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INSPECTION REPORT ROUTING SHEET
To be attached to all inspection reports in-house only.
Laboratory Cert. #: 638
Laboratory Name: Aquatic Ecology Lab – UNCW Center for Marine Science
Inspection Type: Commercial Maintenance
Inspector Name(s): Todd Crawford
Inspection Date: November 12, 2014
Date Report Completed: November 25, 2014
Date Forwarded to Reviewer: November 25, 2014
Reviewed by: Beth Swanson
Date Review Completed: December 1, 2014
Cover Letter to use: Insp. Initial Insp. Reg.
Insp. No Finding Insp. CP
Corrected Insp. Reg. Delay
Unit Supervisor/Chemist III: Dana Satterwhite
Date Received: 12/1/2014
Date Forwarded to Linda: 12/3/2014
Date Mailed: 12/4/2014
_____________________________________________________________________
cc: Carrie Ruhlman
On-Site Inspection Report
LABORATORY NAME: Aquatic Ecology Lab – UNCW Center for Marine Science
ADDRESS: 5600 Marvin Moss Lane
Wilmington, NC 28409
CERTIFICATE #: 638
DATE OF INSPECTION: November 12, 2014
TYPE OF INSPECTION: Commercial Maintenance
AUDITOR(S): Todd Crawford
LOCAL PERSON(S) CONTACTED: Matthew McIver
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 lab analyzes samples for the Lower Cape Fear River Coalition and the City of Wilmington stormwater
permits. The facility has all the equipment necessary to perform the analyses. The system for traceability
of standard and reagent preparation is effective, thorough and easy to follow. Laboratory personnel
communicate well with sample collectors and coordinate sample analyses effectively to manage workload
and holding times.
Proficiency Testing (PT) samples have been analyzed for all certified parameters for the 2014 proficiency
testing calendar year and the graded results were 100% acceptable.
The laboratory is reminded that any time changes are made to laboratory operations; the laboratory must
update the Quality Assurance (QA)/Standard Operating Procedures (SOP) document(s). Any changes
made in response to the 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 approved practice and regulatory requirements. In
some instances, the laboratory may need to create a SOP to document how new functions or policy will
be implemented.
Contracted analyses are performed by Environmental Chemists, Inc. (Certification #94).
The requirements associated with Findings F and G have been implemented by our program since the
last inspection.
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III. FINDINGS, REQUIREMENTS, COMMENTS AND RECOMMENDATIONS:
Documentation
Recommendation: It is recommended that the analytical method reference be added to the Chlorophyll-
a benchsheet.
Recommendation: It is recommended that the following be added to the Chlorophyll-a report sheet.
1) Analysis date.
2) Units for the fluorometer reading.
3) Analytical method reference.
A. Finding: An inconsistency was noted between the Chlorophyll-a Standard Operating Procedure
(SOP) and laboratory practice as follows:
The SOP does not describe in detail how the method is performed, including:
1) Lighting conditions during the filtering and extraction processes.
2) State that samples must not be allowed to go to dryness during the filtering process.
3) Update the holding time to 3½ weeks.
4) Add the value from the fluorometer to the final calculation example.
5) Better define “dilution factor”.
6) Specify that the Laboratory Reagent Blank (LRB) is ground and extracted just like
samples.
7) State the duplicate acceptance criterion.
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). Please submit an updated SOP with the response to this report.
B. Finding: The chlorophyll-a benchsheet is lacking units for temperature, standard
concentrations, pipettor check volume weight, blank concentration, and fluorometer reading.
Requirement: All laboratories must use printed laboratory bench worksheets that include a space
to enter the signature or initials of the analyst, date of analyses, sample identification, volume of
sample analyzed, value from the measurement system, factor and final value to be reported and
each item must be recorded each time samples are analyzed. The date and time BOD and
coliform samples are removed from the incubator must be included on the laboratory worksheet.
Ref: 15A NCAC 2H .0805 (a) (7) (H).
C. Finding: The chlorophyll-a benchsheet is lacking the final volume of the extraction solvent.
This is considered pertinent information.
Requirement: 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. Ref: 15A NCAC 2H .0805 (a) (7)
(A).
D. Finding: Uncertified data is not documented as such on the benchsheets or final reports.
Requirement: All uncertified data must be clearly documented as such on the benchsheet and on
the final report. Ref: 15A NCAC 2H .0805 (e) (3).
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Comment: The uncertified data was Stormwater turbidity and salinity data generated by the YSI
Sonde probe and submitted to the City of Wilmington..
E. Finding: The freezer temperature log does not state the units of measure.
Requirement: All laboratories must use printed laboratory bench worksheets that include a space
to enter the signature or initials of the analyst, date of analyses, sample identification, volume of
sample analyzed, value from the measurement system, factor and final value to be reported and
each item must be recorded each time samples are analyzed. The date and time BOD and
coliform samples are removed from the incubator must be included on the laboratory worksheet.
Ref: 15A NCAC 2H .0805 (a) (7) (H).
F. Finding: The laboratory is not documenting PT sample analyses in the same manner as
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.
G. Finding: The laboratory does not have a documented plan for proficiency testing procedures.
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).
Requirement: Laboratories must have a documented plan (this is usually detailed in the
laboratory’s Quality Assurance Manual) of how they intend to cover the applicable program
requirements for proficiency testing per their scope of accreditation. This plan shall cover any
commercially available proficiency testing and any inter-laboratory organized studies, as
applicable. The laboratory must also be able to explain when proficiency testing is not possible for
certain parameters and provide a description of what the laboratory is doing in lieu of proficiency
testing. This shall be detailed in the plan. The plan must also address the laboratory’s process for
submission of proficiency testing results and related corrective action responses. Laboratory
Standard Operating Procedures (SOPs) must address how low level samples will be analyzed,
including concentration of the sample or adjustment of the normality of a titrant. These instructions
shall be followed when the concentration of a PT sample falls below the range of their routine
analytical method. Instructions shall also be included in the laboratory’s SOP for how high level
samples will be analyzed, including preparation of multiple dilutions of the sample. These
instructions will be followed when the concentration of a PT falls above the range of their routine
analytical method. Ref: Proficiency Testing Requirements, February 20, 2012, Revision 1.2.
pH - Standard Methods, 4500 H+ B-2000
H. Finding: The field sheet does not state the units of measure for pH (i.e., S.U.).
Requirement: All laboratories must use printed laboratory bench worksheets that include a space
to enter the signature or initials of the analyst, date of analyses, sample identif ication, volume of
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sample analyzed, value from the measurement system, factor and final value to be reported and
each item must be recorded each time samples are analyzed. The date and time BOD and
coliform samples are removed from the incubator must be included on the laboratory worksheet.
Ref: 15A NCAC 2H .0805 (a) (7) (H).
I. Finding: A calibration check buffer is not analyzed prior to sample analysis.
Requirement: For routine work, use a pH meter accurate and reproducible to 0.1 pH unit with a
range of 0 to 14, equipped with a temperature compensation device. Follow all manufacturers’
recommendations for the calibration of the meter each analysis day. The meter must be
calibrated with at least two buffers. In addition to the calibration standards, the meter must be
verified with a third calibration standard. The calibration and check standard buffers must
bracket the range of the samples being analyzed. Ref: NC WW/GW LC Approved Procedure
for the Analysis of pH.
Comment: The pH meter is calibrated at the lab and then the meter is carried to multiple sites
for analyses. The check buffer was not being analyzed until after samples had been analyzed
and the analyst had returned to the lab. The calibration must be verified prior to sample
analysis. In addition, the calibration must be verified again after sample analyses to
demonstrate that no calibration drift has occurred as result of moving from site to site.
Conductivity - Standard Methods, 2510 B-1997
Comment: The Automatic temperature Compensator (ATC) was last checked on November 6, 2013,
which is beyond the 12 month frequency requirement. The analyst stated that he was waiting until the
inspection to ask a question about the ATC check procedure before completing the check. The NC
WW/GW LC Approved Procedure for the Analysis of Specific Conductance (Conductivity) document
states: The Automatic Temperature Compensator (ATC) must be verified annually (i.e., 12 months) at two
temperatures by analyzing a standard or sample at 25°C (the temperature that conductivity values are
compensated to) and a temperature(s) that brackets the temperature ranges of the environmental
samples routinely analyzed. This may require the analysis of a third temperature reading that is > 25°C.
Demonstration of acceptable corrective action (i.e., documentation of an acceptable ATC check) was
received by email on 11/12/14. No further response is necessary for this finding.
Temperature - Standard Methods, 2550 B-2000
Comment: The temperature sensor used for compliance monitoring was last checked on November 6,
2013, which is beyond the 12 month frequency requirement. The NC WW/GW LC Approved Procedure
for the Analysis of Temperature document states: 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. Demonstration of acceptable corrective action (i.e., documentation of
acceptable temperature sensor checks) was received by email on 11/12/14. No further response is
necessary for this finding.
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#638 Aquatic Ecology Lab – UNCW Center for Marine Science
Comment: The meters used to measure temperature were not labeled with the temperature correction
factors. The NC WW/GW LC Approved Procedure for the Analysis of Temperature document states: All
thermometers and temperature measuring devices must be checked every 12 months against a NIST
traceable thermometer. The process must be documented and proper corrections made to all compliance
data. 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. Notification of acceptable corrective action (i.e., a statement that the
meters had been labeled with temperature correction factor) was received by email on 11/12/14. No
further response is necessary for this finding.
IV. PAPER TRAIL INVESTIGATION:
No paper trail performed.
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 25, 2014
Report reviewed by: Beth Swanson Date: December 1, 2014