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HomeMy WebLinkAbout#5056_2022_0825_JP_FINAL NC Department of Environmental Quality | Division of Water Resources | Laboratory Certification Branch 4405 Reedy Creek Road | 1623 Mail Service Center | Raleigh, North Carolina 27699-1623 919-733-3908 September 29, 2022 5056 Mr. Glenn Rivenbark Duke Energy Progress - Sutton Steam Electric Plant 801 Sutton Steam Plant Road Wilmington, NC 28401 Subject: North Carolina Wastewater/Groundwater Laboratory Certification Branch (NC WW/GW LCB) Maintenance Inspection Dear Mr. Rivenbark: Enclosed is a report for the inspection performed on August 25, 2022 by Jill Puff. Where Finding(s) are cited in this report, a response is required. Within thirty days, please supply this office with a written item for item description of how these Finding(s) were corrected. Please describe the steps taken to prevent recurrence 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 02H .0800. A copy of the laboratory’s Certified Parameter List at the time of the audit is attached. This list will not reflect any changes made during the audit. Copies of the checklists completed during the inspection may be requested from this office. Thank you for your cooperation during the inspection. If you have questions or need additional information, please contact me at (919) 733- 3908 Ext. 251. Sincerely, Anna Ostendorff Technical Assistance & Compliance Specialist Division of Water Resources Attachment cc: Todd Crawford, Jill Puff, Master File #5056 On-Site Inspection Report LABORATORY NAME: Duke Energy Progress – Sutton Steam Electric Plant NPDES PERMIT #: NC0001422 ADDRESS: 801 Sutton Steam Plant Road Wilmington, NC 28401 CERTIFICATE #: 5056 DATE OF INSPECTION: August 25, 2022 TYPE OF INSPECTION: Field Municipal Maintenance AUDITOR(S): Jill Puff LOCAL PERSON(S) CONTACTED: Kent Tyndall, Glenn Rivenbark and Ricky Stroupe I. INTRODUCTION: This laboratory was inspected by a representative of the North Carolina Wastewater/Groundwater Laboratory Certification Branch (NC WW/GW LCB) to verify its compliance with the requirements of 15A NCAC 02H .0800 for the analysis of compliance monitoring samples. II. GENERAL COMMENTS: The facility is neat and well organized and has all the equipment necessary to perform the analyses. Staff were forthcoming and responded well to suggestions from the auditor. All required Proficiency Testing (PT) Samples for the 2022 PT Calendar Year have not yet been analyzed. The laboratory is reminded that results must be received by this office directly from the vendor by September 30, 2022. Any time changes are made to laboratory procedures, QA/SOP document(s) must be updated and relevant staff retrained. Staff must acknowledge that they have read and understand the changes as part of the documented training program. The same requirements apply when changes are made in response to Findings, Recommendations or Comments listed in this report, to ensure the methods are 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. Revisions to the SOPs, based on the Findings and Comments within this report must be submitted to this office by March 31, 2023. The laboratory is reminded that SOPs are required to be reviewed at least every two years and are intended to describe procedures exactly as they are to be performed. Use of the word “should” is not appropriate when describing requirements (e.g., Quality Control (QC) frequency, acceptance criteria, etc.). Evaluate all SOPs for the proper use of the word “should”. Page 2 #5056 Duke Energy Progress – Sutton Steam Electric Plant Contracted analyses are performed by Duke Power Company LLC d/b/a Duke Energy Carolinas LLC (Certification #248) and Pace Analytical Services LLC Huntersville NC (Certification #12). 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 A. Finding: The laboratory benchsheet is lacking required documentation: the method or Standard Operating Procedure reference; the laboratory identification; the instrument identification; the sample collector; the signature or initials of the analyst; the date and time of sample collection; and the proper units of measure. Requirement: All laboratories shall use printable laboratory benchsheets. Certified Data shall be traceable to the associated sample analyses and shall consist of: the method or Standard Operating Procedure the laboratory identification; the instrument identification; the sample collector; the signature or initials of the analyst; the date and time of sample collection; and the proper units of measure. Each item shall be recorded each time samples are analyzed. Analyses shall conform to methodologies found in Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (2) (A) (B) (C) (D) (E) (F) and (L). Comment: The calibration logs do not contain the laboratory identification; the instrument identification; and the proper units of measure. Comment: The ORC logbook does not contain the method or Standard Operating Procedure reference; the laboratory identification; the instrument identification; the sample collector; the signature or initials of the analyst; the date and time of sample collection; and the proper units of measure. B. Finding: The laboratory is not documenting traceability information for purchased materials, reagents and standards. Requirement: 15A NCAC 02H .0805 (a)(7)(K) and (g)(7) requires laboratories to have a documented system of traceability for the purchase, preparation, and use of all chemicals, reagents, standards, and consumables. That system must include documentation of the following information: 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: NC WW/GW LCB Traceability Documentation Requirements for Chemicals, Reagents, Standards and Consumables Policy. Comment: The date opened is written on the pH buffer box, but this information is lost once the box is discarded. Comment: A traceability log was provided to the laboratory at the time of audit. Page 3 #5056 Duke Energy Progress – Sutton Steam Electric Plant C. Finding: Error corrections are not properly performed. Requirement: All documentation errors shall 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; instead the correction shall be written adjacent to the error. The correction shall be initialed by the responsible individual and the date of change documented. Ref: 15A NCAC 02H .0805 (g) (1). Comment: On June 14, 2022, the DO probe calibration entry was heavily scratched through and initialed but not dated. On August 4, 2022, data were overwritten, but not dated or initialed. D. Finding: Only one time for sample collection and analysis is documented without noting samples are analyzed in situ. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). 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 sampling site (i.e., immediately following collection at a location as near to the collection point as possible). When this 'one time' option is used, state that the documented time is both collection and analysis time. Ref: NC WW /GW LCB Approved Procedure for the Analysis of Temperature. Requirement: Date and time of sample analysis must be documented to verify the 15- minute holding time is being met. Alternatively, one time may be documented for collection and analysis with the notation that samples are measured in situ or immediately at the sampling site. Ref: NC WW/GW LCB Approved Procedure for the Analysis of Dissolved Oxygen and NC WW/GW LCB Approved Procedure for the Analysis of pH. Comment: This Finding applies to pH, DO and Temperature. E. Finding: The units of measure for pH (i.e., Standard Units or S.U.) are not documented on the calibration log. Requirement: All laboratories shall use printable laboratory benchsheets. Certified Data shall be traceable to the associated sample analyses and shall consist of: the proper units of measure. Each item shall be recorded each time samples are analyzed. Ref: 15A NCAC 02H .0805 (g) (2) (L). Proficiency Testing F. Finding: PT Samples have not been distributed among all analysts from year to year. Requirement: Laboratories shall also ensure that, from year to year, PT Samples are equally distributed among personnel trained and qualified for the relevant tests and instrumentation (when more than one instrument is used for routine Compliance Sample analyses), that represents the routine operation of the work group at the time the PT Sample analysis is conducted. Ref: Proficiency Testing Requirements, February 19, 2020, Revision 5, Section 3.6. Page 4 #5056 Duke Energy Progress – Sutton Steam Electric Plant Comment: There are two staff members responsible for the routine analysis of field parameters. The primary laboratory contact analyzes the PT samples every year. G. Finding: The laboratory is not documenting PT Sample analyses in the daily analysis records. Requirement: 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, February 19, 2020, Revision 5, Section 3.6. Requirement: The laboratory shall retain all records necessary to facilitate historical reconstruction of the analysis and reporting of analytical results for PT Samples. This means the laboratory must have available and retain for five years [pursuant to 15A NCAC 02H .0805 (a) (7) (E) and (g) (1)] all of the raw data, including benchsheets, instrument printouts and calibration data, for all PT Sample analyses and the associated QC analyses conducted by all parameter methods. Ref: Proficiency Testing Requirements, February 19, 2020, Revision 5, Section 4.0. Requirement: The analysis of Proficiency Testing (PT) Samples is designed to evaluate the entire process used to routinely analyze and report Compliance Sample results. PT Samples must be analyzed the same as Compliance Samples. Also, documentation must be made on the same benchsheets used for Compliance Samples. Ref: NC WW/GW LCB Proficiency Testing Samples Analyzed and Documented Same as Compliance Samples Policy. Comment: Documentation of the PT analysis is not retained by the laboratory. Temperature – Standard Methods, 2550 B-2010 (Aqueous) H. Finding for Immediate Response: The annual temperature-measuring device check has not been performed. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H 0805 (g) (4). Requirement: All compliance temperature-measuring devices without a valid NIST certificate, or with an expired NIST traceable certificate, must be verified against a Reference Temperature-Measuring Device and the process documented initially and every 12 months. Verification documentation must include the serial number of the device being checked. The serial number stated accuracy and expiration date of the Reference Temperature-Measuring Device used in the comparison must also be documented. Verification data must be kept on file and be available for inspection for 5 years. (Note: International Organization for Standardization (ISO) 17025 compliant vendors or other Certified laboratories may provide assistance in meeting this requirement. When an ISO compliant vendor provides this assistance, they must provide the serial number, accuracy and calibration date for the Reference Temperature-Measuring Device used for the verification. When a Certified laboratory provides this service, they must provide a copy of the NIST traceable certificate of the Reference Temperature-Measuring Device used for the verification. Ref: NC WW/GW LCB Approved Procedure for the Analysis of Temperature. Requirement: A Reference Temperature-Measuring Device is an NIST traceable temperature-measuring device used only to verify the calibration of other temperature- measuring devices. It must have a stated accuracy of ± 0.5 °C, be able to distinguish temperature changes of 0.1 °C and equilibrate rapidly. Ref: NC WW/GW LCB Approved Procedure for the Analysis of Temperature. Page 5 #5056 Duke Energy Progress – Sutton Steam Electric Plant Requirement: To check a compliance temperature-measuring device, compare readings at two temperatures that bracket the range of compliance samples routinely analyzed against a Reference Temperature-Measuring Device and record all four readings. The readings from both devices must agree within 0.5ºC. If they do not, the device may not be used for temperature compliance monitoring. Ref: NC WW/GW LCB Approved Procedure for the Analysis of Temperature. Comment: A Notice of Finding for Immediate Response (NOFIR) was issued due to the impact on reported data and so the laboratory would have the temperature sensor verified more quickly than if waiting to first receive the inspection report to take corrective action. A response due date of September 9, 2022 was negotiated. The laboratory responded by the due date. The Reference Temperature-Measuring Device used for the device check procedure was not acceptable, as it did not have a stated accuracy of ±0.5°C. The temperatures used for the procedure did not bracket the full range of compliance samples. The laboratory was contacted and agreed to redo the verification and resubmit documentation by September 23, 2022. Documentation with the verification properly performed using an acceptable Reference Temperature Measuring Device was received on September 21, 2022. Respond with measures taken to prevent recurrence of this Finding. Dissolved Oxygen – Standard Methods, 4500 O G-2016 (Aqueous) I. Finding: The laboratory is not certified for the method currently in use. Requirement: Commercial Laboratories shall obtain Certification for Field Parameter Methods used to generate data that will be reported by the client to the State in accordance with the rules of this Section. Municipal and Industrial laboratories shall obtain Certification for Field Parameter Methods used to generate data that will be reported to the State in accordance with the rules of this Section. Ref: 15A NCAC 02H .0804 (a). Comment: Standard Methods 4500 O G-2016 refers to the measurement of Dissolved Oxygen (DO) utilizing membrane technology. The laboratory utilizes a HACH DO meter with an LDO probe, which requires certification by a separate method (SM 4500 O H-2016). The laboratory was provided with an Amendment Application and SOP template for SM 4500 O H-2016 to obtain certification for the correct method. Comment: The laboratory has been instructed to report DO data as uncertified until certification is granted for the correct method. J. Finding: The Luminescence Dissolved Oxygen (LDO) meter calibration is not being properly verified each day that sample measurements are taken. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: Instruments are to be calibrated according to the manufacturer’s calibration procedure prior to analysis of samples each day compliance monitoring is performed. For LDO sensors that cannot be calibrated by the user, the internal calibration must be verified each day of use. This can be performed by back calculating the theoretical DO for the current air calibration conditions (e.g., temperature, elevation, barometric pressure, etc.). The calculated DO value must verify the meter reading within ±0.5 mg/L. Refer to the Dissolved Oxygen Meter Calibration Verification handout at the end of this document. If the meter verification does not read within ±0.5 mg/L of the theoretical DO, corrective action Page 6 #5056 Duke Energy Progress – Sutton Steam Electric Plant must be taken. Ref: NC WW/GW LCB Approved Procedure for the Analysis of Dissolved Oxygen (DO). Comment: The % saturation and the slope are recorded each day of use, but no assessment against the theoretical DO is made. Comment: The meter allows the laboratory to utilize the factory calibration or perform a user calibration and they have decided to use the factory calibration. This option requires the laboratory to perform a daily verification and document the variables used to back calculate the theoretical DO and document that the result is within ±0.5 mg/l. pH - Standard Methods, 4500 H+ B-2011 (Aqueous) K. Finding: The laboratory benchsheet does not clearly label which buffer is used to check the meter calibration. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H 0805 (g) (4). 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 LCB Approved Procedure for the Analysis of pH. L. Finding: The acceptance criterion evaluation of the check standard buffer is not documented on the benchsheet. Requirement: All laboratories shall use printable laboratory benchsheets. Certified Data shall be traceable to the associated sample analyses and shall consist of: the quality control assessments. Ref: 15A NCAC 02H .0805 (g) (2) (O). Comment: All of the check buffer values were acceptable in the data reviewed. IV. PAPER TRAIL INVESTIGATION: The paper trail consisted of comparing original records (e.g., laboratory benchsheets, logbooks, etc.) and contract laboratory reports to Discharge Monitoring Reports (DMRs) submitted to the North Carolina Division of Water Resources. Data were reviewed for Sutton Steam Electric Plant (NPDES permit # NC0001422) for February, March and April 2022. No transcription errors were observed. The facility appears to be doing a good job of accurately transcribing 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 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: Jill Puff Date: August 29, 2022 Report reviewed by: Tonja Springer Date: September 2, 2022 Certificate Number:5056 Effective Date:1/1/2022 Expiration Date:12/31/2022 Lab Name:Duke Energy Progress - Sutton Steam Electric Plant Address:801 Sutton Steam Plant Road Wilmington, NC 28401- North Carolina Wastewater/Groundwater Laboratory Certification Certified Parameters Listing Date of Last Amendment:9/22/2021 The above named laboratory, having duly met the requirements of 15A NCAC 2H.0800, is hereby certified for the measurement of the parameters listed below. CERTIFIED PARAMETERS INORGANIC DISSOLVED OXYGEN SM 4500 O G-2016 (Aqueous) pH SM 4500 H+B-2011 (Aqueous) TEMPERATURE SM 2550 B-2010 (Aqueous) This certification requires maintance of an acceptable quality assurance program, use of approved methodology, and satisfactory performance on evaluation samples. Laboratories are subject to civil penalties and/or decertification for infractions as set forth in 15A NCAC 2H.0807.