U.S. Department of Energy’s
Consolidated Audit Program
George E. Detsis
Manager, Analytical Services Program
Office of Corporate Safety Programs, HS-31
Presented before the 2008 Second Annual
RadWaste Summit
September 2-5, 2008
Las Vegas, Nevada
Presentation Outline
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Program Overview
Background (IG/GAO)
Checklists
Common Findings
Accomplishments/Challenges
Overview of
Analytical Services Program
Finding from DOE’s
Office of the Inspector General
and GAO Reports
Report on the Audit of DOE’s Commercial Laboratory
Quality Assurance Evaluation Program (June 1995)
IG and GAO Identified reductions in DOE Auditing and
Contracting of Analytical Services
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Some laboratories were audited numerous times; others were never
audited
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Evaluation methods varied significantly from one contractor to another
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Audit results were not shared between contractors
DOECAP Background
Purpose:
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Reduction audit redundancies
Standardize audit methodology, policies and procedures
Communicate Lessons Learned
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Reduce overall Department risks/liabilities
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Contractual agreement linkage
Involves all DOE line organizations/field operations
Auditor participants primarily DOE contractor holders
 Auditor qualifications/training requirements
 Federal staff lead TSDF audits
Results of Formalized
DOE Auditing Program
DOECAP reduced the Department’s risks and
liabilities, and verified radioactive and chemical waste
accountability
FYO8 DOECAP Auditing Activities:
30 Analytical Environmental Laboratories
1 Laboratory Surveillance
7 TSDF’s
1 Non-radiological TSDF scoping
Criteria Definitions
Priority I Finding
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Programmatic/systematic failure
Imminent threat to worker safety/health
Potential for major property/facility damage
Repeated deficiency
Priority II Finding
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Nonconformance with internal requirements/procedures
Undocumented procedures
Nonconformance with DOE requirements
Observation
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Isolated instance/deficiency
Opportunity for improvement
Audit Checklists
Module 1 – Quality Assurance Management
Systems
Module 2 – Sampling and Analytical Data Quality
Module 3 – Waste Operations
Module 4 – Environmental Compliance and
Permitting
Module 5 – Radiological Control
Module 6 – Industrial & Chemical Safety
Module 7 – Transportation Management
Audit Driver
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DOE Order 435.1 (manual), Radioactive Waste
Management
Requires that DOE first utilize DOE facilities to
manage radioactive waste
 However, if DOE chooses to use a non-DOE waste
vendor, DOE must perform an annual ES&H
review
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Perspective/Context
All 7 TSDFs were found to maintain the
established management systems and
operational activities necessary to meet DOE
requirements for the storage, handling,
transportation, processing and final disposition
of DOE waste.
Percent Distribution of
FY 2008 TSDF Findings
Quality Assurance (8)
20%
15%
7%
9%
13%
13%
23%
Sampling and Data
Quality (4)
Waste Operations (5)
Environmental
Compliance (12)
Radiological Control (7)
Industrial and Chemical
Safety (7)
Transportation (11)
Percent Distribution of
FY 2008 TSDF Observations
Quality Assurance (4)
12%
6%
16%
22%
7%
15%
22%
Sampling and Data
Quality (11)
Waste Operations (5)
Environmental
Compliance (15)
Radiological Control (10)
Industrial and Chemical
Safety (15)
Transportation (8)
TSDFs Audited in FY08
• Diversified Scientific Services, Inc. (DSSI), Kingston, TN
• Energy Solutions, LLC, Oak Ridge, TN
• Energy Solutions of Utah, Clive, Utah
• Materials and Energy Corporation, Oak Ridge, TN
• Perma-Fix Northwest, Richland, WA
• Perma-Fix of Florida, Gainesville, FL
• Waste Control Specialists, Andrews, TX
Common TSDF Findings
by Audit Discipline (FY 08)
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Quality Assurance Management Systems:
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Sampling and Analytical Data Quality:
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Follow-up on corrective actions
SOP reviews are not current
Training records are not complete
Document control is inadequate
Waste Analysis Plan Discrepancies
Incomplete SOPs
Waste Operations:
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Excessive quantities of aged waste on site
Actual work practice not consistent with SOP or Plan
Common TSDF Findings by
Audit Discipline (FY 08) cont’d
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Environmental Compliance/Permitting:
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Container label, designation or storage condition inadequate
Shipment receipt verification incomplete
Area inspections and documentation inadequate
Performing a waste size reduction process without having
regulatory approval (one instance)
Radiological Control:
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Radiological work permit briefing and training inadequate
Inappropriate monitoring instruments for alpha
Visitor monitoring and training inadequate
Inadequate posting or signage
Common TSDF Findings by
Audit Discipline (FY 08) cont’d
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Industrial and Chemical Safety:
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Inadequate Health and Safety Plans or delinquent reviews
Postings for confined space incomplete
Incompatible chemical storage
Inadequate chemical labeling
Transportation Management:
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Lack of training
Records Management not included for all documents
Evaluation of sub-tier contractor incomplete
Incomplete shipping/receiving documentation
TSDF
Accomplishments
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Completed 7 TSDF audits; 1 on-site scoping of nonradiological TSDF
Approved 7 TSDF Corrective Action Plans
Tracked 86% of FY2007 Corrective Actions to
completion (57 FY2007 findings closed out of 66
identified)
Updated all Program audit checklists
Increased number of qualified auditors and lead
auditors
Continued interagency partnering with EPA, State
Agencies, and DoD
DOECAP Challenges
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Increase Federal team leaders
Increase auditor pool
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Radiological control
Industrial and chemical safety
Improve POCs active participation -- HQ/field
Improve localized/regional auditor participation to
reduce travel costs
Improve program ownership/responsibility
Increase incorporation of DOECAP language into
contracts
ASP Program Contact Information
George Detsis, Analytical Services Program (ASP) Manager
Phone: (301) 903-1488
E-mail: [email protected]
Carolyne Thomas - DOECAP Manager, DOE Oak Ridge
Phone: (865) 576-2690
E-mail: [email protected]
Guy Marlette, MAPEP Coordinator, Idaho National Laboratory
Phone: (208) 526-2532
E-mail: [email protected]
Brent Pulsifer, VSP Coordinator, Pacific Northwest National Laboratory
Phone: (509) 375-3989
E-mail: [email protected]
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