MEMORANDUM

TO:     Docket No. EPA‐HQ‐OAR‐2012‐0918

    Air Quality Designations for the 2012 PM2.5 Standards

FROM: Liz P. Naess

    Air Quality Assessment Division, OAQPS

SUBJECT:   Data Quality Issues in Louisville, Kentucky Affecting Air Quality Designations for

the 2012 PM2.5National Ambient Air Quality Standards  

The purpose of this memorandum is to discuss PM2.5 data quality issues identified in Louisville,

Kentucky as a result of a technical systems audit (TSA) of the Louisville Metro Air Pollution

Control District's (LMAPCD) ambient air monitoring program.  TSAs are systematic and objective

examinations of a monitoring program or project to determine whether environmental data

collection activities and related results comply with the project's Quality Assurance Project Plan

and other planning documents, are implemented effectively, and are suitable to achieve its

data quality goals.  

Kentucky Division for Air Quality conducted a TSA in 2013 of LMAPCD’s ambient air monitoring

program and laboratory, which indicated that the PM2.5 samples collected and analyzed by

LMAPCD during multiple timeframes ranging from 2009‐2012 did not meet all of the

requirements of the federal reference method for PM2.5 found in 40 CFR Part 50, Appendix L, or

the requirements of LMAPCD's Quality Assurance Project Plan and Standard Operating

Procedures (see Attachment 1). The TSA also found that in many cases the records maintained

by LMAPCD were not sufficient to verify the validity of the PM2.5 samples being collected. This is

further discussed in EPA Region 4’s August 8, 2014, letter to the Kentucky Department of

Environmental Protection (KDEP) (see Attachment 2).  

EPA Region 4 has made a preliminary determination regarding the data collected and analyzed

by LMAPCD for the period 2009 through 2012. Until a final determination has been made, EPA

has moved the data in the Air Quality System database for the PM2.5 sites in question from

parameter code 88101 (PM2.5 at local conditions; used for regulatory data) to parameter code

88501 (PM2.5 raw data). This change will clarify to data users that data from these sites should

not be compared to the PM2.5 National Ambient Air Quality Standards until EPA has made a

final validity determination. No other changes to this dataset have been made at this time.

Attachments

1. June 3, 2013, letter from John S. Lyons, Director, Kentucky Division for Air Quality, to

Lauren Anderson, Director, Louisville Metro Air Pollution Control District (LMAPCD),

transmitting a copy of the 2013 LAPCD Weigh Lab Technical Systems Audit. Includes

audit attachment.
2. August 8, 2014, letter from Beverly H. Banister, Director, Air Pesticides and Toxics

Management Division, US EPA Region 4, to Sean Alteri, Director, Division for Air Quality,

Kentucky Department for Environmental Protection, regarding data issues in Louisville,

Kentucky.


KDAQ TSA of LMAPCD May 2013 Page 1 of 20

INTRODUCTION 

In late February 2013, Kentucky Division for Air Quality (KDAQ or Division) staff 

inadvertently observed Louisville Metro Air Pollution Control District (LMAPCD) October 2012 

field blank data in AQS, and found the data greatly exceeded acceptance limits. Upon further 

review, it appeared the field blank issue spanned the entire 2012 year. KDAQ staff also 

observed that, despite this issue, there were no qualifier codes on any of the 2012 PM2.5 data in 

AQS. In March 2013, KDAQ staff contacted LMAPCD to inquire about these observations and 

learned that the weigh lab had experienced issues with static electricity in 2012, which coincided 

with the receipt of new MTL filters from EPA. The field blank data results were also discussed 

with LMAPCD staff during the first quarter 2013 performance audit exit interview. LMAPCD 

staff assured KDAQ that the static electricity issue was isolated to only the field blank samples 

and subsequently had been resolved. KDAQ staff, however, felt the severity of the problem and 

the impact on all particulate samples may not have been realized by LMAPCD staff and 

therefore warranted further investigation.

Unfortunately, a review of records showed the last EPA-conducted in-depth technical systems 

audit (TSA) in the LMAPCD weigh lab was in 2001. Given the length of time since the last 

comprehensive weigh lab audit, as well as the static electricity issue that impacted an entire 

year’s worth of data, KDAQ staff felt compelled to conduct a TSA of the LMAPCD weigh lab, 

as well as an in-depth data review. Thus, on April 23, 2013, Stephanie McCarthy and Stacie 

Masters, KDAQ Technical Services Branch personnel, began a TSA of the PM2.5 weigh lab 

operations of the LMAPCD. The audit also included a review of data handling procedures, as 

well as an in-depth review of the agency’s quality systems documents. On April 26, 2013, the 

audit was concluded. 

During the audit, interviews were conducted with LMAPCD staff: 

• Susan Bowman – Weigh Lab Analyst & agency Quality Assurance Staff 

• Terry Carby – Back-up Weigh Lab Analyst & agency Quality Assurance Staff 

• Josh Tennen – Data Coordinator 

• Marty Layman – LMAPCD Quality Assurance Officer (QAO) 

• Billy DeWitt – Air Quality Unit Supervisor 

• Cynthia Lee – Air Program Manager 

The following quality systems documents were reviewed during the TSA, and will be referenced 

in this report, as well as in the attached Weigh Lab Technical Systems Review questionnaire. 

• The LMAPCD Quality Assurance Project Plan (QAPP) entitled QAPP for the LMAPCD 

NCore Ambient Air Quality Monitoring Program, Version 1.0, June 2010 (henceforth 

referred to as the LMAPCD QAPP). This document is the agency’s most current QAPP 

and was approved by EPA on May 17, 2011. 

• The LMAPCD SOP entitled Gravimetric Analysis for the Measurement of Fine 

Particulate Matter as PM2.5, SOP Using Mettler MT5 Microbalance in Support of the 

Federal Reference Method for Measuring PM2.5, AQ-PMF2, Version 1.4, updated 
KDAQ TSA of LMAPCD May 2013 Page 2 of 20

November 8, 2007 (henceforth referred to as the Weigh Lab SOP). This document is the 

most current version of this SOP, and was approved by EPA on June 27, 2008. 

• The LMAPCD SOP entitled Field Operations for Measurement of Fine Particulate 

Matter as PM2.5, SOP Using Rupprecht & Patashnick or TEI Partisol-Plus 2025, AQPMF1, Version 1.2, updated October 9, 2008 (henceforth referred to as the PM2.5 Field 

SOP). This document is the most current version of this SOP, and was approved by EPA 

on January 8, 2009. 

• The LMAPCD SOP entitled Data Handling and Custody SOP for Collecting, Processing, 

and Reporting Ambient Air Quality Data, Version 1.0, February 2009 (henceforth 

referred to as the Data Handling SOP). This SOP was submitted to EPA in March 2009, 

but an approval letter has never been received. 

FINDINGS AND RECOMMENDATIONS 

While addressing the static electricity issue in the LMAPCD weigh lab, additional areas of 

concern were found. The findings from this systems audit will be broken into three main 

sections: weigh lab operations, data handling, and quality assurance. Further details and 

information regarding the audit findings are documented in the accompanying Weigh Lab 

Technical Systems Review questionnaire. 

It is to be noted here that the deviations detailed in this report will focus on PM2.5; 

however, these deviations will also impact the agency’s PM10 and PM10-2.5 data, since all of 

these samples are handled in the LMAPCD weigh lab. 

The deficiencies listed below do not necessarily reflect the capabilities or dedication of 

LMAPCD monitoring staff. However, they do indicate serious concerns with regard to the 

effectiveness of the LMAPCD quality system. 

Findings Regarding the PM2.5 Weigh Lab Operations: 

1. While the minimum and maximum temperatures, as well as relative humidity readings, 

recorded in the weigh lab are being reviewed daily to discern whether the lab is within 

the 20-230C temperature and 30-40% humidity limits, the variability in temperature and 

humidity control in the weigh lab is not being calculated or reviewed. LMAPCD staff 

indicated the variability (standard deviation) has never been calculated for weigh lab 

operations throughout the entirety of the agency’s PM2.5 program. 

40 CFR 50, Appendix L, Section 8.2, requires the variation in temperature and humidity 

control in the weigh lab be determined for each 24-hour period. Specifically, the 

regulation details in Section 8.2.2 that temperature control is ±2oC over 24 hours; Section 

8.2.4 specifies the humidity control is ±5% relative humidity over 24 hours. LMAPCD’s 

Weigh Lab SOP further details these same requirements in Section 12.3.4. Moreover, the 
KDAQ TSA of LMAPCD May 2013 Page 3 of 20

SOP indicates that if these requirements are not met, filter weighing must be postponed 

until the weigh room is again within tolerance. 

Recommendation: LMAPCD must adhere to regulatory and SOP requirements and 

calculate the variability in temperature and relative humidity control in the weigh lab. 

These calculations should begin immediately. The standard deviation data must be 

reviewed daily and filter weighing postponed if environmental conditions are out of 

specification. 

 

Additionally, historical temperature and humidity data must be reviewed in order to 

determine if there have ever been occasions when the weigh room conditions were out of 

specification, but filters were weighed. The Division requests that LMAPCD review its 

available historic minute data for temperature and relative humidity and calculate the 

variability. In instances when weigh room conditions were out of specification, all filters 

weighed during those time periods should be, at a minimum, flagged in the AQS database 

with a critical criteria flag of “1”, or else invalidated. 

At a minimum, data from 2009-2013 should be reviewed and corrected in the manner 

indicated above. 

However, the Division strongly recommends that all data from 2002 forward be 

reviewed. If minute data is no longer available to calculate variability, the Division 

encourages LMAPCD to flag the historical data with an AQS flag of “1”, since the 

agency would not be able to prove that conditions within the weigh lab met regulatory 

requirements. 

2. The LMAPCD utilizes an in-house developed Access database, referred to as the APCD 

Ambient Monitoring Data System, for all PM2.5 weigh lab operations. The Access 

database is programmed to notify the lab analyst whenever environmental conditions are 

out of tolerance in the weigh room, or when required balance checks exceed 

specifications. Unfortunately, during this audit, it was discovered that all limits 

programmed into the LMAPCD Access database were incorrect. 

40 CFR 50, Appendix L, Section 8.2 details the environmental control specifications for 

the weigh room. The temperature range in the laboratory is to be maintained between 20-

23°C; the relative humidity range is to be maintained between 30-40%. The temperature 

range programmed into the LMAPCD Access database was 20-30°C. The humidity 

range programmed into the Access database was 20-50%. 

In accordance with EPA Method 2.12, balance checks are required to be within ±3μg. 

The LMAPCD Access database was programmed to allow a ±25μg deviation. 

Recommendation: In the short term, the Division recommends LMAPCD immediately 

reconfigure the Ambient Monitoring Data System Access database to include the correct 

specifications for environmental conditions and balance checks. Additionally, since these 

values are strongly relied upon for the determination of proper weigh lab operations, it is 
KDAQ TSA of LMAPCD May 2013 Page 4 of 20

recommended that they be reviewed during the quarterly audits of the weigh room as 

well. Looking towards the future, the Division strongly encourages LMAPCD to 

purchase a Laboratory Information Management System (LIMS) for the PM2.5 weigh lab. 

3. LMAPCD field blank data during the January 2012 through February 2013 time frame 

ranged from -175μg to +250μg. Field blank data was uploaded to AQS as required; 

however, no AQS Qualifier Codes were uploaded with that data. 

40 CFR 50, Appendix L, Section 8.3.7, as well as EPA Method 2.12, Section 7.7, detail 

the requirements for field filters blanks. The established acceptance criterion for field 

blank data is ±30μg. This requirement is reflected in the agency’s Weigh Lab SOP. 

In the LMAPCD QAPP, in Section 22.1, the following requirement is stated: “Data 

identified as suspect, or does not meet the acceptance criteria, shall be flagged as 

indicated in Table 21-1”. Additionally, the agency’s Data Handling SOP supports the 

QAPP and provides in Section 8.3 a table of AQS null codes and qualifier flags to apply 

to data that does not meet specifications. 

Recommendation: As directed by the agency QAPP and Data Handling SOP, all PM2.5

filter data in AQS from January 2012-February 2013 should be flagged with an AQS 

qualifier code of “2”, indicating an operational criterion of the method was not met. The 

data should also be flagged with the AQS qualifier code “FB”, indicating the field blank 

value was above the acceptable limit. 

4. A review of laboratory blank data for the January 2012 through February 2013 time 

period showed concentration values ranging from -477μg to +98μg. 

40 CFR 50, Appendix L, Section 8.3.7.2, as well as EPA Method 2.12, Section 7.7, detail 

the requirements for laboratory filters blanks. The established acceptance criterion for 

laboratory blank data is ±15μg. This requirement is also reflected in the agency’s Weigh 

Lab SOP. 

Recommendation: As described in Item #3 above, the LMAPCD QAPP and Data 

Handling SOP directs staff to flag data that does not meet acceptance criteria. 

Due to the extreme variability in laboratory blank data during the January 2012-February 

2013 time frame, all PM2.5 data in AQS should be flagged with an AQS qualifier code of 

“LB”, indicating the lab blank value was above the acceptable limit. 

5. Multiple deviations were noted regarding lot stability testing. 

a. Lot blank stability testing is required prior to use of a new lot of filters. EPA Method 

2.12 requires lot blank stability testing to include 9 filters per lot, with each filter 

demonstrating less than ±15μg change between weighings. The Weigh Lab SOP 

details this procedure in Part I, Section 12.1.2. The lab analyst was found to be 

weighing only 3 filters during this process. 
KDAQ TSA of LMAPCD May 2013 Page 5 of 20

Recommendation: To properly conduct a lot blank stability test, the weigh lab 

analyst must weigh 9 filters per lot, in adherence with the method and SOP 

requirement. 

b. The Weigh Lab SOP states in Part I, Section 12.1.2, that the lab analyst is to 

document the LMAPCD Filter Lot Blank Stability Test Form when completing lot 

stability testing. Per the SOP, “The completed form is to be turned into the Air 

Quality Unit Supervisor for verification and then filed.” This same requirement is 

detailed in the agency’s Data Handling SOP in Section 5.1. However, the lab analyst 

does not turn the form into the Supervisor for verification. Moreover, no one quality 

assures the lab analyst’s work regarding lot blanks to verify the math (which is 

computed by hand) and/or ensure the procedure is completed correctly. 

Recommendation: In accordance with the agency’s Weigh Lab and Data Handling 

SOPs, the Filter Lot Blank Stability Test Form should be submitted to the Supervisor 

for verification and then filed. Moreover, any mathematical computations, especially 

those completed by hand, should be peer reviewed by the supervisor or other 

independent staff to ensure accuracy. 

c. The Weigh Lab SOP states, “To determine the appropriate conditioning time for the 

other filters, make note of how long it takes the weight of the filters to stabilize. A 

stabilized filter weight has been achieved when the difference in the 24-hour weighs 

of each lot blank filter is less than 15μg.” Hence, it may take longer than 24 hours for 

filters to equilibrate; the conditioning time should be determined per the results of the 

lot stability testing. However, in 2012, the weigh lab analyst was unable to achieve 

successful lot conditioning of the blanks as described by the agency’s SOP. Weights 

would not stabilize within 15μg. Eventually, the lab analyst decided to disregard the 

SOP procedure and condition the filters for 24 hours only, which is the minimum 

required per regulation. 

During the audit, all 2012 Corrective Action Report (CAR) forms generated by 

LMAPCD staff were reviewed. There were no CAR forms documenting the stability 

issues within the laboratory or any corrective action that was taken as a result of the 

stability issues. Moreover, the Air Quality Unit Supervisor was not made aware of 

this issue in the laboratory until a significant time period had past.

Recommendation: Whenever discrepancies are noted in filter weighings, or if a lot 

of filters fails the stability testing requirements, the Air Quality Unit Supervisor 

should be immediately notified. All discrepancies and troubleshooting should be 

thoroughly documented in the weigh lab logbook. It is additionally recommended 

that agency CAR forms be documented and submitted. Ideally, if an issue forces a 

deviation from the established procedures, the QAO should be prompted to conduct 

an internal review to ensure a systematic problem does not exist.

 

6. Multiple deviations were noted regarding balance checks. 
KDAQ TSA of LMAPCD May 2013 Page 6 of 20

a. EPA Method 2.12, Section 7.9, requires balance checks to be performed at the 

beginning of each weigh session, every 10th sample weighing, and at the end of the 

weigh session. The method requires ≤ 3μg for this check. Specifically, the method 

states, “If this measurement disagrees from the verified value by more than 3 μg (i.e., 

three times the microbalance’s reproducibility), reweigh the standard.” The agency’s 

Weigh Lab SOP details the balance check procedure in Sections 12.4 and 13.2. More 

specifically, the Weigh Lab SOP states in Sections 12.4.5 and 13.2.6 that the ± 3μg 

(0.003 mg) limit for a balance check is the difference between the actual and 

measured values of the standard weights. The Weigh Lab SOP specifically details 

that if the balance check fails, the balance is to be recalibrated prior to weighing 

filters. 

 

The lab analyst stated during the audit that balance check limits were ±15μg. 

Moreover, as stated previously in Item # 2, a review of the Access database utilized in 

the weigh lab also revealed that the specification for balance checks was programmed 

incorrectly to allow a ±25μg deviation. 

The auditors requested a printout from the Access database of a batch weighing 

session; data from January 14 and February 14, 2013, weigh sessions were reviewed. 

During this data review, there were exceedances of the balance check specification 

observed. For example, when reviewing the batch session from February 14, 2013, 

the 500mg weight standard demonstrated a range from 500.003 to 500.011 mg. 

Recommendation: At a minimum, balance checks from all weigh sessions from the 

past 4 years should be reviewed to ensure they were within ±3μg. If instances where 

the balance check limits were exceeded are discovered, all filters weighed in that 

batch should be flagged in AQS with a qualifier code of “2”, indicating an operational 

criterion of the method was not met. 

Additionally, the Division encourages LMAPCD to investigate purchasing a new 

microbalance in the future, given that repair parts are no longer available for the aged 

Mettler balance being utilized. 

 

b. The Weigh Lab SOP, Section 12.4.10, requires that at the end of a weigh session, a 

balance check is to be performed using both weight standards. A review of data from 

the January 14, 2013, weigh session indicated that only the 200 mg weight was final 

weighed. However, it is noted that both check standards were final weighed during 

the February 14, 2013, session, for which data was also reviewed. 

Recommendation: The weigh lab analyst should adhere to the Weigh Lab SOP and 

weigh both weight standards at the end of each weigh session. 

 

c. According to EPA Method 2.12, Section 7.9, bullet #7, “After approximately every 

10th filter weighing, the analyst should reweigh at least one of the working 

standards.” During the LMAPCD data review, it was observed that the analyst was 
KDAQ TSA of LMAPCD May 2013 Page 7 of 20

reweighing the 200mg working standard after the 20th filter weighing, which deviates 

from the method. Upon discussion with the lab analyst, it appeared there was a 

misinterpretation of what the 10th filter weighing was referencing. The weigh lab 

analyst weighs each filter twice and after weighing 10 filters (i.e., 20 actual 

weighings), the check weight is re-weighed. 

Recommendation: The weigh lab analyst should check the 200mg weight standard 

every 10th filter weighing. 

As stated previously, the Division strongly encourages LMAPCD to purchase a LIMS 

for the PM2.5 weigh lab. A LIMS system would prevent the aforementioned 

deviations (items a, b, & c above) from occurring. 

7. In 2012, staff determined that static electricity was causing erroneous data results, which 

were believed to be isolated to the field blank data only. Because of this determination, 

additional anti-static accessories (such as an anti-static desk pad, grounding clips for the 

conditioning trays, and extra polonium strips) were placed in the lab to neutralize static 

charges. In early 2013, an electrician discovered that the weigh lab was not properly 

grounded to an earth ground. The findings listed above in Items #3, 4, 5, & 6 can be 

partially attributed to the weigh lab not being properly grounded. 

However, throughout the course of the year troubleshooting these issues in the weigh lab, 

the KDAQ auditors found no documentation whatsoever in the lab logbook or within the 

agency CAR forms to recreate this chain of events, and therefore could not produce a 

timeline of troubleshooting and corrective action implementation within the weigh lab. 

The Weigh Lab SOP in Sections 15 & 16 instructs staff to document the logbook with 

information regarding preventive maintenance procedures and troubleshooting. Section 9 

of the LMAPCD QAPP details additional documentation requirements. 

Recommendation: Foremost, given the weigh lab was found by an electrician to not be 

properly grounded, an AQS qualifier flag of “4” should be added to all January 2012-

February 2013 particulate data to indicate a lab issue. 

Additionally, staff should adhere to requirements in the agency SOPs and QAPP and 

document accordingly. Moreover, comments should be detailed and descriptive, so that 

the events can be easily recreated years later. Without detailed documentation, actions 

taken cannot be proven and the defensibility of data is jeopardized. 

8. The Weigh Lab SOP in Part I, Section 10.1.2 states, “Once each quarter, verify the 

working weight standards against the stated mass of the primary weight standards. 

Weigh the primary standards, then the working standards in triplicate, recording each 

measured mass in the microbalance room logbook.” This information was not recorded 

in the microbalance room logbook. The lab analyst stated this procedure was performed 

on a monthly basis, but it was a “visual check” only. 
KDAQ TSA of LMAPCD May 2013 Page 8 of 20

Recommendation: The weigh lab analyst should adhere to the SOP requirements and 

document this information in the logbook. Without written documentation, there is no 

tangible evidence to prove the procedures were completed. 

9. The weigh lab analyst maintained separate forceps for initial (clean) and exposed (dirty) 

filter weigh sessions; however, the analyst only had 1 plastic bag in which to store the 2 

forceps. The analyst stated she never placed both forceps in the bag at the same time. 

Instead, she would rotate which forceps were in the bag for a given length of time, 

leaving the other set of forceps out. 

Recommendation: Forceps for initial and exposed filter weighings should be 

maintained in separate, appropriately labeled plastic bags to minimize potential 

contamination. 

10. Section 12.3.3 of the Weigh Lab SOP instructs the lab analyst to inspect each filter “in 

front of a strong light source.” Damaged filters are to be discarded. When describing the 

procedure for inspecting each filter, the analyst indicated the filter was held up to the 

ceiling light to determine if there was any damage. 

Recommendation: The Division recommends LMAPCD investigate purchasing a small 

lighted table for this process. 

11. Upon returning exposed filters to the weigh lab, the field technician checks the transport 

cooler’s temperature with a small thermometer in the weigh lab that lacks any 

certification paperwork or statement of accuracy. 

Recommendation: The temperature device used for this process should be NISTtraceable and have documentation to verify its traceability and accuracy. Moreover, 

annual verifications against a NIST-traceable standard are needed for this particular 

thermometer. 

12. The Weigh Lab SOP, Part I, Section 12.3.1 states, “Field blanks should amount to 

between 10-15% of filters used for sampling throughout the year... A monitor operating 

on a 1-in-6 day cycle requires 6-9 field blanks per year; 1-in-3 requires 13-18”. The lab 

analyst prepares only 1 field blank each month, which would total only 12 filters per 

year. 

Recommendation: The lab analyst should prepare the amount of field blanks required 

by the agency SOP. 

13. The LMAPCD QAPP in Section 13.5 states that trip blank filters are to be used to 

monitor potential contamination throughout the sampling process. The Weigh Lab SOP 

in Part I, Section 16.3.2 further details the use of trip blank filters to help isolate problems 

with field blanks. However, it was found that trip blanks are not utilized by the agency. 
KDAQ TSA of LMAPCD May 2013 Page 9 of 20

Recommendation: LMAPCD staff should adhere to the requirements in their QAPP and 

SOP and prepare trip blank filters. If there are budgetary constraints preventing 

LMAPCD from allotting extra filters for this purpose, then the requirement should be 

removed from the agency’s quality documents. However, if filters are available, the 

Division strongly encourages LMAPCD to utilize trip blanks because they are excellent 

quality control and troubleshooting tools. 

14. The Weigh Lab SOP, Part II, Section 2.3.2 states, “An analyst other than the one who 

performed the original weighings should reweigh at least 10% of each lot... Record both 

measurements in the logbook.” This same requirement is further detailed in the agency’s 

Data Handling SOP in Section 5.1. However, these measurements were not recorded in 

the logbook as required. Only the filter identification numbers were documented. 

Recommendation: The analyst who reweighs 10% of each lot should completely 

document the weighing session in the logbook, which includes the filter mass obtained 

for each weighing. 

15. The Weigh Lab SOP details in Part II, Section 2.1.1 that performance audits of the 

microbalance are to be completed using an independent set of weight standards. 

However, a review of quarterly performance audit forms for the weigh lab showed that 

the auditor typically used the lab analyst’s set of primary standards, and occasionally 

used the analyst’s working standards, to complete the quarterly performance audits. 

It is to be noted here that 40 CFR 58, Appendix A, requires performance audits to be 

conducted utilizing independent equipment. Using the lab analyst’s set of working or 

primary weight standards does not meet the definition of independence, and therefore 

these quarterly balance checks cannot be classified as audits. 

Recommendation: A separate set of weight standards should be purchased by 

LMAPCD for the purpose of conducting acceptable quarterly performance audits of the 

microbalance. 

Finding and Recommendations Regarding PM2.5 Data Handling: 

1. There were multiple parameters detailed in 40 CFR 50, Appendix L that were not being 

reviewed as part of the routine data verification/validation process. Specifically, the time 

frame between the initial (tare) weight and the sampling date (< 30 days), the sample 

pick-up date (7 days 9 hours from the end of sampling), the post-sample weigh time, and 

the sampler’s coefficient of variance for flow (≤2%) were not reviewed. LMAPCD 

Quality Assurance staff indicated that it was assumed that all of these requirements were 

being met. No documentation was provided to indicate these assumptions were correct. 

Recommendation: Although the agency’s PM2.5 network is small and the lab analyst’s 

routine is uniform, data should still be verified in order to ensure regulatory requirements 

are met. 
KDAQ TSA of LMAPCD May 2013 Page 10 of 20

The Division recommends that the data audit form utilized by agency Quality Assurance 

staff – the “All FRM Particulate Matter Data by Date” Report – be modified to include 

sample weigh dates, sample pick-up dates, and the sampler’s coefficient of variance. 

These parameters should be reviewed in relation to the regulatory requirements detailed 

in 40 CFR 50, Appendix L. 

Moreover, given that these critical criteria components have never been reviewed as part 

of the routine data verification/validation process for PM2.5, the Division recommends 

that LMAPCD staff review its historical data to ensure all filters have met these 

regulatory requirements. At a minimum, 2009-2013 data should be verified. If any 

samples are found to exceed any of the regulatory requirements, the data should be, at a 

minimum, flagged with an AQS qualifier code of “1,” or invalidated. 

2. The Data Handling SOP requires in Section 5.3.3 that PM2.5 mass concentrations be 

manually calculated to verify accuracy. LMAPCD staff indicated that these calculations 

are made; however, there was no documentation provided to demonstrate that these 

calculations were indeed being computed and verified by hand, as per SOP requirements. 

Additionally, the results of these calculations are not reviewed by other LMAPCD 

Quality Assurance staff or by the agency’s QAO. 

Recommendation: The Division recommends that LMAPCD Quality Assurance staff 

document a logbook that shows the manual, mathematical computations completed for 

the samples specified in Section 5.3.3 of the agency SOP. Ideally, the QAO should 

review the results of these manual computations to ensure accuracy, as well as ensure 

data has been handled correctly. 

3. Interval data files downloaded from the PM2.5 samplers are not routinely reviewed during 

the data verification/validation process. 

Recommendation: Interval data files from R&P 2025 samplers can provide significant 

insight into health and operation of the 2025 samplers, which is a valuable tool for 

Quality Assurance staff. Interval data can also be a useful troubleshooting diagnostic for 

field technicians, as it will illustrate when flow controllers may be faltering. This data 

should be routinely reviewed during the QA process.

4. The Chain-of-Custody (COC) forms being utilized by agency staff are not the same COC 

forms shown in the LMAPCD QAPP in Section 12.3 in Figure 12-1. Unfortunately, the 

COC form currently utilized by the agency is not as robust as the one shown in the 

QAPP. 

The current COC form is shown in the PM2.5 Field SOP in Section IV. The form does 

not contain spaces for field technician or weigh lab analyst comments, the date the 

samples were picked up from the weigh lab, the date samples were returned to the weigh 

lab, or the temperature of the samples upon return to the weigh lab. Additionally, the 
KDAQ TSA of LMAPCD May 2013 Page 11 of 20

COC form only has one space for the lab analyst’s signature (“Prepared by”) and the field 

technician’s signature (“Received by”). 

When reviewing documentation on the COC forms, it was noted by the KDAQ auditors 

that, in some instances, COC forms were found to have multiple sets of handwriting that 

were not attributed to anyone. Additionally, there were multiple temperature readings 

and multiple dates listed on the individual forms that were undefined and, therefore, 

confusing. 

In short, the current COC forms do not provide the necessary level of defensibility to the 

data. 

Additionally, it is to be noted here that in Section 12.3 of the LMAPCD QAPP, it states 

that, during the data validation process, notes on the COC forms are used to determine 

the validity of samples and to assign validation flags. However, LMAPCD staff 

indicated that they do not make comments on the COC forms regarding any sources or 

events that could impact data integrity. Such information is recorded only in the site 

logbooks, and is not reviewed during the data validation process. 

Recommendation: Foremost, the COC form shown in the agency QAPP should be 

utilized by LMAPCD, but it should be enhanced to include additional information. The 

Division recommends that spaces designated for sample pick-up date and time (from the 

field) be added to the COC form. Also, it would provide better insight into the total 

handling of the filters if the lab analyst signed (or initialed) and dated the COC form 

when the magazine was prepared for deployment, as well as signed and dated the form 

upon receiving the samples back into the laboratory. The same holds true for the field 

technician. Ultimately, the COC forms should be signed by any and all staff members 

who maintained physical custody of the samples for any period of time. 

A specific space for “Comments” should also be added to the COC forms, where field or 

lab issues that could impact data validity can be noted. Moreover, LMAPCD staff should 

adhere to the agency QAPP and review those COC notes during the data validation 

process and AQS qualifier codes be added to data, when warranted. 

5. KDAQ auditors reviewed LMAPCD PM2.5, PM10, PM10-2.5, and lead data, as found in the 

AQS database, during this audit. Numerous issues were found. 

a. Inconsistencies in data coding were observed. While CAR forms were 

documented in most cases of invalid data, the documentation on the forms did not 

always compliment the data found in AQS. In several instances, it was noted by 

KDAQ auditors that similar situations were coded differently. When asked to 

explain why different codes were used to null similar events, staff relied heavy on 

their collective memories to recreate the events. Unfortunately, the Access 

database, upon which they primarily depend, does not contain enough information 

to help them retrace AQS coding decisions. 
KDAQ TSA of LMAPCD May 2013 Page 12 of 20

Recommendation: Foremost, all staff members should be trained on data 

handling procedures, which should include how to consistently apply AQS null 

codes and qualifier flags. A more detailed Data Handling SOP should be 

developed. 

 

Second, documentation should exist that is thorough enough that any data coding 

decision can be easily recreated years later. The Division recommends that 

LMAPCD Quality Assurance staff develop internal data audit reports that recount 

data handling decisions. The Division recommends these reports be submitted to 

the Air Quality Unit Supervisor for approval, as well as the QAO. 

b. For some data points chosen by the KDAQ auditors to review, LMAPCD staff 

provided no documentation to justify why the data had been invalidated. There 

were instances noted where data could have been retained, but flagged in AQS 

with a qualifier code. 

Recommendation: The reasons for invalidating data should be clearly 

documented. Additionally, the agency should adhere to the requirements of its 

QAPP and SOPs and apply qualifier codes to data. Application of qualifier codes 

will allow, in certain instances, for data to be retained that would otherwise be 

invalidated. 

c. A review of 2012 lead data indicated that sample results were uploaded on days 

which did not correspond to PM10 sample days. The low-volume lead analysis is 

performed on the PM10 sampled filters, which means the lead results should be 

uploaded on the same day as the PM10 results. 

Recommendation: The LMAPCD data review process should be enhanced so 

that Quality Assurance staff, and/or the QAO, reviews data to ensure that it is 

entered into AQS on the appropriate days. Entering data on the wrong days will 

negatively impact data completeness results. 

d. For all particulate parameters observed, there appeared to be missing data in AQS 

(i.e., scheduled sample days were blank). 

Recommendation: All scheduled run dates must have either a concentration 

value or null value code assigned. The LMAPCD data review process should be 

enhanced so that Quality Assurance staff, and/or the QAO, reviews data to ensure 

that all scheduled run days contain the necessary information. Entering data on 

the wrong days, or not entering data at all, will negatively impact data 

completeness results. 

6. Precision and accuracy data files are generated utilizing the P &A Transaction Generator 

tool (i.e., an Excel program) provided by EPA. Use of this Excel program requires 

manual data entry. However, there is no independent review of the information entered 

into the Transaction Generator to ensure the appropriate data is entered and typographical 
KDAQ TSA of LMAPCD May 2013 Page 13 of 20

errors are not made. Staff indicated that a peer review process for P&A data was 

unnecessary. In fact, the QAO stated during the audit that the individual who is 

responsible for P&A data rarely makes mistakes, and therefore, the QAO does not closely 

review his work. 

Recommendation: The Division strongly recommends LMAPCD develop a more robust 

peer review process. All maintenance, precision, and audit forms used to generate the 

precision and accuracy AQS upload file should be reviewed by another independent staff 

member (ideally, the QAO) to screen for outliers. Additionally, the generated P&A file 

should also be reviewed by independent staff for transcription errors (such as entering 

precision data on the wrong date, or entering the wrong audit equipment type). Ideally, 

the QAO should review the completed AQS AMP 250 report against the original 

precision and accuracy forms to ensure the accuracy of the data entry. 

7. The Data Handling SOP does not detail any of the procedures employed by the QAO 

during the data certification process. Additionally, neither the Data Handling SOP nor 

the LMAPCD QAPP clearly details the follow-up procedures employed by staff to ensure 

data corrections are correctly implemented after recommendation by the QAO. When 

asked to detail the data correction process to the KDAQ auditors, the QAO stated that 

data is reviewed after it is entered into AQS, and if any corrections are deemed necessary, 

a request is forwarded to the staff member responsible for originally coding the data. The 

QAO assumes the staff member revises the data as requested and the correction is 

successfully uploaded into AQS. However, there was no documentation of this process 

provided to the KDAQ auditors for review. At the end of the year, while performing the 

annual data certification, the QAO stated that data corrections requested during the 

course of the year are then reviewed in AQS. However, no reports are printed from the 

AQS database; it is just a visual check. It was unclear to the KDAQ auditors if all of the 

requested data corrections were verified or if the QAO picked only 10% of the data 

corrections and assumed, based on this random sampling, that all corrections were in fact 

submitted correctly as requested. 

Recommendation: The Data Handling SOP should be revised to include more specific 

information regarding the QAO’s data review procedures and the data certification 

process itself. Additionally, the Division strongly recommends that all data corrections 

be reviewed at the time of the correction and not during the tedious process of data 

certification, which could occur a year or more after the corrections were requested. 

Findings and Recommendations Regarding Quality Assurance: 

1. On Friday, April 26, 2013, the weigh lab analyst informed the KDAQ auditors that the 

2002 version of the Weigh Lab SOP was the document being utilized in the lab over the 

course of the last 4 years. The analyst further indicated that she had no knowledge of the 

current, EPA-approved version of the document until the audit conducted by KDAQ. 
KDAQ TSA of LMAPCD May 2013 Page 14 of 20

Recommendation: Foremost, if the lab analyst has been following an outdated SOP for 

the entirety of her tenure in the weigh lab, the Division recommends that all of the data 

that she has handled be flagged in AQS with a qualifier code of “6”, indicating a 

QAPP/SOP issue. Given all of the QAPP/SOP deviations listed in this audit report, this 

AQS flag is warranted for the agency’s particulate data, regardless of whether or not the 

2002 version of the Weigh Lab SOP had been approved by EPA. 

(It is to be noted here that the auditors did not conduct an in-depth review of the 2002 

version of the Weigh Lab SOP during this audit.) 

Secondly, all employees should be supplied the most current version of SOPs. There 

should be a system in place to ensure that employees not only possess the most current 

version of SOPs, but that they have read and understood them, and are actually following 

the stated procedures. 

Although the agency has a shared network drive (i.e., the M: drive) where documents are 

shared and stored, that does not guarantee that employees are actually using the 

documents housed on that drive. If older versions of SOPs are retained on the M:drive, 

they should be archived or labeled to indicate they are not the current versions. 

In Section 19.8.1, the LMAPCD QAPP directs the following: “The Quality Assurance 

Officer (QAO) maintains overall responsibility for management and administrative 

aspects of the QA program.” Therefore, the LMAPCD QAO should develop a plan to 

resolve these issues. 

2. The LMAPCD quality system provides for employee training. The culmination of that 

training involves a certification of acceptable performance by the LMAPCD QAO (see 

the LMAPCD QAPP, Section 4.1.2). The weigh lab analyst received “on the job training” 

from the previous weigh lab analyst. However, the weigh lab analyst was never observed 

by the LMAPCD QAO to ensure that procedures were being performed correctly. 

Moreover, the QAO admitted that an “over the shoulder review” of the employees in the 

weigh lab had never been completed, which means that the employee who trained the 

current weigh lab analyst was most likely never “certified” either. Therefore, erroneous 

or incomplete procedures could have been passed down without detection. 

Recommendation: The LMAPCD QAPP requires the QAO to certify that staff can 

perform all duties correctly. Therefore, the QAO must certify all employees in all aspects 

of the air monitoring program – including the weigh lab, which is the foundation of 

LMAPCD’s particulate network. 

3. In the Weigh Lab SOP, Part I, Section 16.3.3, it states, “Systems audits are used to 

determine if procedures are being followed.” This requirement is found in the 

“Troubleshooting” section of the document, and directs that systems audits are especially 

required when there is a significant issue in the weigh lab that warrants further 

investigation. Additionally, the LMAPCD QAPP, in Section 4.1.2, states the following: 
KDAQ TSA of LMAPCD May 2013 Page 15 of 20

“The QAO will perform internal audits to identify potential problems and review quality 

control data.” 

During the audit, there was no documentation of these reports in relation to the weigh lab 

provided. 

Recommendation: A technical systems audit is a great tool for assessing staff 

understanding of the job duties assigned as well as identifying deficiencies. Based upon 

the severity and duration of the weigh lab issues in 2012, an audit should have been 

conducted and would most likely have revealed that procedures were being followed 

from the incorrect SOP. 

The QAO should perform internal technical systems audits as specified in the agency’s 

SOPs and QAPP for all areas of the air monitoring network. Additionally, reports of the 

findings from these audits should be disseminated to staff to ensure that any corrective 

actions required are properly addressed. 

4. During the audit, there appeared to be a disconnect amongst staff members regarding data 

handling and AQS principles. Staff did not appear to have a clear understanding of the 

data quality objectives (DQOs) or measurement quality objectives (MQOs) for the 

particulate network. Staff also did not appear to have clear understanding of the 

requirements in the agency QAPP. 

Moreover, in regards to the technical issues within the weigh lab in 2012, as mentioned 

previously, staff attributed the static electricity issues to impacting field blank filters only. 

Unfortunately, this issue impacted all filters in the lab, including PM10, and required that 

all particulate data from January 2012-February 2013 be flagged in AQS. 

 

These findings illustrate another issue regarding the LMAPCD training program. 

Reading SOPs alone does not guarantee understanding of content or that the fundamental 

scientific principles upon which these programs are built are comprehended. Moreover, 

simply watching one employee do his or her job and learning to “mimic” those 

procedures does not guarantee an understanding of EPA methods or the “big picture” of 

the monitoring program. Without an understanding of the mathematics and scientific 

principles upon which air monitoring programs are implemented, the potential for staff 

producing questionable data increases. 

Recommendation: LMAPCD staff would greatly benefit from additional training, 

particularly in the areas of EPA methods, data handling, and quality assurance. 

Specifically, training on data verification versus validation, chain-of-custody, and AQS 

coding are needed. The Division recommends that the LMAPCD QAO develop a more 

robust training program for agency staff. In the interim, KDAQ staff will provide 

additional training to LMAPCD staff. 

5. In the LMAPCD QAPP, Section 20.5, it states the following: “LMAPCD performs 

technical systems audits of the monitoring system. These audits are performed by the 
KDAQ TSA of LMAPCD May 2013 Page 16 of 20

QAO and reports are issued to the Air Quality Unit Supervisor.” Unfortunately, 

however, technical systems audit reports are not issued to the Air Quality Unit 

Supervisor, as required by the agency QAPP. 

The KDAQ auditors requested copies of the QAO’s technical systems audits reports 

during the TSA. The auditors were supplied “checklists” to represent the systems 

findings. The QAO visits each site in the field once per year. However, a review of 

these “checklists” showed incomplete documentation. There were sections of the 

checklists that were left completely blank. On some of the checklists, the QAO had 

written comments regarding findings that could imply field problems or questionable 

data, but there did not appear to be any follow-up investigation by the QAO regarding 

these findings. Moreover, without these checklists being translated into reports which are 

submitted to the Air Quality Unit Supervisor, any questionable findings in the field would 

not be relayed to management so that corrective actions could be immediately 

implemented. 

Recommendation: First, the QAO should completely document all audit checklists. 

Gaps in documentation imply that procedures were not reviewed. Second, the QAO 

should augment the systems audit process and develop a detailed questionnaire to use, as 

opposed to the abbreviated checklist. The current checklist does not provide an 

independent reviewer with a clear understanding of the systems finding. Third, it is 

further recommended that the QAO write a detailed report regarding the findings from 

the systems audit, and submit that written report to the Air Quality Unit Supervisor, as 

required by the QAPP. The QAO should submit his checklist to the Air Quality Unit 

Supervisor as well, to supplement the written report. 

The QAO and the Air Quality Unit Supervisor should mutually determine a deadline for 

systems audit report submissions. The deadline should be long enough to allow the QAO 

to detail his findings, but short enough that the Air Quality Unit Supervisor can direct his 

staff to implement corrective actions before there is an adverse impact on data. 

Finally, the Division encourages the QAO to conduct more than one systems audit per 

site per year. Given that the LMAPCD network is small, multiple systems audits could 

easily be conducted across the course of the year. 

6. An in-depth review of the quality systems documents detailed in the Introduction of this 

report revealed several areas of concern. 

a. When reviewing documents side-by-side, there were inconsistencies in 

terminology and procedures noted. 

Recommendation: All particulate SOPs should be updated. The QAPP and 

SOPs should be complimentary documents. The terminology utilized in the most 

recent document (i.e., the LMAPCD QAPP) should be the terminology used in 

the other documents. 
KDAQ TSA of LMAPCD May 2013 Page 17 of 20

b. For the particulate SOPs, it has been 5 or more years since the documents have 

been updated. Staff admitted that several procedures in these documents did not 

reflect their current activities. 

Recommendation: SOPs should be reviewed on an annual basis and revised 

when/if procedures change. The QAO should implement and oversee the schedule 

for annual SOP review, and ensure that all stated procedures are current and 

accurate. 

c. Several of the quality documents utilized by LMAPCD staff had not received 

EPA-approval, and/or there was confusion as to whether or not the document had 

ever been submitted to EPA. 

i. The Data Handling SOP was submitted to EPA in March 2009, but 

LMAPCD has not received approval for this document.

ii. The LMAPCD Quality Assurance Project Plan (QAPP) entitled QAPP for 

the LMAPCD Ambient Air Quality Monitoring Program, Version 2.1, 

December 2009, appears to be the most recent version of the agency’s 

criteria pollutant (non-NCore) QAPP. This criteria pollutant QAPP is 

identical to the NCore QAPP throughout its sections, except that it does 

not contain MQO tables for the trace-level analyzers found at the Cannons 

Lane site, and certain references to hi-volume lead sampling have been 

removed. This criteria pollutant QAPP was submitted to KDAQ by the 

previous Air Quality Unit Supervisor as an official document. However, 

this QAPP has not been approved by EPA, and there is uncertainty as to 

whether or not the document was ever sent to EPA for approval. 

Recommendation: The LMAPCD QAO should develop a system for document 

tracking. When SOPs or QAPPs are submitted to EPA, the QAO should followup with EPA if documents have not been approved after an extended time frame 

(e.g., 6 months after submittal). 

7. There appeared to be a significant breakdown in the LMAPCD corrective actions process 

in 2012. Section 19.9 of the LMAPCD QAPP details the structure and protocols 

employed by the agency for this purpose. 

a. In 2012, weigh lab quality control data (i.e. lot blank, lab blank, field blank, and 

balance check data) significantly exceeded agency acceptance limits, but there 

were no CAR forms generated that detailed these issues or any actions taken as a 

result of the issues. 

Recommendation: Corrective Action Report (CAR) forms should be generated 

for all issues which could impact data validity. These forms should be thoroughly 

documented and descriptive. It is also recommended that logbooks be 
KDAQ TSA of LMAPCD May 2013 Page 18 of 20

documented with the corrective action information, in addition to agency CAR 

forms. Without thorough documentation, defensibility of data is jeopardized. 

b. Quality control data detailed above exceeded limits throughout the entire 2012 

year, which indicates that initial corrective actions were unsuccessful and further 

investigation was warranted. In Part I, Section 16.3.1, of the Weigh Lab SOP, 

staff are directed to clean samplers whenever field blank results are outside of the 

acceptable limits of ±30μg. Likewise, in Section 16.3.2, the SOP details that trip 

blanks collected when field blanks exceed limits can help isolate where 

contamination may be occurring. Finally, the SOP directs in 16.3.3 that a systems 

audit is to be conducted to review filter handling procedures. 

A review of all 2012 CAR forms indicated that none of these SOP-directed 

corrective action procedures were completed during the field blank investigation. 

Recommendation: Staff should adhere to agency SOPs. The Air Quality Unit 

Supervisor should ensure that all required corrective actions are implemented. 

The QAO should also evaluate the efficacy of the corrective action(s) and 

determine if data quality has been impacted. And, the QAO should complete the 

required internal systems audits. 

c. The LMAPCD QAPP directs that any staff who perceives the need for corrective 

action shall present the situation to the Air Quality Unit Supervisor within 30 days 

of perceiving the need. Air monitoring staff are then responsible for 

implementing the corrective actions within 30 days, notwithstanding extenuating 

circumstances. In 2012, the Air Quality Unit Supervisor was not notified within 

30 days of the need for corrective action in the weigh lab. And, unfortunately, the 

situation took over a year to resolve. 

Recommendation: Staff should adhere to the agency’s QAPP requirements and 

notify the Air Quality Unit Supervisor of the need for corrective actions. 

However, it is to be noted here that the KDAQ auditors were given the impression 

that staff did not have a sense of urgency in regards to the quality control data 

issues within the weigh lab, which may be why the Air Quality Unit Supervisor 

was not notified within 30 days. Therefore, again, additional training would 

greatly benefit staff. 

Additionally, the Division strongly recommends shortening the length of time 

given for notifying management of the need for corrective actions, as well as the 

length of time given to implement corrective actions. With data quality at stake, 

30 days to report the need for corrective action and then 30 days to correct it 

seems extensive. A five-day turnaround time is suggested. 

8. All LMAPCD technicians are responsible for certifying their own standards. There is no 

single individual designated within the agency to track equipment certifications, and 

therefore ensure that all standards are actually within specification. Without a single 
KDAQ TSA of LMAPCD May 2013 Page 19 of 20

individual overseeing this activity, there is increased potential for equipment expiring in 

the field. 

Recommendation: The Division recommends that the LMAPCD QAO be responsible 

for tracking the certification of all standards used in the agency network. 

9. The LMAPCD QAPP states in Section 14.2, “Control charts will be used extensively by 

LMAPCD”. The QAPP specifically requires control charting of balance check samples 

in the weigh lab. The QAPP details control charts for PM2.5 sampler flow rates as well. 

Later, in Section 20.7, the review frequency for control charts is detailed. However, staff 

admitted that no control charts are developed or reviewed. 

Recommendation: Control charts are excellent tools for tracking trends in data. 

However, if control charts will not be utilized by staff, the QAPP should be revised to 

remove all references to control charts, which are found throughout the document. In the 

absence of control charts, quality assurance staff should develop another method for 

analyzing data for trends. 

10. LMAPCD staff have an internal deadline established of 45 days for data to be uploaded 

into AQS, but the goal is 30 days. They routinely meet this expedited deadline, for which 

staff are to be commended. However, the regulatory deadline for AQS data entry 

(pursuant to 40 CFR 58.16) is 90 days after the end of the calendar quarter. 

Recommendation: The Division strongly encourages LMAPCD to reconsider its 

stringent data-entry deadline, in order to allow time for a more in-depth data review 

process to occur. Allowing staff more time to analyze and review data will minimize 

data entry mistakes. 

CONCLUSION 

During the course of this audit, numerous significant issues were discovered, including 

regulatory deficiencies. These issues impact all particulate samples handled in the weigh lab, 

including PM2.5, PM10, and PM10-2.5. Luckily, several of the operational deviations that were 

identified can be quickly rectified. Other issues, particularly in regards to the agency’s quality 

system, will require extensive modification and subsequent employee training. Due to the 

magnitude of the issues uncovered during this audit, an in-depth historical data review is 

necessary. At a minimum, data from 2009-forward must be reviewed for all criteria identified in 

this report, which will most likely result in data corrections and subsequent re-certification. 

The following summarizes the most significant findings of this audit: 

• The grounding issue in the weigh lab seriously impacted operations and subsequent data 

results. All January 2012-February 2013 particulate matter data should be flagged in 

AQS with qualifier codes of 2, 4, 6, FB, and LB. 
KDAQ TSA of LMAPCD May 2013 Page 20 of 20

• Regulatory and EPA method deviations were found, all of which have been occurring for 

at least 4 years. Historical data should be reviewed to determine the extent of the 

deviations, and data corrections should be entered into AQS. 

• The agency’s QAPP and SOPs are not being followed. 

• There is a lack of documentation in-house, which weakens the defensibility and quality of 

data. 

• The structure of the agency’s data handling process is problematic, leading to 

inconsistencies. 

• Internal systems audits are not being conducted. 

• There is a communication and procedural breakdown in the agency’s corrective action 

system. 

• Staff, including the QAO, would benefit greatly from additional training. 

• The agency would greatly benefit from the purchase of a LIMS for the weigh lab. 

While the totality of these audit findings represents significant areas of concern, KDAQ is 

confident that corrections within the weigh lab can be swiftly implemented to rectify the abovementioned deficiencies. Adhering to the quality systems documents could have prevented many 

of the audit findings and should be stressed to staff moving forward. The development of more 

robust and unified quality assurance procedures will provide staff the stability and consistency 

that appears to be lacking in the current system. 

The Division requests follow-up correspondence from LMAPCD detailing the corrective actions 

implemented as a result of this audit. The Division specifically requests notification once 

LMAPCD has completed the review of its historical data. As a conclusion to this audit, KDAQ 

staff will also review the historical data for concurrence of the findings and ensure data 

corrections are complete and appropriate. In the interim, the Division is committed to providing 

training to LMAPCD staff. Questions regarding this audit may be directed to Ms. Stephanie 

McCarthy, Technical Services Branch Manager.