## Technical System Audit Report

Clark County Department of Air Quality and Environmental Management Ambient Air Quality Monitoring

Program

July 28

– July 30, 2009

Conducted by

Air Quality Analysis Office Quality Assurance Office

Air Divisio n Management and Technical

Services Division

US EPA Region 9

75 Hawthorne Street San Francisco, California 94105

February 2010Clark Co. TSA Report: September 2009

2 CONTENTS

PAGE

GLOSSARY OF ACRONYMS

................................................... ...................... 3

EXECUTIVE SUMMARY

................................................................................ 4

INTRODUCTION

............................................................................................ . 6

A. GENERAL PROGRAM

.. ............................................................................ . 8

B. NETWORK MANAGEMENT

..................................................................... 1 4

C. FIELD OPERATIONS

............................................................. ..................... 17

D. LABORATORY OPERATIONS

................................................................ . 20

E. DATA AND DATA MANAGEMENT

......................................................... 22

F. QUALITY MANAGEMENT

......................... ............................................... 2 3

APPENDIX A, Summary of Findings

....................................... ............ 2 5

APPENDIX B, QMP and QAPP Comments

.............................. ............. 27Clark Co. TSA Report: September 2009

3 GLOSSARY OF ACRONYMS

AQS..............................

........ Air Quality System

CO........................................ Carbon Monoxide

CFR...................................... Code of Federal Regulations

EMS............................ Electronic Management System

LEADS......................... Leading Environmental Analysis and Dis play System NAAQS................................ National Ambient Air Quality Standard

NCore.................................. National Core multipollutant monitoring stations

NIST............................ National Institute for Standards and Technology NOx/NOy.......

...................... Nitrogen Oxides

NV............................... State of Nevada

O 3

.......................................... Ozone

ORD............................. Office of Research and Development

PM........................................ Particulate matter

PM 2.5

................. .................... Particulate matter 2.5 microns or less in aerodynamic

diameter

PM 10

...................................... Particulate matter 10 microns or less in aerodynamic

diameter PQAO................................... Primary Quality Assurance O rganization QA........................................ Quality Assurance QC........................................ Quality Control QAPP................................... Quality Assurance Project Plan QMP............................ Quality Management Plan

SPM..........

........................... Special Purpose Monitor

SOP...................................... Standard Operating Procedure

SLAMS................................ State or Local Air Monitoring Station

SO 2

....................................... Sulfur Dioxide

SRP............................. Standard Reference Photometer

STN............................. Speciation Trends Network

TSA...................................... Technical System Audit

EPA

...................................... United States Environmental Protection AgencyClark Co. TSA Report: September 2009

4

EXECUTIVE SUMMA RY

This report document s the findings made by EPA Region 9 during its Technical System Audit (TSA) of the Clark County Department of Air Quality and Environmental Management (DAQEM) ambient air monitoring program. A TSA is an on

- site review and inspectio n of a state or local ambient air monitoring program to assess its compliance with established regulations governing the collection, analysis, validation, and reporting of ambient air quality measurement data. This TSA meets the requirements for EPA Region al 9 audits of the DAQEM monitoring organization required by 40 CFR Part 58, Appendix A, Section 2.5.

Th e TSA was conduct ed by EPA Region 9 staff from July 28

– July 30, 2009

. The audit team interviewed management and staff on specific aspects of the ai r monitoring program including network design, field operations, laboratory operations, data handling, quality assurance and quality control procedures. The audit team also inspected several monitoring sites and visited several additional monitoring sites including the proposed NCore monitoring station. The site inspections consisted of

interview ing the site operator, reviewing station and instrument logbooks, and evaluating the station siting with respect to EPA requirements for probe siting 1

.

The TSA is one of the ways EPA oversees data collection activities performed by state and local agencies to ensure they meet certain minimum data quality objectives.

Other assessments

, such as network reviews and performance evaluations

, are also used

to collect information on the overall quality of ambient air monitoring data. These assessments enable agencies to identify and correct program elements which may be adversely affecting the quality of ambient air data.

The result s of th e TSA are summarized belo w and discussed in more detail i n the specific sections of this report Recommendations for addressing each of the findings are provided . The specific actions taken by DAQEM to address the findings should be approved by EPA and documented by DAQEM in a co rrective action plan.

EPA would like to thank all the staff and management of DAQEM for their support and cooperation during the audit.

Program Strengths:

Overall, DAQEM has well qualified, very knowledgeable

, and experienced staff.

DAQEM has recen tly upgraded the data collection system for continuous pollutants. This upgrade has improved its ability to process data efficiently and control data quality.

1 40 CFR, Part 58, Appendix E, “Probe and Monitoring Path Siting Criteria for Ambient Air Quality Monitoring”Clark Co. TSA Report: September 2009

5 Each DAQEM monitoring station visited is well sited to collect representative

data.

DAQEM dat a specialists were able to easily track the data points requested by the

auditors.

The PM 2.5 laboratory is well maintained and organized by the analysts.

Many DAQEM staff members ha ve implemented measures to improve the quality

of the overall monitorin g program.

Program F indings:

While acknowledging the strengths of DAQEM’s monitoring program, EPA identified several program elements that could be improved

. Specifically, DAQEM

should :

Strengthen the Quality Assurance program by giving it a more fo rmal role in its oversight of the monitoring program, and by providing technical capacity at higher levels of management to oversee the QA officer’s work.

Ensure the Quality Management Plan and Quality Assurance Plans include

sufficient information to mee t EPA requirements.

Improve procedures for maintaining hard copy records that are consistent, secure, and regularly updated. DAQEM should also standardize procedures for creating

records in the Leading Environmental Analysis and Display System (LEADS)

da ta system.

Improve the procedures for reporting data in A ir Quality System (A QS ) by adequately identifying compromised data. DAQEM should maintain records in

the LEADS data system that document why data have been flagged in AQS and should verify that dat a submitted to AQS is consistent with the data that are published on its website.

Improve the systems for tracking the location and statu s of equipment, and improve the procedures for initiating and documenting equipment repairs.

In addition to these si gnificant findings, EPA has identified additional findings and made recommendations. The individual findings are reported in the topic sections of this document and are also summarized in Appendix A.Clark Co. TSA Report: September 2009

6

INTRODUCTION

The Clark County DAQEM is the governm ent agency with delegated authority and responsibility for collecting ambient air quality data pursuant to the Clean Air Act of

1977 and the Clean Air Act Amendments of 1990.

From July 28 through July 30

, 2009, Michael Flagg of the Region 9 Air Quality Analysis Office and Matthew Plate of the Region 9 Quality Assurance Office conducted a Technical System Audit of DAQEM’s ambient air monitoring program. The TSA covered the following program areas:

General / Quality Management

o Program Organization

o Facil ities

o Independent Quality Assurance and Quality Control

o Planning Documents (including QMP, QAPPs, & SOPs)

o General Documentation Policies

o Training

o Corrective Action

o Quality Improvement

o External Performance Audits Network Management / Field Operations

o Networ k Design

o Changes to the Network since the last audit

o Proposed changes to the Network

o Field Support

 SOPs

 Instrument Acceptance

 Calibration

 Repair

 Site and Monitor Information Form Laboratory Operations

o Routine Operations

o Quality Control

o Laboratory Preventiv e Maintenance

o Laboratory Record Keeping

o Laboratory Data Acquisition and Handling

o Specific Pollutants: PM 10 , PM 2.5 and Lead Data and Data Management

o Data Handling

o Software Documentation

o Data Validation and Correction

o Data Processing

o Internal Reporting

o Exter nal ReportingClark Co. TSA Report: September 2009

7 Additionally, EPA tracked supporting documentation for several data points/sets from calendar year 2008.

Participating DAQEM managers, supervisors and staff included :

Mike Sword , Engineering Manager Yousaf Hameed, Monitoring Supervisor Mickey Palmer, Senior Monitoring Tech. (QA Officer ) Mickey Turner, Senior Monitoring Tech. Phillip Wiker, Senior Monitoring Tech. Pravin Perna, Monitoring Tech. II Dave Dickens, Monitoring Tech. II Mathew Nelson, Monitoring Tech. II
Kris Simonian, Monitor ing Tech. II

This report is divided into ten sections. The first sec tion is an executive summary that describes the purpose of the TSA and a summary of the most significant findings.

The following section is an introduction that provides a brief descri ption of the DAQEM air monitoring program, identifies participating DAQEM personnel and the EPA audit team, and describes the report ’s organization. The third section discusses the general /significant findings . The next five sections address specific aspe cts of the air monitoring program: network management, field operations, laboratory operations, data management and quality assurance/quality control. Appendix A is a summary listing of the findings contained in this report. Appendix B includes EPA conce rns with the DAQEM Quality Management Plan, QA Project Plans, and associated Standard Operating Procedures. Recommendations for each finding are provided to give some

indication of the EPA Region 9’s expectations as to how findings can be addressed. If

t he DAQEM has other approaches or alternatives to address the concerns identified, the Region will consider them, provided the corrective action adequately addresses the finding.Clark Co. TSA Report: September 2009

8

A. G ENERAL PROGRAM

The Governor of Nevada gave authority for Air Quality Matters in Clark County to the Clark County Board of Commissioners in 2001. This is reflected in the Nevada Revised Statutes 445B.500, which delegate significant air pollution control authority to Nevada counties with populations greater than 400,000. Th e Clark County Board of Commissioners created an Air Quality Management Board to govern air quality programs and DAQEM to implement air quality programs

, including ambient air quality monitoring. Prior to 2001, ambient air quality monitoring was implement ed by the Clark County District Health Department.

DAQEM currently has 16 active monitoring stations for criteria pollutants. The pollutants measured include:

Carbon Monoxide
Nitrogen Dioxide

Ozone

Particulate Matter (PM 10 and PM 2.5 )

DAQEM is headed by a Director and two Assistant Directors . A t the time of the audit one of the Assistant Director positions was vacant. Ambient air monitoring is conducted by the Engineering Division, which is lead by an Engineering Manager

, who reports to an Assistant Di rector. The Engineering staff consists of a Monitoring Supervisor

, who oversees 11 technical staff

. A t the time of the audit one of these staff positions was vacant. An Office Specialist and a Senior Technician/QA Officer report directly to the Engineer ing Manager.

FINDING A1:

DAQEM’s Quality Assurance program may lack sufficient management and should have a more formal and independent role in the oversight of the monitoring program.

Discussion: The EPA requirements for independence of quality assura nce for Primary Quality Assurance Organizations (PQAOs) are in 40 CFR Part 58, Appendix A, Section 2.2. This section states that “the quality assurance management function must have sufficient technical expertise and management authority to conduct indepe ndent oversight and assure implementation of the organization’s quality system.” The DAQEM program includes one senior technician who serves as the quality assurance auditor and quality assurance officer. While this organizational structure provides a le vel of independence for the QA functions performed that is generally acceptable, it is less than the two layers of management that EPA recommends. More significantly, the quality assurance function does not include sufficient formal technical oversight of the monitoring program and there is no mechanism for independent review of the QA officer’s work. EPA also found thatClark Co. TSA Report: September 2009

9 the following functions, which should be performed by the independent QA officer, were either not being performed or were not being perfo rmed adequately:

Periodic audits of the quality management system (management system reviews), routine procedure s , and data quality to identify areas of improvement and to ensure that monitoring programs continue to follow sound and documented procedure s. Formalized review of certain QA activities, such as data validation, annual

certification of the O 3 transfer and flow standards, and the certification of calibration gas cylinders for NOx, CO, and SO 2 instrument calibration. Review and approval of cor rective actions. Review and tracking of precision and accuracy data.

EPA QA/R

- 5, EPA Requirement for Quality Assurance Project Plans

, lists the types of assessments that should be elements of a quality management program

. T hese include, “surveillance, management systems reviews, readiness reviews, technical systems audits, performance evaluations, audits of data quality, and data quality assessments.”

Recommendations:

1. DAQEM should consider alternative organizational or reporting struct ures which will provide for greater technical capacity at higher levels of management to oversee the work of the QA officer.

2. DAQEM should strengthen the Quality Assurance/Quality Management function by giving it more formal authority to oversee the m onitoring

program. 3. DAQEM should also consider moving functions

, such as data management and validation, into the QA unit because it is not directly involved in data

collection.

FINDING A2:

The Quality Management Plan (QMP) and Quality Assurance Pr oject Plans (QAPPs) need additional information to meet EPA requirements.

Discussion: The QMP and QAPPs submitted to EPA by DAQEM in 2008 do not include many elements required in QA planning documents . Specific comments on these documents are provided in Appendix B.

All organizations conducting environmental programs funded by EPA are required to establish and implement a quality management system. In accordance

with 40 CFR Part s 31 and 35, grant recipients are required to document their quality system s in a Quality Management Plan through EPA Order 5360.1 A2, Policy and Program Requirements for the Mandatory Agency

- wide QualityClark Co. TSA Report: September 2009

10 System (EPA 2000). Additionally, specific ambient air monitoring requirements are found in 40 CFR, Part 58, Appendix A, Secti on 2.1. Guidance on developing QMPs can be found in the EPA guidance document “EPA Requirements for Quality Management Plans”, EPA/240/B

- 01/002, March 2001.

EPA also requires that organizations develop a QAPP for each type of ambient pollutant that is be ing measured. The QAPP integrates all technical and quality aspects of a project, including planning, implementation, and assessment. The purpose of the QAPP is to document planning results for environmental data operations and to provide a project

- specif ic “blueprint” for obtaining the type and quality of environmental data needed for a specific decision or use.

The QAPP documents the quality assurance and quality control that are applied to an environmental data operation to assure the results obtaine d are of the type and quality needed and expected. Further guidance on developing QAPPs can be found in the guidance documents “EPA Requirements for Quality Assurance Project Plans,” EPA/240/B

- 01/003, March 2001, and “Guidance for Quality Assurance Projec t Plans,” EPA/240/R

- 02/009, December 2002.

Recommendation: DAQEM should work with EPA Region 9 to develop approved QA planning

documents.

FINDING A3:

The consistency of r ecords generated and maintained in the LEADS Electronic Managemen t System (EMS) is inadequate

. Inconsistencies in the generation and retention of other records may also exist.

Discussion: Many of the records DAQEM generates and maintains are kept in the LEADS EMS, which is an useful central repository. However, EPA noted inconsistencies in the generation and completeness of records in the system. Significant examples are the monitoring station logs and data validator ’ s notes.

When comparing data in the LEADS system to data in AQS, it was not always clear why cer tain data were flagged in AQS and other data were not. This was mainly due to the level of detail in the electronic “logs” and comments. Because the LEADS EMS entry fields are “free form”

, it is especially important that the operators and validators deve lop and use a standardized minimal level of detail when entering information. The procedure for documenting peer, supervisor, validator, and QA Officer review of these records should also be standardized.

DAQEM has established systems for maintaining ot her information in instrument logbooks and laboratory records. For other records maintained by individualClark Co. TSA Report: September 2009

11 staff, the department has no clear recordkeeping procedures. The Department should evaluate the records maintained by individuals to ensure they are consistent, secure, regularly maintained, and (for electronic records) backed

- up.

Also see Finding C6.

Recommendation: DAQEM should create a standardized method for creating and maintaining “station logs” and other entries within the LEAD S system. Additionally, the Department should evaluate other electronic and hard

- copy documentation to

ensure that they are consistently prepared and maintained.

FINDING A4:

Procedures for submitting d ata to the AQS

, flagging data in AQS, and reportin g data to the public need to be improved.

Discussion: In the past year and a half

, DAQEM has shifted most data reporting to a new data system supported by IPS MeteoStar.

If data are compromised, the appropriate AQS flags should be applied. DAQEM

uses the “miscellaneous void (AM)” flag to describe a number of different issues with the data. Using flags that specifically describe how the data are compromised enables DAQEM and EPA staff and the public to understand better what the

issues associated with t he data are . All AQS codes and flags can be found at: http://www.epa.gov/ttn/airs/airsaqs/manuals/codedescs.htm

.

Data that DAQEM intends to submit for consideration under EPA’s except ional events rule have not been flagged as such in AQS. Pursuant to 40 CFR 50.14(c)(2)(iii), “Flags placed on data being due to exceptional events together with an initial description of the event shall be submitted to EPA not later than July 1 st of the c alendar year following the year in which the flagged measurement occurred.” Because the exceptional events rule allows for the exclusion of data from consideration against the NAAQS, values affected by exceptional events will impact the planning process o f both DAQEM and EPA Region 9. This timeline ensures the efficiency of exceptional event evaluation and should be met

in accordance with the CFR.

Finally, EPA noted discrepancies when comparing validated data reported by DAQEM on its website with data in AQS. An example of this is ozone data reported from the E. Craig Road site from February 1

- 4, 2008. The Department

web

- based system reported zeros during this time period, while the data in AQS were invalidated. An evaluation of similar data during the audit found that this was an artifact of importing data into the system. This raises the possibility that aClark Co. TSA Report: September 2009

12 significant amount of data available to the public may not match what was reported to AQS.

One instance of data not being reported to AQS was also noted. This was for

ozone at the Joe Neal site from November 3

- 5, 2008. An evaluation of the data system revealed the data were not reported to AQS by the LEADS EMS because it had not been marked as “validated” in the system.

Recommenda tions:

1. DAQEM should improve its use of flagging by using more descriptive flags and by avoiding overuse of the “miscellaneous void (AM)” flag.

2. DAQEM should identify and resolve all discrepancies between the data in AQS and the data reported on it s website. DAQEM should additionally implement procedures to eliminate such discrepancies in the future.

FINDING A5:

DAQEM lacks an adequate system for tracking equipment status, initiating equipment repairs, and documenting repair history.

Discussion : DAQEM does not have an established mechanism for tracking instrument location, condition, and repair history. Currently monitors that are not functioning properly are replaced with working instruments as available from the main office. Because poorly f unctioning equipment may have bearing on data quality, this information should be tracked in a manner that is easily recoverable. Improved e fforts to track such information may prevent the deployment of poorly functioning instruments and allow DAQEM to re duce the number of instruments

held in reserve.

At the time of the audit, it was also not clear who was responsible for initiating repairs to broken instruments. This should be resolved so that instrument repair is undertaken and verified by qualified individuals.

Overall, it is evident that establishing a formal communication system related to instrument operation and maintenance would improve data quality in all elements of the quality management system, including some which may not have been

identi fied in this audit.

Recommendations:

1. DAQEM should develop a system to track the location and status of all

instruments.

2. DAQEM should establish standard procedures for initiating and documenting equipment repairs.Clark Co. TSA Report: September 2009

13

B. N ETWORK MANAG EMENT

The Clark County network for state and local air monitoring stations (SLAMS)

consists of 16 stations. The following table summarizes the SLAMS air monitoring sites

in Clark County by the respective pollutants monitored and the year monitoring bega n at
the site.

SITE NAME (year established) POLLUTANT

CO SO 2 NO 2 O 3 PM 10 PM

2.5 PM

2.5 continuous Apex(1998) X X X Boulder City (1998) X X E. Craig Road (1992) X X X E. Sahara (1995) X Green Valley (1998) X X J.D. Smith (199 8) X X X X X X Jean (1995) X X X X Joe Neal(2000) X X X Lone Mountain (1998) X X Mesquite(2001) X X Orr (2002) X X X Palo Verde (1998) X X Paul Meyer (1998) X X Sunrise Acres (1996) X X X X Walter Johnson (1995) X Winterwood (1979) X X Source: DAQEM 2008 Air Monitoring Network Plan

The Clark County network currently meets or exceeds the requirements for the minimum number of monitoring sites designated as SLAMS for all of the criteria pollutants . A ll of t he monitoring sites are properly located with respect to monitoring objectives

, spatial scales and other siting criteria.

Pursuant to 40 CFR 58.20 , s tates must perform an annual review of their ambient monitoring network. The annual network revie w is used to determine how well the network is achieving its required air monitoring objectives, how well it is meeting data users needs, and how it should be modified ( e.g. , through termination of existing stations, relocation of stations, or establishmen t of new stations) to continue to meet its monitoring objectives and data needs. The main purpose of the review is to improve the network to ensure it provides adequate, representative, and useful air quality data. Based on changes to the monitoring regul ations, which went into effect in December 2006, the annual network plan now requires evidence of a public inspection process. Clark County DAQEM submits a monitoring network plan every year. The most recent submittal by DAQEM, in 200 9

, contains all of the required information about the monitoring stations

,Clark Co. TSA Report: September 2009

14

including the information required by 40 CFR Part 58, Appendix A ( quality assurance requirements ) and Appendix D ( network requirements and monitoring site objectives )

.

Network Management

Finding B1 :

The DAQEM system lacks the necessary flexibility to establish new monitoring stations in response to changing conditions

.

Discussion: DAQEM has been working through the logistics of establishing a new NCore monitoring station for over a year. DAQEM ha s indicated that this is due to Clark County facility and permitting requirements, which are outside its control. In the future, DAQEM may be required to move and/or establish new monitoring sites to accommodate new monitoring requirements and/or other ch anges in the

network. Excessive start

- up times could mean required data are not collected.

Recommendation: DAQEM should develop a system to establish monitoring sites more expeditiously (e.g., develop standardized pre

- approved monitoring station configur ations).

Finding B 2 :

DAQEM is working to resolve the status of its formal application for a PM 2.5 Approved Regional Method (ARM) for the continuous monitors.

Discussion: In 2006, EPA published criteria for approving continuous methods for PM 2.5 moni toring ARMs in 40 CFR Part 58, Appendix C. ARMs must be approved or disapproved by EPA within 120 days of submittal. EPA ORD is currently requesting more information from DAQEM to supplement its ARM application,

which will reset the 120

- day clock.

A m ore recent model of the Thermo Beta Attenuation Monitoring being used by DAQEM has recently been approved as a Federal Equivalent Method (FEM). It would be advantageous from a collocation standpoint to use the FEM rather than

an ARM method as the latter r equires 30% collocation with an FRM or FEM and 7.5% collocation ARM to ARM (see the text below from 40 CFR Part 58, Appendix C).Clark Co. TSA Report: September 2009

15 2.4.4.5 Collocation with an ARM under this part for purposes of determining the coefficient of variation of the method shall be conducted at a minimum of 7.5 percent of the sites with a minimum of 1 per network.

This is consi stent with the requirements in A ppendix A to this part for one

half of the required collocation of FRM/FEM (15 percent) to be collocated

with the same meth od.

Recommendation: DAQEM and EPA Region 9 should follow up on the status of the ARM submittal, but also consider initiating a program to upgrade the continuous instruments to FEMs in order to save on long

- term operational costs.Clark Co. TSA Report: September 2009

16

C. F IELD OPERATIONS

Fi eld operation s for ambient monitoring are performed by staff who report to the Monitoring Supervisor

. Staff are assigned to monitoring stations and are responsible for all criteria pollutant operations at their respective stations. One Senior Technician is assigned the responsibility for calibration of field standards for gaseous pollutants and

flow.

As part of this TSA, Monitoring Technicians were interviewed about their duties

related to monitoring station operation. All station operators interview ed demonstrated a thorough knowledge of the monitoring equipment for which they were responsible.

The Field Sites reviewed included Apex, Joe Neal, East Craig, and East Sahara.

EPA evaluation at these sites included inspection of the inlet manifolds, e xamination of station and instrument log books, and a specific check of whether appropriate Q uality

C ontrol (QC) checks and Quality Assurance ( QA ) audits were being performed for dates

in 200 7 selected for review prior to the audit. Each of the eight sites visited were well organized and had clean sampling lines. I nstrument logbooks were up to date and contained relevant information on operations and maintenance activities. Station logbooks are maintained electronically in the data acquisition system. All sites met the siting criteria of 40 CFR 58, Appendix E

.

Field Operations

Finding C 1:

EPA and DAQEM staff noted significant problems with the operations of the Tanabyte Engineering Calibrators. DAQEM staff also noted issues with the nitrogen dioxide

instruments.

Discussion: In order to maintain an effective and efficient monitoring system, problems with equipment should be identified and corrected promptly. If problems cannot be prevented from occurring, formal procedures should be established to minimize the impact of instrument deficiencies on day

- to

- day monitoring operations. These

could include: Changing the QC frequency of the given instrument. Adding additional QC checks. Having additional back

- up instruments available.

Recommendation: DAQ EM should issue a formal corrective action plan to address potential equipment problems. For equipment with persistent or recurrent problems, the plan should call for the development of a replacement schedule.Clark Co. TSA Report: September 2009

17

Finding C2 :

DAQEM typically fits each pro be line end with an unacceptable stainless steel mesh filter cap.

Discussion: According to DAQEM staff, the stainless steel mesh filters are used to keep insects out of the probe lines. However, t his material is inconsistent with the requirements of 40 CFR Part 58, Appendix E, Section 9

, which states that borosilicate glass or Teflon are the “only acceptable probe materials” for reactive gasses ( o zone, s ulfur d ioxide, and n itrogen d ioxide).

Recommendation: DAQEM must replace the stainless steel mes h caps with an equivalent Teflon mesh cap.

Finding C3 :

DAQEM has identified upgrades that need to be made to many of the monitoring stations, some of which have safety implications.

Discussion: DAQEM has developed a list of “Site Conditions & Safety U pgrades.” Items on the list are specific to physical condition, aesthetics, and unsafe conditions; they do not include information about any needed equipment and instrument upgrades. While these items do not directly relate to monitoring, they have the p otential to impact the monitoring program if they are not addressed.

Recommendation: DAQEM should develop a target schedule for site upgrades.

Finding C4 :

DAQEM lacks a consistent method for documenting activities and required duties performed at eac h site. There is variability in documentation based on the site location and the site operator.

Discussion: The level of detail in the logbooks varies with the station operator. DAQEM currently utilizes two different methods for documenting field and eq uipment operation. An “equipment logbook” is used to document calibrations, problems associated with the instrument, and repairs. This log book is kept with theClark Co. TSA Report: September 2009

18 instrument (e.g. the logbook follows the instrument from site to site). The “station logbook” i s maintained in the LEADS system and does not have a formal structure (see finding A3).

Recommendation: DAQEM should establish a standardized method for documenting field operations.

Finding C5 :

DAQEM does not document the quality of zero air used in the program.

Discussion: Zero air scrubbers are used in place of certified zero air for instrument

calibrations. This is a common

, acceptable practice. Because zero air is used to generate the zero point and it is mixed as part of the calibration

, it must be treated as a standard. As such, zero air scrubbers should be verified after maintenance

and this verification must be documented.

Recommendation: DAQEM should document the performance verification of zero air scrubbers.

Finding C6:

DAQEM has i nadequate procedures for scheduling and documenting preventive maintenance for the gaseous and PM instruments.

Discussion: Preventive maintenance is a key component in the successful operation of air monitoring equipment. These procedures help to increase the lifetime of instruments and ensure they continue to operate efficiently and correctly. The preventive maintenance schedules are currently loosely kept within the “equipment logbook.” Some site operators keep them in different locations.

The current form of documentation is incomplete and inconsistent. There is no place on the schedule to indicate who has performed the operation and whether or not the required maintenance is being checked by the QA officer or the monitoring manager.

Recommendation:
DAQEM should reevaluate the structure of the preventive maintenance schedule to address inconsistent and incomplete documentation. These documents should be kept in a common location to ensure they are not misplaced or lost.Clark Co. TSA Report: September 2009

19

D. LAB ORATORY OPERATIONS

DAQEM has a PM 2.5 l aboratory located in the basement of the main County Office Building Complex. The primary responsibility of the laboratory is the handling of PM filters

, which includes preparation, wei ghing, tracking, and storage

.

The PM2.5 l aborator y is well run and organized. It was noted that the laboratory relies on manual data collection methods for the recording of laboratory conditions and filter weighing sessions. This process is acceptable. However, it is recommended that DAQEM evaluate th e cost/benefit of automating the laboratory processes. If filter weighing sessions were automated

, less hand written documentation would be required and the analyst and data validator would not need to evaluate the manually entered data for transcription errors. This would have the potential to substantially increase laboratory productivity and data quality.

Laboratory

Finding D1 :

The times that filters are weighed and the time that filter conditioning begins are not

documented.

Discussion:

Pursuant to 40 CFR Part 50, Appendix L, Section 8.2, PM 2.5 filters must be conditioned for a minimum of 24 hours prior to weighing. In order to document that filters have been conditioned appropriately, sample weighing time and the conditioning start time must be documented.

Recommendation: DAQEM should record the times that filter batches begin conditioning and the times that individual filters are weighed.

Finding D2 :

The temperature and humidity of the weigh

- room occasionally fluctuate outside of the

accepta ble control limits.

Discussion: It was noted that the laboratory temperature and humidity occasionally violate the control limits established in 40 CFR Part 50, Appendix L, Section 8.2. The analyst indicated that the average temperature and humidity ove r 24 hours is evaluated when excursions are noted. While EPA recognizes that the temperature and humidity may fluctuate at times

, such as when the air handling system cyclesClark Co. TSA Report: September 2009

20 or when individuals enter and exit the conditioning environment, the regulatory

c riteria for the laboratory environment are not based on a daily average.

Recommendation: DAQEM should identify and address the causes of unacceptable temperature and humidity fluctuations in the weigh

- room. In the absence of other corrective measures, la boratory staff should wait until conditions in the room re

- stabilize before proceeding.

Finding D3 :

The dates that filters are received from EPA, and the dates that exposed filters are disposed of are not tracked.

Discussion: Sampling media and filter s should be tracked through the laboratory.

Recommendation: DAQEM should develop a procedure to track the dates of new filter receipt and exposed filter disposal.Clark Co. TSA Report: September 2009

21

E. D ATA MANAGEMENT

DAQEM has defined procedures in place for handling data fro m the time of acquisition to the time that it is submitted to EPA. The procedures are well known to the principal data providers and reviewer s. The Air Monitoring Group is responsible for managing ambient monitoring data and reporting to the EPA AQS data base

.

Air quality data measured by the continuous analyzers at the field stations are stored in data loggers and on DAQEM servers. Each station is polled every fifteen minutes and the data are transmitted directly to the central server in the IT facilit y. The first review of the data is performed by the station operators.

Data from continuous analyzers are received and processed using an IPS MeteoStar data management system that began operations 2008. The system provides

real

- time, as well as histo rical, data on the DAQEM internet portal. Several of the monitoring staff are involved in evaluating/validating the gaseous measurement and quality control data provided by the LEADS Electronic Management System (EMS)

. The LEADS EMS prepares the validate d data for submittal to the AQS system.

DAQEM l aboratory

- generated data includes 24

- hour PM 2.5 d ata. Laboratory

generated data are processed using spread

- sheets and validated and submitted separately to AQS from the LEADS EMS

.

DAQEM submits all requ ired data to the AQS database

, including concentrations for all criteria pollutants, supporting precision and accuracy information and data from the network. Data submitted to AQS are annually certified by DAQEM

.

Please refer to items 3 and 4 in Section A for a discussion of data management findings.Clark Co. TSA Report: September 2009

22

F. Q UALITY MANAGEMENT

The Code of Federal Regulations Volume 40, Part 58, Appendix A, establishes minimal requirements for quality assurance for Primary Quality Assurance Organizations (PQAOs) such as D AQEM . These requirements include quality planning, independent

qu ality management, and cooperation with performance and technical audits by EPA. EPA views the application of quality management systems as integral to monitoring programs. Insufficient qua lity management and control has been cited a as rationale for legal challenges to NAAQS redesignation decisions.

DAQEM has a defined quality management system, which includes a quality management plan and oversight by an independent quality assurance off icer/auditor. While some QA issues are formally raised with the Engineering Manager

, many formal QA oversight and review functions are either not performed or are performed informally with minimal or no documentation. EPA recognizes that t he QA Officer’s role has recently been elevated and DAQEM is developing a more formal and comprehensive role for the QA Officer.

EPA regulation s require independent performance audits of gaseous pollutants

and flow audits of PM 2.5

, and PM 10 and monitors. For gaseous p ollutants

, the current regulation requires that 25% of each pollutant monitoring network be audited per calendar quarter so that each instrument is audited once per year. Prior to 2007, flow audits of these monitors were also required. Additionally, quar terly independent flow

audits of PM 2.5 samplers were required. Beginning in calendar year 2007

, semi

- annual

flow audits of each PM 2.5 , PM 10 , and TSP sampler are required (40 CFR, Part 58, Appendix A, Sections 3.2.4 and 3.3.3.) This is in add ition to the req uired monthly flow

evaluations (40 CFR, Part 58, Appendix A, Sections 3.2.3 and 3.3.2.)

.

The Quality Assurance Officer is responsible for conducting the required gaseous pollutant audits and PM 10 and PM 2.5 flow audits. Audits are performed at the mini mum frequency or more for all pollutants. The audit or provides audit results to site operators, but does not use audit data to perform statistical analy ses or develop control charts. DAQEM does not have an audit program for meteorological equipment, but plans to institute one in the near future. EPA recommends that a meteorological audit program be instituted prior to bringing the NCore site online.

Quality Assurance and Quality Control

Finding F1 :

The DAQEM QA Auditor does not formally communicate fa iling audit results to the data managers/validators.Clark Co. TSA Report: September 2009

23 Discussion: The results of the required QA audits of gaseous and particulate monitors are not

transmitted so that they can be responded to formally by the site Monitoring

Technicians and the Monitor ing Supervisor and evaluated during the data validation process. The audit results sh ould be transmitted to the data validator and other staff formally

, using the LEADS EMS or another formal process developed by the QA Officer.

Recommendation: DAQEM sho uld develop a formal process for the auditor to inform the data management group of failing audits

, as this can be incorporated into data

validation decisions.Clark Co. TSA Report: September 2009

24

APPENDIX A: Summary of Findings

Significant Findings

FINDING A1: DAQEM’s Quality Assurance pr ogram may lack sufficient management and should have a more formal and independent role in the oversight of the monitoring program.

FINDING A2: The Quality Management Plan (QMP) and Quality Assurance Project Plans (QAPPs)

need additional information to m eet EPA requirements.

FINDING A3: The consistency of r ecords generated and maintained in the LEADS Electronic Management System (EMS) is inadequate

. Inconsistencies in the generation and retention of other records may also exist.

FINDING A4:

Procedures for submitting d ata to the EPA Air Quality System ( AQS ), flagging data within AQS, and reporting data to the public need to be improved.

FINDING A5: DAQEM lacks an adequate system for tracking equipment status, initiating equipment repairs, and documenting repair history.

Other Findings

Finding B1 : DAQEM lacks the necessary flexibility to establish new monitoring stations in response to changing conditions

.

F inding B 2 : DAQEM is working to resolve the status of its formal application for a PM 2.5 Approved Regional Method (ARM) for the continuous monitors.

Finding C 1: EPA and DAQEM staff noted significant problems with the operations of the Tanabyte Engineering Calibrators. DAQEM staff also noted issues with the nitrogen dioxide

instruments.

Finding C2 : DAQEM typically fits each probe line end with an unacceptable stainless steel mesh filter

cap.Clark Co. TSA Report: September 2009

25

Finding C3 : DAQEM has identified upgrades that need to be made to many of the monitoring stations, some of which have safety implications.

Finding C4 : DAQEM lacks a consistent method for documenting activities and required duties performed at each site. There is variability in documentation based on the site location and the site operator.

Finding C5 : DAQEM does not document the quality of zero air used in the program.

Finding C6: DAQEM has inadequate procedures for scheduling and documenting preventive maintenance for the gaseous and PM instruments.

Finding D1 : The times that filters are weighed and the time that filter conditioning begins are not

documen ted.

Finding D2 : The laboratory does not have criteria for evaluating short

- term excursions of weigh

- room temperature and humidity outside of the control limits.

Finding D3 : The dates that filters are received from EPA, and the dates that exposed filters are disposed of are not tracked.

Finding F1 : The DAQEM QA Auditor does not formally communicate failing audit results to the data managers/validators.Clark Co. TSA Report: September 2009

26

APPENDIX B: QMP and QAPP Comments

All Documents

1) [Distribution List] These documents should include a distribution list.

Quality Management Plan

2) [Quality Policy] The QMP should include a Quality Policy for the organization that clearly and concisely states the importance of QA/QC to the organization, the QA goals of the organization, and the commitme nt to allocate and prioritize resources for QA/QC activities. 3) [Authority] The QMP should discuss how DAQEM derives its authority from the EPA, the State of Nevada, and Clark County to provide air monitoring to support the NAAQS. 4) [Additional Sections] Thi s document should include sections that discuss Planning and Assessment & Response. 5) [Section 2, User] This section refers to EPA’s “Quality Management Plan requirement.” EPA recommends that the plan discuss the specific regulatory requirements. Note tha t EPA requires organizations it funds which use or collect environmental information to have a Quality Management System (40 CFR Part 30, 31, and 35). EPA also requires that data collected for NAAQS decision making must be performed under a Quality Manage ment System that conforms to EPA requirements and guidance for Quality Management (EPA QA/R

- 2) (40 CFR Part 58, Appendix A). 6) [Section 3, User Requirements] This section should discuss the requirements in 40 CFR Part 58, Appendix A, Section 2 to: develop QA planning documents; provide independent Quality Assurance; use data quality objectives or another systematic planning process; provide for and submit to independent system and performance audits; and follow all relevant EPA requirements and guidance. 7) [ Section 4.2, Organization] The QMP should provide the entire organizational chart for DAQEM in addition to the chart provided for the Engineering Division. 8) [Section 4.2, Organization; Section 4.3, Responsibilities] These sections should discuss the respo nsibilities of organizational groups that are important to DAQEM air monitoring efforts such as EPA, the State of Nevada, and the DAQEM Engineering Division. Additionally, the responsibilities of the senior DAQEM managers for the Quality System should be discussed (i.e., who authorizes the QA/QC system, provides resources, and reviews QA summaries). 9) [ Section 4.4, Training] This section should be expanded to describe personnel qualifications associated with key QA positions or responsibilities. The presen t
discussion does not explain why monitoring technicians are in the E ngineering

Division . A reference is made to a training plan, but no detailed information about the training program is provided.

. 10) [ Sections 5, User Requirements Reconciliation (Quality C ontrol); Section 6, User Reconciliation Assurance (Quality Assurance)] These sections should include a discussion of policy. Such issues as the minimum requirements for qualityClark Co. TSA Report: September 2009

27 control and quality assurance, and their authority should be discussed. The DQO process and systematic planning should be explained. Note that DQOs for criteria pollutant NAAQS monitoring are developed by EPA. Other monitoring objectives should be evaluated by DAQEM to determine if they require additional QA/QC measures or more stringent criteria, as compared to relevant federal regulations. These sections should expand on the different documents and what their role is in defining the DAQEM air monitoring quality system. 11) [ Section 7, Dispute Resolution] This section discusses th e QA Manager’s responsibilities with respect to corrective action requests (CARs) without first describing the process associated with them. The discussion should be expanded to include a description of the overall corrective action system. A discussion of what triggers a CAR , w hat paperwork is generated and how is it tracked should be

included. 12) [Section 8, Recording and Documentation] This section should define how custody of the documentation, in both hard copy and electronic form, will be

tracked and it should discuss how documents are made accessible to all staff. The section also should contain provisions for retaining copies of some documents, such as SOPs, for historical purposes in case there is a need to track how data were generated. Some of the terms in the accompanying table are not well defined (i.e., “keeper,” “access,” “medium,” “retention,” and “disposition”). The section does not provide information on documentation requirements for

routine activities. At a minimum

, the QMP should in dicate where these documentation requirements can be found, for example in SOPs or a QA Project

Plan. 13) [Section 10.1.1, Purchasing and Procurement; Section 10.1.2, Subcontracting]

These sections should discuss the quality assurance measures that will be ta ken to assure goods and services are of acceptable quality and that problems with such goods and services will be corrected. 14) [Section 10.2, Electronic Data Handling Systems] These sections should discuss the policies and/or procedures for validation and m onitoring of the quality of data from these systems.

Quality Assurance Project Plans (QAPPs)

15) [Additional Sections] The following sections should be specifically included in each QAPP:

a. Project description and background

b. Sampling design (i.e., probe desig n and residence time)

c. Quality control checks

d. Instrument inspection and maintenance, instrument calibration

e. Inspection of supplies

f. Assessment and response (including internal and EPA technical and performance assessments), reports to management, data review and validation, and reconciliation with user requirements 16) [Section 4.1, Organization] This section should include a discussion of external organizations that support this monitoring program.Clark Co. TSA Report: September 2009

28

17) [Section 5, User Requirements Reconciliation] This section shou ld include a discussion of the EPA’s DQO for Ozone and PM2.5 monitoring. Additionally,

any non

- NAAQS specific data uses should be evaluated to determine if they have monitoring or data quality objectives that are more stringent than those prescribed by re gulation. 18) [Table 5, Ozone Measurement Quality Objectives (MQOs) and Measurement Quality Indicators (MQIs) by Sampling Site] The MQOs and MQIs for ozone should be updated to reflect the 7% DQO for ozone monitoring. 19) [QAPP, Appendix Equipment] This appendix discusses various standards and certifications of these standards, but does not include criteria for evaluation of

standards. 20) [SOPs, Standards] All supporting standards and calibration and verification of these standards should be included the QAPP and/o r the attached SOPs. 21) [SOPs, Criteria] Many of the required tasks discussed in the SOPs do not include acceptance criteria. 22) [SOPs, Ozone Standard] The procedure and criteria for certification of ozone primary and transfer standards is not included in the SOPs. 23) [SOPs, Zero Air] The equipment used for generation of zero air is not specified

in the SOPs.