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HomeMy WebLinkAbout#248_2016_1102_BS_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: Date Review Completed: Cover Letter to use: Unit Supervisor/Chemist III: Date Received: Date Forwarded to Admin: Date Mailed: 248 Duke Power Company LLC d/b/a Duke Energy Carolinas, LLC Commercial Maintenance Beth Swanson, Gary Francies, Dana Satterwhite Todd Crawford Jason Smith Nick Jones and Anna OstendorFf November 2, 2016 November 29. 2016 November 29, 2016 Tonia Springer December 7 2016 ❑ Insp. Initial ® Insp. Reg. ❑ Insp. No Finding ❑ Insp. CP ❑ Corrected ❑ Insp. Reg. Delay Gary Francies 12/8/2016 1 /5/17 1 /12/2017 Special Mailing Instructions: Send copy to Wes Bell MRO ROY COOPER Water Resources ENVRONMENTAL QUALTY January 11, 2017 248 Mr. Girish Sharma Duke Power Company LLC d/b/a Duke Energy Carolinas, LLC 13339 Hagers Ferry Road, Mail Code: MG03A2 Huntersville, NC 28078-7929 Subject: North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW LC) Maintenance Inspection Dear Mr. Sharma: Enclosed is a report for the inspection performed on November 2, 2016 by Beth Swanson, Gary Francies, Dana Satterwhite, Todd Crawford, Jason Smith, Nick Jones, and Anna Ostendorff. I apologize for the delay in getting this report to you. 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. 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 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 me at (828) 296-4677. Sincerely, Gary Francies, Technical Assistance/Compliance Specialist Division of Water Resources Attachment cc: Beth Swanson Master File LABORATORY NAME: Duke Power Company LLC d/b/a Duke Energy Carolinas, LLC ADDRESS: 13339 Hagers Ferry Road, Mail Code: MG03A2 Huntersville, NC 28078-7929 CERTIFICATE #: 248 DATE OF INSPECTION: November 2, 2016 TYPE OF INSPECTION: Commercial Maintenance AUDITOR(S): Beth Swanson, Gary Francies, Dana Satterwhite, Todd Crawford, Jason Smith, Nick Jones and Anna Ostendorff LOCAL PERSON(S) CONTACTED: Girish Sharma 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: The laboratory has a detailed and effective system of traceability. Records are complete and readily accessible. Personnel were forthcoming and enthusiastic and the overall interactions presented a laboratory culture focused on quality. All required Proficiency Testing (PT) samples have been analyzed and the laboratory has fulfilled its PT requirements for the 2016 PT calendar year. 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 2, 2017. 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 #248 Duke Power Company LLC d/b/a Duke Energy Carolinas, LLC (e.g. Quality Control (QC) frequency, acceptance criteria, etc.). Evaluate all SOPS for the proper use of the word "should". Requirements that reference 15A NCAC 2H .0805 (a) (7) (A), stating "All analytical data pertinent to each certified analysis must be filed in an orderly manner so as to be readily available for inspection upon request", are intended to be a requirement to document information pertinent to reconstructing final results and demonstrating method compliance. Use of this requirement is not intended to imply that existing records are not adequately maintained unless the Finding speaks directly to that. Contracted analyses are performed by Shealy Environmental Services, Inc. (Certification # 329) and Pace Analytical Services, LLC — Ormond Beach, FL (Certification # 667). III. FINDINGS, REQUIREMENTS, COMMENTS AND RECOMMENDATIONS: Documentation Comment: It was noted at the inspection that the LIMS system is sometimes adding significant figures to a value that was already rounded. This gives the impression of greater precision than exists. The specific example found was a Total Suspended Solids sample (#2016002086) which had a measured value of 5.8 mg/L. The result was rounded to 6 mg/L for reporting into LIMS, which then added an extra significant figure and appeared in the final report as 6.0 mg/L. Comment: Refrigerator temperature logs were missing units of measure. The logs stated the range of the refrigerators were 1 to 6 °C, but there was no unit on the temperature column or a note that all recorded temperatures were in 'C. Code of Federal Regulations, Title 40, Part 136; Federal Register Vol. 77, No. 97, May 18, 2012; Table II states: Cool, :56 'C. North Carolina Administrative Code, 15A NCAC 2H .0805 (a) (7) (A) states: All analytical data pertinent to each certified analysis must be filed in an orderly manner so as to be readily available for inspection upon request. Notification of acceptable corrective action (i.e., an updated temperature log, implemented November 14, 2016, with "°C" on all temperature columns and a note "All temps are measured in °C") was received by email on November 11 and 14, 2016. No further response is necessary for this Finding. Comment: Error corrections were not consistently performed properly. Specific examples include error corrections without the date documented and some over -writing. NC WW/GW LC Policy states: 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. Notification of acceptable corrective action (i.e., documentation stating that the analysts reviewed the policy and affirmed that they would follow the proper error correction requirements as of November 10, 2016) was received by email on November 11, 2016. No further response is necessary for this Finding. Quality Control Comment: The laboratory is having their weight sets verified every year. NC WW/GW LC Policy states that although some manufacturers will assign a one-year calibration due date, reference weight sets are only required to be verified at least every five years due to their limited use. See the Weight Verification Policy attached to the end of this report as reference. Page 3 #248 Duke Power Company LLC d/b/a Duke Energy Carolinas, LLC Anions (Br, CI-, F-, NOs', NOZ , SO4"1— EPA 300.0, Rev. 2.1, 1993 (Aqueous) Anions (Br, CV, F-, NOs NOZ , SO4"1— SW-846 9056 A (Aqueous) Recommendation: Data showed that the laboratory was analyzing continuing calibration verifications (CCV) and continuing calibration blanks (CCB) at least every ten samples, but at times there were more than ten injections between each CCV/CCB set. This was due to additional analysis of sample dilutions. The CCV and CCB are meant to check instrument drift and contamination. Even though the methods and NC WW/GW LC Policy only state the frequency in terms of the word "samples", that may be interpreted as every ten sample infections. Therefore, it is recommended that these be analyzed after every ten sample injections. A. Finding: A filtered standard is not analyzed when samples are filtered. Requirement: Laboratory Fortified Blank (LFB) — An aliquot of reagent water or other blank matrices to which known quantities of the method analytes are added in the laboratory. The LFB is analyzed exactly like a sample, and its purpose is to determine whether the methodology is in control, and whether the laboratory is capable of making accurate and precise measurements. Ref: EPA Method 300.0, Rev. 2.1, 1993. Requirement: The Laboratory Control Sample (LCS) is analyzed to assess general method performance based on the ability of the laboratory to successfully recover target analytes from a control matrix. Although the frequency of LCS analysis should be determined by the needs of a project, typically one LCS is prepared and analyzed for every analytical batch. The LCS sample is prepared and analyzed in the same analytical batch and in exactly the same manner as the other routine samples. Ref: EPA SW-846 Test Methods for Evaluating Solid Waste, Physical/Chemical Methods; 31 Edition, Chapter One, Rev. 2, July 2017, Section 1.5. Comment: The analyst was already analyzing a filtered blank as required. B. Finding: The reason for performing manual integration is not documented. Requirement: When manual integration is employed, the laboratory must clearly identify manually integrated compounds, document the reason the manual integration was performed, the date performed and who completed the work. A flag or qualifier code may suffice for simple manual integrations. Ref: NC WW/GW LC Policy. Comment: The requirement is included in the laboratory's manual integration SOP; however, it has not been put into practice for this parameter. Nitrogen, Ammonia — EPA 350.1, Rev. 2.0, 1993 (Aqueous) Nitrogen, NOs + NOz — EPA 353.2, Rev. 2.0, 1993 (Aqueous) Nitrogen, Total Kieldahl — EPA 351.2, Rev. 2.0, 1993 (Aqueous) Phosphorus, Total — EPA 365.1, Rev. 2.0, 1993 (Aqueous) Comment: The CCB and CCV were not being analyzed after every ten samples. It was noted that there may have been non -regulatory samples mixed with the regulatory samples, which were not counted as part of the ten samples. It was not clear from sample labeling whether this was the case. EPA Method 350.1, Rev. 2.0, 1993, Section 9.3.3, EPA Method 351.2, Rev. 2.0, 1993, Section 9.3.4, EPA Method 353.2, Rev. 2.0, 1993, Section 9.3.4 and EPA Method 365.1, Rev. 2.0, 1993, Section 9.3.4 state: For all determinations the laboratory must analyze the IPC (mid -range check standards) and a calibration blank immediately following daily calibration, after every tenth sample (or more frequently, if required) and at the end of the sample run. Notification of Page 4 #248 Duke Power Company LLC d/b/a Duke Energy Carolinas, LLC acceptable corrective action (i.e., documentation showing retraining o about this requirement and a signed statement that they will adhere November 10, 2016) was received by email on November 11, 2016. necessary for this Finding. Nitrogen, Ammonia — EPA 350.1, Rev. 2.0, 1993 (Aqueous) Nitrogen, NOs + NOz — EPA 353.2, Rev. 2.0, 1993 (Aqueous) Nitrogen, Total Kieldahl — EPA 351.2, Rev. 2.0, 1993 (Aqueous) Phosphorus, Total — EPA 365.1, Rev. 2.0, 1993 (Aqueous) Phosphate, Ortho — EPA 365.1, Rev. 2.0, 1993 (Aqueous) f the Lachat lab analysts to the requirement as of No further response is Comment: The LCS is currently being analyzed with every CCV and blank. The LCS is only required once before sample analysis to verify the curve. Recommendation: Duplicate Relative Percent Difference (RPD) is being calculated from the percent recovery of the MS/MSD instead of the concentrations of the spike and duplicate spike. While the referenced methods do not contain a calculation for determination of RPD, Standard Methods states the calculation for RPD is: I e icy [exult — dupl[ceteresult),' i i (sample result + dup[[cste resu[t); 2 It is recommended that this equation be used to determine RPD for duplicates. Nitrogen, Total Kieldahl — EPA 351.2, Rev. 2.0, 1993 (Aqueous) Recommendation: It was recommended at the inspection that an organic nitrogen standard be analyzed periodically to check the digestion efficiency. The laboratory sent notification on November 11, 2016 that a total nitrogen (glycine) standard, at a concentration between 50 and 100 mg/L, will be analyzed at least annually. Organic Carbon, Total — Standard Methods, 5310 C- 2000, Rev. 2011 (Aqueous) Metals — EPA 200.8, Rev. 5.4, 1994 (Aqueous) Metals — SW-846 6020 B (Aqueous) C. Finding: Corrective action is not being applied to all data associated with unacceptable blanks. Requirement: Verify calibration by periodically analyzing a calibration standard and calibration blank during a run - typically, after each batch of ten samples and at the end of the run. For the calibration verification to be valid, (unless the method specifies otherwise) check standard results must not exceed ±10% of its true value, and calibration blank results must not be greater than one-half the reporting level. If a calibration verification fails, immediatelv cease analvzina samples and initiate corrective action. Then, re -analyze the calibration standard and blank. If the calibration verification passes, continue the analysis. Otherwise, repeat initial calibration and re- analvze samples run since the last acceptable calibration verification. Ref: Standard Methods, 5020 B-2010. (2) (b). Requirement: 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 Page 5 #248 Duke Power Company LLC d/b/a Duke Energy Carolinas, LLC 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. Ref: NC WW/GW LC Policy. Comment: The Total Organic Carbon (TOC) batch Q16080140 contained three contaminated blanks. According to the Standard Methods calibration verification requirements, the blanks were to have been reanalyzed and if still unacceptable, the calibration and all samples since the last acceptable calibration verification (CCV and blank) re -run. However, the analysis was continued and only samples analyzed after a contaminated blank were qualified. Samples must be bracketed by two acceptable blanks, so all the samples analyzed between an acceptable blank and unacceptable blank must be qualified as well since the calibration and samples were not reanalyzed. Comment: For EPA 200.8/SW-846 6020B, sample 2016013089 was not qualified when it was followed by an unacceptable blank. There was a notation in the data that this was due to carry over and the sample would not be qualified because it was greater than the reporting limit (RL). There is no exception for data qualification per NC WW/GW LC Policy. Metals — EPA 200.8, Rev. 5.4, 1994 (Aqueous) Metals — SW-846 6020 B (Aqueous) Comment: The QC summary and review sheet for project Q16020460 was not initialed by the analyst who manually entered the data. This appears to be an isolated incident based on the data reviewed. D. Finding: The acceptance limit for the highest concentration standard is ±15% recovery. Requirement: Conformance to the LDR/LCR is demonstrated since a lab does not report outside their calibration range, and analysis of the highest calibration standard yields results that are ± 10% of the true value. Ref: NC WW/GW LC Policy. Comment: No instances were found during data review, but the SOP states that a standard of greater concentration than the highest calibration standard can be analyzed to extend the calibration range. It also states that the acceptance criterion for this standard is ±15% recovery. E. Finding: Recovery of the MS/MSD is not always evaluated. 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). Comment: No instances were found during data review, but the MS/MSD recovery is not calculated if the spike concentration is less than 30% of the sample concentration. There is no exception for when QC elements need not be evaluated. Page 6 #248 Duke Power Company LLC d/b/a Duke Energy Carolinas, LLC F. Finding: The laboratory's reporting limit is below the calculated Method Detection Limit (MDL) for Iron. Requirement: Do not report element concentrations below the determined MDL. Ref: EPA Method 200.8, Rev. 5.4, 1994, Section 12.1. Comment: The calculated MDLs for the two most recent studies were 1.7 and 2.3 pg/L. The reporting limit is 1 pg/L. The methods are analyzed together in combined runs, so the most stringent QC is applied. G. Finding: The required blank acceptance criterion of <_ 1/z RL is not consistently used. Requirement: For analyses requiring a calibration curve, the concentration of reagent, method and calibration blanks must not exceed 50% of the reporting limit or as otherwise specified by the reference method. Ref: NC WW/GW LC Policy. Comment: The laboratory is using two instruments for ICP-MS analysis. The older 7500 model software uses a blank acceptance criterion of 1 pg/L, which is the reporting limit, to evaluate blank acceptance. None of the data reviewed were affected by this elevated acceptance criterion. Comment: The QC summary and review benchsheet has not been updated since the newer instrument was installed. It states the acceptance criterion is <RL and only lists the 7500 model in the instrument list. Mercury — EPA 245.1, Rev. 3.0, 1994 (Aqueous) Comment: An instance was found during data review where the LCS analysis was cancelled with no notation as to why. The results showed it's likely that there was not enough liquid in the vial. To avoid the appearance of manipulation of QC data, a notation stating the reason why needs to be made when analysis is cancelled for QC elements. North Carolina Administrative Code, 15A NCAC 2H .0805 (a) (7) states: 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. Notification of acceptable corrective action (i.e., documentation of raw data analyzed on November 8, 2016 with a notation that an LCS was cancelled due to insufficient volume in the vial and a statement that the practice of notating the reason an injection is cancelled has been fully implemented as of November 10, 2016) was received by email on November 11, 2016. No further response is necessary for this Finding. H. Finding: The standards are being digested. Requirement: Dilute the standard aliquots to 100 mL with reagent water (Section 7.2) and process as described in Sections 11.1.2, 11.1.3 (without heating), and 11.1.5. Ref: EPA Method 245.1, Rev. 3.0, 1994, Section 11.2.2. Mercury —EPA 245.1, Rev. 3.0, 1994 (Aqueous) Mercury — SW-846 7470 A (Aqueous) Recommendation: A recommendation was made at the inspection that limits be set on percent Relative Standard Deviation (RSD) for multiple injections to monitor system performance. Page 7 #248 Duke Power Company LLC d/b/a Duke Energy Carolinas, LLC Notification was received by email on November 11, 2016 that the laboratory will use <10% RSD as a guideline for monitoring the mid -range standard, samples, LCS and MS/MSD injections. Comment: The calculated recoveries for the initial calibration verification (ICV) and CCV were not being documented. North Carolina Administrative Code, 15A NCAC 2H .0805 (a) (7) states: 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. Notification of acceptable corrective action (i.e., documentation of recovery calculations for the ICV and CCV written on raw data analyzed November 8, 2016 with a statement that the practice has been fully implemented as of November 10, 2016) was received by email November 11, 2016. No further response is necessary for this Finding. Mercury — SW-846 7471 B (Non -Aqueous) Comment: It was noted at the inspection that a separate non -aqueous mercury PT sample is intended to be analyzed annually since the method is matrix specific. However, due to inconsistencies in applying the requirement and the late notification, it will not be required until the 2017 PT calendar year. Oil & Grease — EPA 1664 Rev. B (Aqueous) Oil & Grease — SW-846 9070 A (Aqueous) Comment: The laboratory was not applying a consistent acceptance criterion for the MS and LCS. The SOP lists the recovery acceptance range as 78-114% and the "Data Review Checklist" stated it was 80-114%. North Carolina Administrative Code, 15A NCAC 2H .0805 (a) (7) states: 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). Notification of acceptable corrective action (i.e., documentation including an updated Data Review Checklist and LIMS printout implemented November 7, 2016 with 78-114% stated as the acceptance criterion for MS and LCS recovery) was received by email on November 11, 2016. No further response is necessary for this Finding. Residue, Dissolved 180 C — Standard Methods, 2540 C-1997, Rev. 2011 (Aqueous) Residue, Suspended — Standard Methods, 2540 D-1997, Rev. 2011 (Aqueous) Residue, Total — Standard Methods, 2540 B-1997, Rev. 2011 (Aqueous) Comment: An incorrect temperature correction was being applied to the residue and evaporation ovens. The ovens all had a sticker with out of date temperature corrections. The stickers did not have a date of verification so it was assumed that these stickers were applicable to the most recent verification, which they were not. The current correction for all oven thermometers is zero. NC WW/GW Policy States: Document any correction that applies (even if zero, e.g., 0.0) on both the thermometer/meter and on a separate sheet to be filed. Notification of acceptable corrective action (i.e., a statement that a new sticker with the current correction of zero and the temperature sensor verification date was in place for each oven on November 15, 2016 and that the vendor will provide a new sticker after every verification) was received by email on November 11 and 18, 2016. No further response is necessary for this Finding. IV. PAPER TRAIL INVESTIGATION: The paper trail consisted of comparing original records (e.g., laboratory benchsheets, logbooks, etc.) chain of custodies, electronic DMRs and final reports. Data were reviewed for the months Page 8 #248 Duke Power Company LLC d/b/a Duke Energy Carolinas, LLC of February, May and August 2016. Additional data reviewed outside of these months include: Metals (EPA 200.7/SW-846 6010D): 3/7/2016; Metals (EPA 200.8/SW-846 6020B): 3/2/2016 and 5/10/2016; Nitrate + Nitrite: 10/26/2016; Ammonia: 4/9/2016. 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 Recommendations 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 and implementation dates for each corrective action. Report prepared by: Beth Swanson Date: November 29, 2016 Report reviewed by: Tonja Springer Date: December 7, 2016 Weight Verification (NC WW/GW LC Policy 05/23/2008) ASTM Class 1 and 2 weights must be verified at least every 5 years. ASTM Class 1 weights (20 g to 25 kg) and ASTM Class 2 weights (10 g to 1 mg) are equivalent to the NBS Class S weights specified in 15A NCAC 2H .0805 (a) (7) (K). Verification may be accomplished by: 1. Sending laboratory weights back to the manufacturer for recertification - reference weights shall be calibrated by a body that can provide traceability to ASTM specifications, or 2. Checking laboratory weights against certified reference weights (i.e., weights that have been recertified as above) and found to be within ASTM Class 1 or Class 2 tolerances (see table below) - often the balance service technician may provide this service. Note: Although some manufacturers will assign a one-year calibration due date, 5 years is considered an acceptable calibration interval due to the limited use of the reference weight set. Documentation of weight verifications or recertification must be maintained for 5 years. If the condition of a weight(s) is in question at any time due to damage (e.g., corrosion, nicks, scratching, etc.), the laboratory must have that weight(s) re -verified as described above. Maximum tolerances (Ref. ASTM E 617-97, 2003) Denomination Maximum tolerance for ASTM Class 1 and 2 weights, (± mg) 500 g 1.2 300 g 0.75 200 g 0.50 100 g 0.25 50 g 0.12 30 g 0.074 20 g 0.074 log 0.074 5 g 0.054 3 g 0.054 2 g 0.054 1 g 0.054 500 mg 0.025 300 mg 0.025 200 mg 0.025 100 mg 0.025 50 mg 0.014 30 mg 0.014 20 mg 0.014 10 mg 0.014 5 mg 0.014 3 mg 0.014 2 mg 0.014 1 mg 0.014