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HomeMy WebLinkAbout#5600_06_2012_FINALINSPECTION 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: 5600 Nantahala Outdoor Center, Inc. Field Initial Jason Smith June 20, 2012 July 11, 2012 July 12, 2012 Todd Crawford Date Review Completed: July 16, 2012 Cover Letter to use: X Insp. Initial _ Insp. Reg. _ Insp. No Finding _ Insp. CP Unit Supervisor: Gary Francies Date Received: 7/17/2012 Date Forwarded to Linda: 7/24/2012 Date Mailed: Corrected NCDENR North Carolina Department of Environment and Natural Division of Water Quality Beverly Eaves Perdue Charles Wakild, P. E. Governor Director July 24, 2012 5600 Mr. Lance Ingram Nantahala Outdoor Center, Inc 13077 Hwy. 19 — W Bryson City, NC 28713 Dee Freeman Secretary Subject: North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW LC) Maintenance Inspection Dear Mr. Ingram: Enclosed is a report for the inspection performed on June 20, 2012 by Jason Smith. 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. 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 828-296-4677. Sincerely, Gary Francies Certification Unit Supervisor Laboratory Section Enclosure Cc: Master File Jason Smith DENR DWQ Laboratory Section NC Wastewater/Groundwater Laboratory Certification Branch 1623 Mail Service Center, Raleigh, North Carolina 27699-1623 Location: 4405 Reedy Creek Road. Raleigh, North Carolina 27607-6445 Phone: 919-733.3908 \ FAX: 919-733-6241 Internet: www.dwglab.org An Equal opportunity \ Affirmative Action Employer LABORATORY NAME: NPDES PERMIT #: ADDRESS: CERTIFICATE #: DATE OF INSPECTION: TYPE OF INSPECTION: AUDITOR(S): LOCAL PERSON(S) CONTACTED: INTRODUCTION: On -Site Inspection Report Nantahala Outdoor Center, Inc. NCO057193 13077 Hwy. 19 — W Bryson City, NC 28713 5600 June 20, 2012 Field Initial Jason Smith Lance Ingram 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: This is the initial inspection for this facility. Proficiency Testing (PT) samples were analyzed for all certified parameters for the 2011 proficiency testing calendar year in order to obtain certification. Please be reminded that acceptable PT results must be received in our office before September 30, 2012 in order to satisfy the 2012 PT requirements. III. FINDINGS, REQUIREMENTS, COMMENTS AND RECOMMENDATIONS: General Laboratory A. Finding: Error corrections were not properly performed. 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: Manufacturer assigned expiration dates are exceeded. Requirement: Adherence to manufacturer expiration dates is required (except for gel standards for Total Residual Chlorine). Chemicals, reagents, standards, consumables exceeding the expiration date can no longer be considered reliable. If the expiration is only listed as a month and year (with no specific day of the month), the last day of the month will be considered the actual date of expiration. Monitor materials for changes in appearance or consistency. Any changes may Page 2 #5600 Nantahala Outdoor Center, Inc. indicate potential contamination and the item should be discarded, even if the expiration date is not exceeded. If no expiration date is given, the laboratory must have a policy for assigning an expiration date. If no date received or expiration date can be determined, the item should be discarded. Ref: Quality Assurance Policies for Field Laboratories. Comment: The 4.0 S.U. pH buffer expired in December 2008. The 7.0 S.U. pH buffer expired in January 2009. Documentation Comment: The laboratory was not aware of the requirement to note quality control failures on the Discharge Monitoring Report. No instances of quality control failures were observed in the data review. The Quality Assurance Policies for Field Laboratories document states: 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, 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. C. Finding: The sample collection times are 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: 15A NCAC 2H .0805 (g) (1) D. Finding: Sample analysis times are 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: 15A NCAC 2H .0805 (g) (1) E. Finding: The daily log is not signed or initialed by the analyst. 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: 15A NCAC 2H .0805 (g) (1) F. Finding: The laboratory needs to increase the documentation of purchased materials and reagents. 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. 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 Page 3 #5600 Nantahala Outdoor Center, Inc. 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. Ref: Quality Assurance Policies for Field Laboratories. Proficiency Testing G. Finding: The preparation of 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 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. H. Finding: The laboratory is not documenting Proficiency Testing (PT) sample analyses in the same manner as environmental samples (i.e. on a laboratory benchsheet or field notebook). 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. Temperature — Standard Methods, 18th Edition, 2550 B I. Finding: The temperature sensor on the pH meter, which is used to obtain the temperature reported on the DMR, is not checked annually with an MIST certified or traceable thermometer. Requirement: All thermometers and temperature measuring devices must be checked every 12 months against a NISI certified or MIST 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 NISI traceable thermometer and record the two temperatures. The thermometer/meter readings must be less than or equal to 1 °C 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 document any correction that applies on both the thermometer/meter and on a separate sheet to be filed. Other certified laboratories may provide assistance in meeting this requirement. Ref: Technical Assistance for Field Analysis of Temperature. pH — Standard Methods, 181" Edition, 4500 H+ B J. Finding: The meter is not consistently calibrated each day it is used. Requirement: The meter must be calibrated prior to the analysis of samples. Ref: Technical Assistance for Field Analysis of pH. K. Finding: The meter calibration times are not documented. Requirement: Time of calibration must be documented whenever sample analysis is performed. Ref: Technical Assistance for Field Analysis of pH. L. Finding: The values of the buffers used to calibrate the meter were not documented. VJ Page 4 #5600 Nantahala Outdoor Center, Inc. Requirement: Values of buffers used for calibration must be documented whenever sample analysis is performed. Ref: Technical Assistance for Field Analysis of pH. M. Finding: The check buffer result is not recorded. Requirement: The value obtained for the check buffer must be documented whenever sample analysis is performed. Ref: Technical Assistance for Field Analysis of pH. Recommendation: It is recommended that calibration efficiency of the meter be documented. Total Residual Chlorine — Standard Methods, 181h Edition, 4500 CI G Comment: The calibration curve verification was last performed on June 24, 2011. Since this is an annual requirement, the laboratory must schedule this with their contract lab immediately. Please submit a copy of the 2012 curve verification with the reply to this report. N. Finding: A meter calibration check is not consistently performed prior to sample analyses. Requirement: instruments are to be calibrated or a calibration check must be performed prior to analysis of samples each day compliance monitoring is performed. Calibration checks must be for the curve and/or program used for sample analysis. Ref: Technical Assistance for Field Analysis of Residual Chlorine. O. Finding: The meter calibration check time is not documented. Requirement: The time the calibration check was performed must be documented whenever sample analysis is performed. Ref: Technical Assistance for Field Analysis of Total Residual Chlorine. P. Finding: The check standard result is not documented. Requirement: Value obtained for the check standard (verification of ± 10% recovery) must be documented whenever sample analysis is performed. Ref: Technical Assistance for Field Analysis of Total Residual Chlorine. PAPER TRAIL INVESTIGATION: The paper trail consisted of comparing field testing records and contract lab reports to Discharge Monitoring Reports (DMRs) submitted to the North Carolina Division of Water Quality. Data were reviewed for Nantahala Outdoor Center, Inc. (NPDES permit #NC0057193) for October, November and December, 2011. No transcription errors were detected. The facility appears to be doing a good job of accurately transcribing data. 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. Report prepared by: Jason Smith Report reviewed by: Todd Crawford Date: July 11, 2012 Date: July 16, 2012