1. Corporate Overview Consolidated Auditing and Proficiency Testing Programs
George E. Detsis
Manager, Analytical Services Program
Office of Environment, Health, Safety and Security
Office of Sustainability Support
2014 ASER Workshop
Los Alamos, New Mexico
November 4-6, 2014

2. Topics Program accomplishments Common problems -- audit findings
DOECAP lessons learned
Future considerations

3. Accomplishments
Implemented Department of Defense (DoD)/DOE Consolidated Quality Systems Manual (QSM) for Environmental Laboratories, and updated the Lab Audit Checklists
20 Lab Audits, which includes 1 Lab Surveillance and 4 Lab Closure Audits
8 Treatment, Storage, and Disposal Facility Audits
Processed Corrective Action Plans
Maintained a cadre of 134 trained volunteer auditors

4. Accomplishments (cont.)
DOECAP TSDF Checklist Pilot – The facility completed the audit checklists in advance and self-identified deficiencies (treated DOECAP “SI” as observations rather than audit findings)
Initiated a DOE Technical Standard on Lab Proficiency Testing (PT)
Engaged DOE managers – Briefings on audit results/recruiting for auditor participation
Analytical Services Program – FY 2013 Report

5. DOECAP Making a Difference
Improving Lab/TSDF Performance
Improved QA programs
Reduction/elimination of legacy waste streams
Corrective action plans that address “causal effects” to prevent reoccurrences
Improving audit report quality – findings tied to requirements, specific requirements are cited, and the supporting evidence identified by the auditors is explained
DoD/DOE Consolidated QSM improves the ability of Labs to prepare for Federal agency audits

6. Laboratory Audits

7. Distribution of FY 2014 Laboratory Findings

8. Common Problems -- FY 2014 Lab Findings
Procedures, Procedures, Procedures
Laboratory practices/SOPs do not accurately reflect the current analytical method
Facilities lack the necessary SOPs
Employees not trained to latest/approved procedures (lack of training documentation).
Employees not following approved laboratory procedures
Procedures not updated annually
Not running quality control samples at required frequency
Not maintaining equipment (preventive maintenance) and supplies (reagents/solvents) records.
Not updating Quality Assurance Management Plan
Opening incoming sample shipments outside of a ventilation hood, which means that personnel are potentially being exposed to hazardous materials.

9. Common Problems -- FY 2014 Lab Findings (cont.)
Performing calculations associated with sample analysis using spreadsheets with formula cells that are not write-protected.
Using acceptance criteria for analytical balances and pipettes that do not meet QSM requirements.
Lack of analytical waste segregation, labeling , storage and disposal practices
Lack of internal audits, and annual management review that fosters continuous improvements
Logbook documentation issues

10. Tentative Laboratory Audit Schedule for FY 2015
Month & Year
TestAmerica, Inc., Knoxville, TN
November 2014
Eberline Analytical Corporation, Oak Ridge, TN
December 2014
ALS Laboratory Group, Cincinnati, OH
January 2015
Materials and Chemistry Laboratory, Inc., Oak Ridge, TN
Shealy Environmental Services, Inc., West Columbia, SC
February 2015
ALS Laboratory Group, Salt Lake City, UT
American Radiation Services, Inc., Port Allen, LA
March 2015
TestAmerica, Inc., Arvada, CO

11. Tentative Laboratory Audit Schedule for FY 2015 (cont.)
Month & Year
Southwest Research Institute, San Antonio, TX
March 2015
GEL Laboratories, LLC, Charleston, SC
April 2015
ALS Environmental Group, Fort Collins, CO
May 2015
Shealy Consulting, LLC, Lexington, SC
TestAmerica, Inc., Earth City, MO
TestAmerica, Inc., Richland, WA
June 2015
BC Laboratories, Inc., Bakersfield, CA
Brooks Rand Labs, LLC, Seattle, WA

12. DOECAP TSDF Audits

13. Distribution of FY 2014 TSDF Findings

14. Common Problems -- FY 2014 TSDF Audit Findings
Outbound shipping paperwork does not meet the requirements; for example:
Technical Name requirements for hazardous material shipments
Shipping Description and Hazard Class for hazardous material shipments
Required content and signatures on outbound shipping papers
Not ensuring that workers complete the required training for work under the hazardous waste management permit and/or failing to properly document completion of the required training.

15. Common Problems -- FY 2014 TSDF Audit Findings (cont.)
Not meeting the requirements for:
Chemical storage (incompatibles)
Waste segregation
Universal waste labeling and marking
Failing to properly label measuring and test equipment with the calibration status.

16. Tentative TSDF Audit Schedule for FY 2015
Month & Year
Clean Harbors Colfax, LLC, Colfax, LA
November 2014
Clean Harbors Environmental Services – Deer Park, LaPorte, TX
December 2014
Diversified Scientific Services, Inc., Kingston, TN
January 2015
EnergySolutions, LLC, Oak Ridge, TN
February 2015
Materials and Energy Corporation, Oak Ridge, TN
March 2015
Perma-Fix Northwest, Inc., Richland, WA
April 2015
EnergySolutions, LLC, Clive, UT
Perma-Fix of Florida, Inc., Gainesville, FL
May 2015
Waste Control Specialists LLC, Andrews, TX
9/12/2013, kb

17. DOECAP Lessons Learned
Need to incorporate consistent DOE contract language for lab closures associated with the timeframe for waste disposition
What will be the consequences of the Hanford Site Lab Closure?
Taxpayer cost savings
DOE will be farming that work out to other commercial labs

19. Mixed Analyte Performance Evaluation Program (MAPEP) Accomplishments
130 labs participation domestic and 42 foreign
Semiannual PT evaluations:
MAPEP Series 30: Shipped March 2014
MAPEP Series 31: Shipped August (reporting deadline November 5 ,2014)

20. MAPEP Accomplishments (cont.)
Initiated DOE - PT Technical Standard
Performed special studies for uranium and strontium
RMCC -- International collaborations – building lasting partnerships through science, not weapons

21. Uranium Isotopes Measurement by Alpha & Gamma Spectroscopy

22. Participation in MAPEP Improves Performance
Laboratories’ performance for analysis of iodine‑129 in water

23. DOE Senior Management Support for MAPEP
DOE Chief Health, Safety, and Security Officer memo on December 30, 2013, to program line and field element managers recommends that all onsite and sub- contracted environmental laboratories performing radiological, inorganic, or organic analyses for DOE be encouraged to participate in MAPEP.

24. Laboratory Audit Programs – Overall Objective
The overall objective is to provide data of known, documented quality to field managers for use in making sound environmental management and cleanup decisions.

25. Future Considerations
DOECAP Auditing Activities
New labs being considered
New non-radiological TSDFs being considered
Budget considerations – FY 2015 budget remains flat

26. Future Considerations (cont.)
Continuing TSDF Pilot Study of Self – Identified findings/completed checklists
More focused DOECAP audit scopes:
Laboratory Audit Disciplines
Quality assurance
Data quality for organic, inorganic, and radiochemistry analyses
TSDF Audit Disciplines
Environmental compliance and permitting
Waste operations

27. Conclusion Flexibility
Dealing with reorganizations, loss of institutional knowledge and changing priorities
Maintaining excellence and consistency while continuing to provide value-added stakeholder benefits – risk reductions/performance improvements

28. George E. Detsis Office of Environment, Health, Safety and Security

29. Questions?
9/20/2018