HomeMy WebLinkAbout#5625_ 2012
INSPECTION REPORT ROUTING SHEET
To be attached to all inspection reports in-house only.
Laboratory Cert. #: 5625
Laboratory Name: Caledonia Correctional Institute
Inspection Type: Field Initial
Inspector Name(s): Todd Crawford
Inspection Date: November 1, 2012
Date Report Completed: November 8, 2012
Date Forwarded to Reviewer: November 8, 2012
Reviewed by: Chet Whiting
Date Review Completed: November 9, 2012
Cover Letter to use: Insp. Initial Insp. Reg.
Insp. No Finding Insp. CP
Corrected
Unit Supervisor: Dana Satterwhite
Date Received: November 13, 2012
Date Forwarded to Linda: November 20, 2012
Date Mailed: November 20, 2012
___Enclose updated NC WW/GW LC Approved Procedure for Field Analysis of Temperature.
__________________________________________________________________
On-Site Inspection Report
LABORATORY NAME: Caledonia Correctional Institute
NPDES Permit #: NC0027626
ADDRESS: 2787 Caledonia Drive
Tillery, NC 27887
CERTIFICATE #: 5625
DATE OF INSPECTION: November 1, 2012
TYPE OF INSPECTION: Field Initial
AUDITOR(S): Todd Crawford
LOCAL PERSON(S) CONTACTED: Geoffrey Pittard
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 is the initial inspection for this facility. Proficiency Testing (PT) samples have been analyzed for
all certified parameters for the 2012 proficiency testing calendar year and the graded results were
100% acceptable.
Current quality assurance policies for Field laboratories and approved procedures for the analysis of
the facility’s currently certified parameters were provided at the time of the inspection.
Contracted analyses are performed by Statesville Analytical (Certification #440).
It is recommended that the point of contact (Geoffrey Pittard) have an email address to facilitate
communication with this program. It is also recommended that he join our program’s list-serve to
better keep up with requirement changes that are posted to our website by sending a blank email to
the following address: DENR.DWQ.Lab_Cert-join@lists.ncmail.net.
III. FINDINGS, REQUIREMENTS, COMMENTS AND RECOMMENDATIONS:
Documentation
A. Finding: No analytical data prior to October, 2012 could be produced.
Requirement: Data pertinent to each analysis must be maintained for five years. Certified
Data must consist of date collected, time collected, sample site, sample collector, and sample
analysis time. The field bench sheets must provide a space for the signature or initials of the
analyst, and proper units of measure for all analyses. Ref: 15A NCAC 02H .0805 (g) (1).
Page 2
#5625 Caledonia Correctional Institute
Comment: The analyst stated that analytical results were only being documented on the
Discharge Monitoring Report (DMR). It is unclear as to why required documentation was not being
retained. Documentation requirements were provided to the facility via email on June, 29, 2012.
This information was provided to Mr. Dan Gibson, since Mr. Pittard does not have email access.
B. 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 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
C. 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.
D. Finding: Proficiency Testing (PT) sample analyses were not documented in the same manner
as routine 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: 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. Please document PT
sample analyses on the benchsheets in the same manner environmental samples are
documented.
E. Finding: The laboratory is not analyzing Proficiency Testing (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 (QC). Extra QC may only be analyzed (and is
Page 3
#5625 Caledonia Correctional Institute
encouraged) as part of a root cause analysis and corrective action procedure when an
unacceptable PT result is obtained or an analytical problem is identified.
Quality Control
F. Finding: The auto-pipette is not being calibrated annually.
Requirement: Mechanical volumetric liquid-dispensing devices (e.g., fixed and adjustable auto-
pipettors, bottle-top dispensers, etc.) must be calibrated at least every twelve months and
documented. Each liquid-dispensing device must meet the manufacturer’s statement of
accuracy. For variable volume devices used at more than one setting, check the accuracy at
the maximum, middle and minimum values. Testing at more than three volumes is optional.
When a device capable of variable settings is dedicated to dispense a single specific volume,
calibration is required at that setting only. Ref: Quality Assurance Policies for Field
Laboratories. (See attached guidance document) Submit documentation of the calibration
with the response to this report.
Comment: The auto-pipette is only being used to transfer reagents for the analysis of Total
Residual Chlorine. Switching to powder reagents would eliminate the need for the auto-pipette.
pH – Standard Methods, 4500 H+ B - 2000
Temperature – Standard Methods, 2550 B - 2000
Total Residual Chlorine – Standard Methods, 4500 Cl G - 2000
G. Finding: No sample collection and/or analysis times are documented.
Requirement: Data pertinent to each analysis must be maintained for five years. Certified Data
must consist of date collected, time collected, sample site, sample collector, and sample analysis
time. The field benchsheets must provide a space for the signature or initials of the analyst, and
proper units of measure for all analyses. Ref: 15A NCAC 2H .0805 (g) (1). Submit a copy of a
completed benchsheet with the response to this report.
Comment: Temperature and pH are analyzed in-situ. Only an analysis time is required. The
benchsheet should state that those analyses are performed in-situ.
H. Finding: The sample location/site is not documented.
Requirement: The sample location/site must be documented whenever sample analysis is
performed. Ref: NC WW/GW LC Approved Procedure for Field Analysis of pH, NC WW/GW
LC Approved Procedure for Field Analysis of Temperature and NC WW/GW LC Approved
Procedure for Field Analysis of Total Residual Chlorine. Submit a copy of a completed
benchsheet with the response to this report.
pH – Standard Methods, 4500 H+ B - 2000
Total Residual Chlorine – Standard Methods, 4500 Cl G - 2000
I. Finding: Meter calibration times are not documented.
Requirement: Time of calibration must be documented whenever sample analysis is
performed. Ref: NC WW/GW LC Approved Procedure for Field Analysis of pH, NC WW/GW
LC Approved Procedure for Field Analysis of Total Residual Chlorine. Submit a copy of a
completed benchsheet with the response to this report.
Page 4
#5625 Caledonia Correctional Institute
Temperature – Standard Methods, 2550 B - 2000
J. Finding: Sample temperature measurements are not documented with the applicable
temperature correction applied.
Requirement: The following must be documented whenever sample analysis is performed.
Document sample temperature measurements with any applicable temperature corrections
applied. Ref: NC WW/GW LC Approved Procedure for Field Analysis of Temperature.
Comment: This policy was finalized since the lab inspection. A copy of the updated NC WW/GW
LC Approved Procedure for Field Analysis of Temperature is enclosed with this report for your
reference.
Total Residual Chlorine – Standard Methods, 4500 Cl G - 2000
Comment: DPD Total Chlorine Reagent Powder Pillows are acceptable for use in place of the liquid DPD
and buffer ampoules.
K. Finding: Values less than the established reporting limit are being reported on the Discharge
Monitoring Report (DMR).
Requirement: For analytical procedures requiring analysis of a series of standards, the
concentrations of those standards must bracket the concentration of the samples analyzed. One
of the standards must have a concentration equal to the laboratory’s lower reporting concentration
for the parameter involved. Ref: NC WW/GW LC Approved Procedure for Field Analysis of Total
Residual Chlorine.
Comment: If the laboratory chooses to have a lower reporting limit of 20 µg/L for residual
chlorine, you must analyze at least 20 µg/L or lower standard and report lower concentrations
as < 20 µg/L or < the concentration of the chosen standard.
IV. PAPER TRAIL INVESTIGATION:
The paper trail consisted of comparing contract lab reports to Discharge Monitoring Reports (DMRs)
submitted to the North Carolina Division of Water Quality. Data were reviewed for July, August and
September, 2012. There was no field data to review for these months. No transcription errors were
detected. The facility appears to be doing a good job of accurately transcribing contract lab data.
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: November 8, 2012
Report reviewed by: Chet Whiting Date: November 9, 2012