HomeMy WebLinkAbout#5293 - 2012 Insp-Final
INSPECTION REPORT ROUTING SHEET
To be attached to all inspection reports in-house only.
Laboratory Cert. #: 5293
Laboratory Name: Snug Harbor on Nelson Bay
Inspection Type: Field Maintenance
Inspector Name(s): Todd Crawford
Inspection Date: December 4, 2012
Date Report Completed: December 5, 2012
Date Forwarded to Reviewer: December 5, 2012
Reviewed by: Nick Jones
Date Review Completed: December 6, 2012
Cover Letter to use: Insp. Initial Insp. Reg.
Insp. No Finding Insp. CP
Corrected
Unit Supervisor: Dana Satterwhite
Date Received: December 7, 2012
Date Forwarded to Linda: December 7, 2012
Date Mailed: December 7, 2012
_____________________________________________________________________
On-Site Inspection Report
LABORATORY NAME: Snug Harbor on Nelson Bay
NPDES Permit #: NC0028827
ADDRESS: P.O. Box 150
Sea Level, NC 28577
CERTIFICATE #: 5293
DATE OF INSPECTION: December 4, 2012
TYPE OF INSPECTION: Field Maintenance
AUDITOR(S): Todd Crawford
LOCAL PERSON(S) CONTACTED: Donald Copeland
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:
The facility has all the equipment necessary to perform the analyses. 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 Environment 1, Inc. (Certification #10).
The requirements associated with Findings B, C, D, and E are new policies that have been implemented
by our program since the last inspection.
III. FINDINGS, REQUIREMENTS, COMMENTS AND RECOMMENDATIONS:
Documentation
A. Finding: Error corrections are not performed properly.
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.
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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.
Quality Control
E. 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.
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pH – Standard Methods, 4500 H+ B - 2000
Dissolved Oxygen – Standard Methods, 4500 O G - 2001
Total Residual Chlorine – Standard Methods, 4500 Cl G - 2000
F. Finding: No sample collection 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.
Temperature – Standard Methods, 2550 B – 2000
Comment: Temperature is analyzed in situ. Only an analysis time is required. The benchsheet must state
that this analysis is performed in situ.
G. Finding: The digital temperature sensing device used to obtain reported temperature values is
not being checked against a National Institute of Standards and Technology (NIST)
thermometer annually.
Requirement: All thermometers and temperature measuring devices must be checked every 12
months against a National Institute of Standards and Technology (NIST) traceable thermometer.
The process must be documented and proper corrections made to all compliance data. To
check a thermometer or the temperature sensor of a meter, read the temperature of the
thermometer/meter against a NIST traceable thermometer and record the two temperatures.
The verification must be performed in the approximate range of the sample temperatures
measured. The thermometer/meter readings must be less than or equal to 1ºC from the NIST
traceable thermometer reading. The documentation must include the serial number of the 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. (NOTE: Other
certified laboratories may provide assistance in meeting this requirement.)Ref: NC WW/GW LC
Approved Procedure for Field Analysis of Temperature. Submit documentation of the
temperature sensor check with the response to this report.
Requirement: 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: The original certificate of accuracy and the sticker on the Extech 421501 meter with
Fluke probe (S/N G03389) stated the calibration date was 4/21/06 and that the next calibration was
due 4/21/07.
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.
H. Finding: A calibration check standard is not being analyzed each day that sample analysis is
performed.
Requirement: When a five-standard annual standard curve verification is used, the laboratory
must check the calibration curve each analysis day. To do this, the laboratory must analyze a
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calibration blank to zero the instrument and analyze a check standard each day that samples
are analyzed. The value obtained for the check standard must read within 10% of the true value
of the check standard. If the obtained value is outside of the ±10% range, corrective action must
be taken. 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.
IV. 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 August, September and October, 2012. The following error was noted:
Date Parameter Location Value on Benchsheet Value on DMR
08/30/12 Temperature Effluent 26.8ºC 28.2ºC
In addition to the error noted above, “less than” signs on the contracted analyses reports were not
being transferred to the DMRs. Because of these incorrectly reported values, the monthly average and
the monthly minimum are also incorrect. A copy the NC DWQ NPDES Permitting Guidance for DMR
Calculations document was provided at the time of the inspection.
In order to avoid questions of legality, it is recommended that you contact the appropriate Regional
Office for guidance as to whether an amended Discharge Monitoring Report will be required. A copy of
this report will be made available to the Regional Office.
V. CONCLUSIONS:
Correcting the above-cited findings 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: December 5, 2012
Report reviewed by: Nick Jones Date: December 6, 2012