Plant Field Maintenance Tonia Springer May 13, 2015 June 25, 2015 June 25, 2015 Jason Smith June 26, 2015 ❑ Insp. Initial ® Insp. Reg. ❑ Insp. No Finding ❑ Insp. CP ❑ Corrected ❑ Insp. Reg. Delay Dana Satterwhite June 26 2015 and Auqust 7, 2015 August 17 2015 August 17 2015 Mr. Steve Cohoon was contacted 07/14/2015 and an email was sent outlining the items in the report for additional corrective actions responses but a reply was not sent. On -Site Inspection Report LABORATORY NAME: ADDRESS: WATER QUALITY PERMIT # CERTIFICATE #: DATE OF INSPECTION: TYPE OF INSPECTION: AUDITOR(S): LOCAL PERSON(S) CONTACTED: INTRODUCTION: Duke Energy Carolinas — Cape Fear Plant 500 CP&L Road Moncure, NC 27559 NC0003433 5101 May 13, 2015 Field Maintenance Tonja Springer Henry G. Gales, III and Johnathan Stamas 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: At the time of the inspection, the facility had not had any flow for 17 months; therefore, there was no compliance monitoring data to review. There was no proficiency testing data for review since proficiency testing data was not documenting PT sample analyses in the same manner as environmental samples. The facility has all the equipment necessary to perform the analyses. Proficiency Testing (PT) samples have been analyzed for all certified parameters for the 2015 proficiency testing calendar year and the graded results were 100% acceptable. Contracted analyses are performed by Pace Analytical Services, Inc. (Certification #67) and Pace Analytical Services, Inc. Asheville (Certification #40). 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 A, C and I have been implemented by our program since the last inspection. III. FINDINGS, REQUIREMENTS, COMMENTS AND RECOMMENDATIONS: Documentation A. Finding: Instrument identification was not documented on the pH and Temperature benchsheet. Page 2 #5101 Duke Energy Carolinas - Cape Fear Plant Requirement: The following must be documented in indelible ink whenever sample analysis is performed: Instrument identification. Ref: NC WW/GW LC Approved Procedure for the Analysis of pH and NC WW/GW LC Approved Procedure for the Analysis of Temperature. Please submit a benchsheet implementation date with the response to this report. Comment: An updated benchsheet which included Instrument identification was received by email on May 20, 2015 but the date of implementation was not given. B. Finding: Indelible ink was not used to record pertinent information for pH and Temperature. Requirement: The following must be documented in indelible ink whenever sample analysis is performed. Ref: NC WW/GW LC Approved Procedure for the Analysis of pH and the NC WW/GW LC Approved Procedure for the Analysis of Temperature. Please submit an implementation date with the response to this report. Comment: Original observations are documented using a pencil and then the results are typed in the computer and printed. Comment: Notification of acceptable corrective action was received by email on May 20, 2015, stating "ink will be used in the future", but an implementation date was not given. C. Finding: The laboratory needed to increase the documentation of purchased pH buffers. Requirement: 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. Consumable materials such as PH buffers and lots of pre -made standards are included in this requirement. Ref: Quality Assurance Policies for Field Laboratories. Please submit an implementation date with the response to this report. Comment: Demonstration of acceptable corrective action (i.e., an updated benchsheet which included spaces to record traceability information for pH buffers) was received by email on May 20, 2015 but no implementation date was given. pH — Standard Methods, 4500 H+ B-2000 Comment: The pH meter is required to have an Automatic Temperature Compensating (ATC) device, but the (ATC) check is no longer required. D. Finding: Units of measure (i.e.,) were not documented. Requirement: Data pertinent to each analysis must be maintained for five years. Certified Data must consist of date collected, time collected, samples site, sample collector, and sample analysis time. The field benchsheets must provide a space for the signature of the analyst, and proper units of measure for all analyses. Ref: The North Carolina Administrative Code, 15A NCAC 2H .0805 (g) (1). Please submit an implementation date with the response to this report. Comment: Demonstration of acceptable corrective action (i.e., an updated benchsheet which includes units of measure) was received by email on May 20, 2015 but no implementation was given. E. Finding: The meter is calibrated each analysis day but the time was not documented. Page 3 #5101 Duke Energy Carolinas - Cape Fear Plant 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 pH. Please submit an implementation date with the response to this report. Comment: Demonstration of acceptable corrective action (i.e., an updated benchsheet with a column to document the calibration time) was received by email on May 20, 2015 but an implementation date was not given. F. Finding: The pH check buffer is not clearly labelled on the benchsheet as the check buffer. Requirement: The following must be documented in indelible ink whenever sample analysis is performed: True value for the check standard buffer. Ref: NC WW/GW LC Approved Procedure for the Analysis of pH. Please submit a copy of an updated benchsheet including an implementation date with the response to this report. Comment: A revised benchsheet was submitted on May 20, 2015 and it has a 7.0 Standard Unit (S.U.) buffer documented but it does not have the 7.0 S.U. buffer identified as the check buffer to distinguish it from the calibration buffers. The acceptance criteria of the check buffer (verification of ± 0.1 S.U.) must also be documented. This can be put on the bottom of the page as well. Recommendation: If there is not enough space to add the check buffer, a statement can be written on the bottom of the page to say "the 7.0 S.U. buffer listed above is the check buffer". Temperature — Standard Methods, 2550 B-2000 pH — Standard Methods, 4500 H+ B-2000 G. Finding: The benchsheet does not clearly document the sample collection and sample analysis times for Temperature and pH measurements. 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: NC WW/GW LC Approved Procedure for the Analysis of Temperature. Please submit a copy of an updated benchsheet and an implementation date with the response to this report. 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 to verify the 15 minute holding time is met. 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: NC WW/GW LC Approved Procedure for the Analysis of pH. Comment: Temperature is measured in -situ and pH is measured at the bench, but there were spaces to enter only one sample collection time and one analysis time for each parameter. A revised benchsheet was submitted on 5/20/2015 by email, which has "pH/Temp" as a column header to document the sample collection time for both parameters and "pH su" as a column header to document pH sample analysis time. A statement added at the bottom of the benchsheet to indicate why only one time for Temperature is documented will satisfy this requirement. For example: Temperature is measured "in situ". Page 4 #5101 Duke Energy Carolinas - Cape Fear Plant Temperature — Standard Methods, 2550 B-2000 H. Finding: The temperature correction was not posted on the thermometer used for Temperature measurements. Requirement: The temperature correction (even if it is zero) must be posted on the thermometer/meter as well as in hard copy format (to be retained for 5 years). Ref: NC WW/GW LC Approved Procedure for the Analysis of Temperature. Please submit an implementation date with the response to this report. Comment: Notification of acceptable corrective action (i.e., a statement that the lab will post the temperature correction on the meter monthly) was received by email on May 20, 2015 but an implementation date was not given. Comment: The thermometer is being checked monthly internally against an NIST traceable thermometer. Proficiency Testing I. Finding: The laboratory is not documenting PT sample analyses in the same manner as environmental samples. PT samples are not being documented on the benchsheets. 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. The analysis of 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: Proficiency Testing Requirements, February 20, 2012, Revision 1.2. Please submit an implementation date with the response to this report. Comment: Demonstration of acceptable corrective action (i.e., an updated benchsheet was submitted showing the last row of the benchsheet with the statement "extra space for pt sample data" documented was received by email on May 20, 2015. Also a statement was submitted "Change to worksheet to reflect this request") was received by email on May 20, 2015 but no implementation date was given. Comment: Results were only documented on the vendor reporting form then submitted electronically. The vendor reporting forms are retained for 5 years as required. IV. PAPER TRAIL INVESTIGATION: No paper trail was performed. V. CONCLUSIONS: Correcting the above -cited findings and implementing the recommendation 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: June 25, 2015 Report reviewed by: Jason Smith Date: June 26, 2015