#629_2017_0920_BS_FINAL

INSPECTION REPORT ROUTING SHEET

To be attached to all inspection reports in-house only.

Laboratory Cert. #: 629
Laboratory Name: N.L. Mitchell WTP Lab (City of Greensboro)
Inspection Type: Municipal Maintenance
Inspector Name(s): Beth Swanson
Inspection Date: September 20, 2017
Date Forwarded for Initial
Review: October 2, 2017
Initial Review by: Jason Smith
Date Initial Review
Completed: October 4, 2017
Cover Letter to use:
Insp. Initial
Insp. No Finding
Corrected

Insp. Reg
Insp. CP
Insp. Reg. Delay
Unit Supervisor/Chemist III: Dana Satterwhite
Date Received: October 4, 2017
Date Forwarded to Admin.: October 25, 2017
Date Mailed: October 25, 2017
Special Mailing Instructions:

On-Site Inspection Report

LABORATORY NAME: N.L. Mitchell WTP Lab (City of Greensboro)

NPDES PERMIT #: NC0081426

ADDRESS: 1041 Battleground Ave
Greensboro, NC 27408

CERTIFICATE #: 629

DATE OF INSPECTION: September 20, 2017

TYPE OF INSPECTION: Municipal Maintenance

AUDITOR(S): Beth Swanson

LOCAL PERSON(S) CONTACTED: Marie Shandor and Telora Kalu

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:

This facility has been undergoing construction and has not had a discharge since May 2015 but
has maintained Certification and submitted annual Proficiency Testing (PT) Samples during that
time. All Findings in this report pertain to PT Sample analysis only and comments are included
based on Findings from the Townsend Water Treatment Plant (Certification #551) report because
one supervisor oversees both facilities.

All required PT Samples have been analyzed for the 2017 PT Calendar Year and the graded
results were 100% acceptable.

The laboratory submitted their Quality Assurance (QA) and/or Standard Operating Procedures
(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 November 30, 2018.

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.

The laboratory is also 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
Page 2
#629 N.L. Mitchell WTP Lab (City of Greensboro)

(e.g., Quality Control (QC) frequency, acceptance criteria, etc.). Evaluate all SOPs for the proper
use of the word “should”.

Current 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

Comment: Review all benchsheets for proper units of measure before putting them into use for
Compliance Samples.

Comment: Review the laboratory’s system of traceability to assure all required information is
documented.

Quality Control

Comment: Any sample analyses that are duplicated must have all results reported, either by
averaging or recording the duplicate result in the comments section of the electronic Discharge
Monitoring Report (eDMR).

Proficiency Testing

A. Finding: The laboratory is not documenting PT Sample analyses in the same manner as
would be required for routine Compliance Samples.

Requirement: As specified in 15 NCAC 2H .0800, in order to meet the minimum standards
for Certification, laboratories must use acceptable analytical methods. The acceptable
methods are those defined or referenced in the current State and federal regulations for the
environmental matrix being tested. All samples, (including PT Samples) that are, or that
may, be used for Certification purposes, must be analyzed using approved methods only.
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. Laboratories must
document any exceptions. 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, May 31, 2017, Revision 2.0.

B. Finding: The laboratory does not have a documented plan for PT procedures.

Requirement: Each laboratory shall develop and maintain a document outlining the
analytical quality control practices used for the parameters included in their certification.
Supporting records shall be maintained as evidence that these practices are being
effectively carried out. Ref: 15A NCAC 2H .0805 (a) (7).

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
Page 3
#629 N.L. Mitchell WTP Lab (City of Greensboro)

process for submission of PT results and related Corrective Action Reports (CARs). Ref:
Proficiency Testing Requirements, May 31, 2017, Revision 2.0.

C. 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 Certified Parameter List (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, May 31, 2017, Revision 2.0.

Comment: The laboratory purchases and analyzes an extra known QC standard to
analyze with the PT Sample.

D. 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 (e.g., pH), but it is recommended that the instructions be maintained. Ref:
Proficiency Testing Requirements, May 31, 2017, Revision 2.0.

Comment: Dating and initialing the instruction sheet for each prepared PT Sample would
satisfy the documentation requirement.

pH – Standard Methods, 4500 H+B-2000 (Aqueous)
Chlorine, Total Residual – Hach 10014 ULR (Aqueous)

Comment: Duplicate analyses are not required for pH and TRC.

IV. PAPER TRAIL INVESTIGATION:

No paper trail was conducted due to the lack of Compliance Sample 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
Page 4
#629 N.L. Mitchell WTP Lab (City of Greensboro)

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: Beth Swanson Date: October 2, 2017
Report reviewed by: Jason Smith Date: October 4, 2017