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Home My WebLink About#300 - 2012 Insp - Final INSPECTION REPORT ROUTING SHEET To be attached to all inspection reports in-house only. Laboratory Cert. #: 300 Laboratory Name: Town of Beaufort Inspection Type: Municipal Maintenance Inspector Name(s): Todd Crawford Inspection Date: March 13, 2012 Date Report Completed: April 11, 2012 Date Forwarded to Reviewer: April 11, 2102 Reviewed by: Chet Whiting Date Review Completed: April 16, 2012 Cover Letter to use: Insp. Initial X Insp. Reg. Insp. No Finding __ Insp. CP___ Corrected Unit Supervisor: Dana Satterwhite Date Received: April 18, 2012 Date Forwarded to Linda: April 23, 2012 Date Mailed: April 23, 2012 _____________________________________________________________________ On-Site Inspection Report LABORATORY NAME: Town of Beaufort NPDES PERMIT # NC00021831 ADDRESS: 412 Hedrick St Beaufort, NC 28516 CERTIFICATE #: 300 DATE OF INSPECTION: March 13, 2012 TYPE OF INSPECTION: Municipal Maintenance AUDITOR(S): Todd Crawford LOCAL PERSON(S) CONTACTED: Larry Third I. INTRODUCTION: This laboratory was inspected to verify its compliance with the requirements of 15A NCAC 2H .0800 for the analysis of environmental samples. II. GENERAL COMMENTS: The laboratory was clean and well organized. The facility has all the equipment necessary to perform the analyses. The laboratory is reminded that any time changes are made to laboratory operations; the laboratory must update the Quality Assurance (QA)/Standard Operating Procedures (SOP) document(s). Any changes made in response to the 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 approved practice and regulatory requirements. In some instances, the laboratory may need to create a SOP to document how new functions or policy will be implemented. The requirements associated with Findings C, D, F, G and H are new policies that have been implemented by our program since the last inspection. III. FINDINGS, REQUIREMENTS, COMMENTS AND RECOMMENDATIONS: Quality Control A. Finding: The facility has not updated established Standard Operating Procedures (SOPs) since 2000. 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). Recommendation: It is recommended that SOPs include a review date history, to show maintenance, and a revision date history with a brief description of the change(s) made. Page 2 #300 Town of Beaufort B. Finding: The thermometer in the sample storage refrigerator has not been calibrated against a NIST certified or traceable thermometer in the past 12 months. Requirement: All thermometers and temperature measuring devices must be checked every 12 months against a NIST certified or NIST traceable thermometer and the process documented. To check a thermometer or the temperature sensor of a meter, read the temperature of the thermometer/meter against a NIST certified or NIST traceable thermometer and record the two temperatures. The calibration must be performed at a temperature that corresponds to the temperature used by the incubator, refrigerator, freezer, etc. In the case of temperature measuring devices used to perform variable temperature readings the calibration must be performed at a temperature range that approximates the range of the samples. The thermometer/meter readings must be less than or equal to 1ºC from the NIST certified or NIST traceable thermometer reading. The documentation must include the serial number of the NIST certified thermometer or NIST traceable thermometer that was used in the comparison. Also make any corrections to the data and document any correction that applies (even if zero) on both the thermometer/meter and on a separate sheet to be filed. • NIST traceable thermometers used for temperature measurement must be recalibrated in accordance with the manufacturer’s recalibration date. If no recalibration date is given, the NIST traceable thermometer must be recalibrated annually. • NIST certified thermometers must be recalibrated, at a minimum, every five years. A new certificate must be issued and maintained for inspection upon request. Ref: North Carolina Wastewater/Groundwater Laboratory Certification Policy. C. Finding: Auto-pipettors have not been calibrated. Requirement: Mechanical volumetric liquid-dispensing devices (e.g., fixed and adjustable auto- pipettors, bottle-top dispensers, etc.) must be calibrated at least twice per year, approximately six months apart and documented. Each liquid-dispensing device must meet the manufacturer’s statement of accuracy. Ref: North Carolina Wastewater/Groundwater Laboratory Certification Policy. Documentation D. Finding: The laboratory needs to increase the documentation of purchased materials and reagents, as well as documentation of standards and reagents prepared in the laboratory. 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 (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: North Carolina Wastewater/Groundwater Laboratory Certification Policy. Page 3 #300 Town of Beaufort Comment: A standard/reagent prep log was in place; however, there was not an adequate link to the specific analyses in which they were used. Temperature - Standard Methods, 18th Edition, 2550 B E. Finding: The temperature sensor on the Dissolved Oxygen meter used to obtain reported temperature values has not been checked against a NIST thermometer. Requirement: All thermometers, or temperature sensing devices on field meters used to measure temperature for compliance monitoring must meet NIST specifications for accuracy or must be calibrated against a NIST certified or NIST traceable thermometer annually (every 12 months) and proper corrections made and documented. A correction factor must be posted on the meter even if that correction factor is 0ºC. Ref: North Carolina Wastewater/Groundwater Laboratory Certification Policy. Total Suspended Solids - Standard Methods, 18th Edition, 2540 D Comment: Samples were not weighed to a constant weight, nor had an annual multiple weighing study, to verify the adequacy of the drying time, been performed. North Carolina Wastewater/Groundwater Laboratory Certification Policy states: Constant weights must be documented. The approved methods require the following: “Repeat the cycle of drying, cooling, desiccating, and weighing until a constant weight is obtained or until the weight change is less than 4% of the previous weight or 0.5 mg, whichever is less.” In lieu of this, an annual study documenting the time required to dry representative samples to a constant weight may be performed. Verify minimum daily drying time is greater than or equal to the time used for the initial verification study drying cycle. Drying cycles must be a minimum 1 hour for verification. Demonstration of acceptable corrective action (i.e., documentation of an acceptable drying study) was received by email on 3/26/12. No further response is necessary for this finding. F. Finding: Filters are not weighed to constant weight prior to sample analysis, nor is a dry filter blank analyzed with each set of samples. Requirement: If pre-prepared filters are not used, the method requires that filters must be weighed to a constant weight after washing. Repeat cycle of drying, cooling, desiccating, and weighing until a constant weight is obtained or until weight change is less than 4% of the previous weighing or 0.5 mg, whichever is less. In lieu of this process, it is acceptable to analyze a single daily dry filter blank to fulfill the method requirement of drying all filters to a constant weight prior to analysis. Ref: North Carolina Wastewater/Groundwater Laboratory Certification Policy based upon Standard Methods 20th Edition 2540 D. (3) (a). G. Finding: The laboratory is not basing the reporting limit on the minimum weight gain required by the method. Requirement: The minimum weight gain allowed by any approved method is 2.5 mg. Choose sample volume to yield between 2.5 and 200 mg dried residue. This establishes a minimum reporting value of 2.5 mg/L when 1000 mL of sample is analyzed. If complete filtration takes more than 10 minutes increase filter diameter or decrease sample volume. In instances where the weight gain is less than the required 2.5 mg, the value must be reported as less than the appropriate value based upon the volume used. Ref: North Carolina Wastewater/Groundwater Laboratory Certification Policy based upon Standard Methods, 20th and 21st Editions, 2540 D. (3) (b). Page 4 #300 Town of Beaufort Enterococci – Enterolert IDEXX H. Finding: The Quanti-Tray® sealer is not checked monthly for leaks. Requirement: If the Quanti-Tray® or Quanti-Tray®/2000 test is used, the sealer must be checked monthly by adding a dye (e.g., bromcresol purple) to a water blank. If dye is observed outside the wells, either perform maintenance or use another sealer. Ref: North Carolina Wastewater/Groundwater Laboratory Certification Policy. Coliform, Fecal – Standard Methods, 18th Edition, 9222 D (MF) I. Finding: Consumable materials used for the Fecal Coliform MF method are not tested prior to use to ensure that they are reliable. Requirement: When a new lot of culture medium, pads, or membrane filters is to be used, a comparison of the current lot in use (reference lot) against the new lot (test lot), be made. As a minimum, make single analyses on five positive samples. Ref: Standard Methods, 18th Edition, 9020 B. (3) (d). Include all supporting documentation with your response to this report. Recommendation: At this time the laboratory will not be able to conduct consumables testing against materials that have been previously tested. In effect the baseline for the evaluation has been lost. It is recommended that the laboratory obtain materials from a laboratory or facility that have been tested in order to reestablish a baseline evaluation against material of proven quality. Comment: Guidance for conducting the comparison was provided during the inspection. Since there is no baseline for determining the acceptability of materials currently in use, acceptable consumables from another lab must be used for the initial testing of materials currently in use. Another option would be to use a contract laboratory with acceptable consumables to perform this testing. J. Finding: Forceps are not being flamed before handling each sample filter. Requirement: Sterilize before use by dipping in 95% ethyl or absolute methyl alcohol and flaming. Ref: Standard Methods, 18th Edition, 9222 B. (1) (i). Residual Chlorine – Standard Methods, 18th Edition, 4500 Cl G K. Finding: The HACH meter’s internal curve has not been verified in last 12 months. Requirement: For colorimetric analyses, a series of five standards for a curve prepared annually or three standards for curves established each day or standards as set forth in the analytical procedure must be analyzed to establish a standard curve. Ref: 15A NCAC 02H .0805 (a) (7) (I). Recommendation: It is recommended that the laboratory verify the internal calibration using the concentrations: 10, 25, 50, 150 and 300 µg/L. This will verify the analytical range used to measure Proficiency Testing (PT) samples as well as environmental samples. L. Finding: A daily mid-range calibration check standard is not being analyzed. Requirement: The curve must be updated as set forth in the standard procedures, each time the slope changes by more than 10 percent at midrange, each time a new stock standard is prepared, or at least every twelve months. Ref: 15A NCAC 02H .0805 (a) (7) (I). Page 5 #300 Town of Beaufort IV. PAPER TRAIL INVESTIGATION: The paper trail consisted of comparing laboratory benchsheets and contract lab reports to Discharge Monitoring Reports (DMRs) submitted to the North Carolina Division of Water Quality. Data were reviewed for October, November and December, 2011. Data for metals were reviewed for January, October, November and December, 2011. No transcription errors were detected, however, values with a “less than” sign were reported in the “average” field on the DMR. When calculating an arithmetic mean, you may consider a "less than" value as equal to zero. Therefore, if all monthly values are “less than” values, the monthly arithmetic average would be “zero”. The documents, NC DWQ NPDES Permitting Guidance for DMR Calculations and Directions for Completing Monthly Discharge Monitoring Reports were provided during the inspection for additional guidance. 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. Report prepared by: Todd Crawford Date: April 11, 2012 Report reviewed by: Chet Whiting Date: April 16, 2012