U.S. Department of Energy’sU.S. Department of Energy’sConsolidated Audit ProgramConsolidated Audit Program

George E. DetsisGeorge E. DetsisManager, Analytical Services ProgramManager, Analytical Services Program

Office of Corporate Safety Programs, HS-Office of Corporate Safety Programs, HS-3131

Presented before the 2008 Second Annual Presented before the 2008 Second Annual RadWaste SummitRadWaste Summit

September 2-5, 2008September 2-5, 2008Las Vegas, NevadaLas Vegas, Nevada

Presentation OutlinePresentation Outline

Program OverviewProgram Overview Background (IG/GAO)Background (IG/GAO) ChecklistsChecklists Common FindingsCommon Findings Accomplishments/ChallengesAccomplishments/Challenges

Overview of Overview of Analytical Services ProgramAnalytical Services Program

Finding from DOE’s Finding from DOE’s Office of the Inspector General Office of the Inspector General

and GAO Reportsand GAO Reports

Report on the Audit of DOE’s Commercial LaboratoryReport on the Audit of DOE’s Commercial LaboratoryQuality Assurance Evaluation Program (June 1995)Quality Assurance Evaluation Program (June 1995)IG and GAO Identified reductions in DOE Auditing IG and GAO Identified reductions in DOE Auditing

and and Contracting of Analytical ServicesContracting of Analytical Services

Some laboratories were audited numerous times; others Some laboratories were audited numerous times; others were never auditedwere never audited

Evaluation methods varied significantly from one contractor Evaluation methods varied significantly from one contractor to anotherto another

Audit results were not shared between contractorsAudit results were not shared between contractors

DOECAP BackgroundDOECAP Background

Purpose:Purpose: Reduction audit redundanciesReduction audit redundancies Standardize audit methodology, policies and proceduresStandardize audit methodology, policies and procedures Communicate Lessons LearnedCommunicate Lessons Learned Reduce overall Department risks/liabilitiesReduce overall Department risks/liabilities

Contractual agreement linkageContractual agreement linkage Involves all DOE line organizations/field Involves all DOE line organizations/field

operationsoperations Auditor participants primarily DOE contractor Auditor participants primarily DOE contractor

holdersholders Auditor qualifications/training requirementsAuditor qualifications/training requirements Federal staff lead TSDF auditsFederal staff lead TSDF audits

Results of FormalizedResults of FormalizedDOE Auditing ProgramDOE Auditing Program

DOECAP reduced the Department’s risks DOECAP reduced the Department’s risks and liabilities, and verified radioactive and liabilities, and verified radioactive and chemical waste accountabilityand chemical waste accountability

FYO8 DOECAP Auditing Activities: FYO8 DOECAP Auditing Activities: 30 Analytical Environmental 30 Analytical Environmental

Laboratories Laboratories 1 Laboratory Surveillance 1 Laboratory Surveillance 7 TSDF’s 7 TSDF’s 1 Non-radiological TSDF scoping1 Non-radiological TSDF scoping

Criteria DefinitionsCriteria Definitions

Priority I FindingPriority I Finding Programmatic/systematic failure Programmatic/systematic failure Imminent threat to worker safety/healthImminent threat to worker safety/health Potential for major property/facility damagePotential for major property/facility damage Repeated deficiencyRepeated deficiency

Priority II FindingPriority II Finding Nonconformance with internal requirements/procedures Nonconformance with internal requirements/procedures Undocumented procedures Undocumented procedures Nonconformance with DOE requirements Nonconformance with DOE requirements

Observation Observation Isolated instance/deficiency Isolated instance/deficiency Opportunity for improvementOpportunity for improvement

Audit ChecklistsAudit Checklists

Module 1Module 1 – Quality Assurance Management – Quality Assurance Management SystemsSystemsModule 2Module 2 – Sampling and Analytical Data – Sampling and Analytical Data QualityQualityModule 3Module 3 – Waste Operations – Waste OperationsModule 4Module 4 – Environmental Compliance and – Environmental Compliance and PermittingPermittingModule 5Module 5 – Radiological Control – Radiological ControlModule 6Module 6 – Industrial & Chemical Safety – Industrial & Chemical SafetyModule 7Module 7 – Transportation Management – Transportation Management

Audit DriverAudit Driver

DOE Order 435.1 (manual), DOE Order 435.1 (manual), Radioactive Waste ManagementRadioactive Waste Management

Requires that DOE first utilize DOE Requires that DOE first utilize DOE facilities to manage radioactive wastefacilities to manage radioactive waste

However, if DOE chooses to use a non-However, if DOE chooses to use a non-DOE waste vendor, DOE must perform DOE waste vendor, DOE must perform an annual ES&H reviewan annual ES&H review

Perspective/ContextPerspective/Context

All 7 TSDFs were found to maintain All 7 TSDFs were found to maintain the established management the established management systems and operational activities systems and operational activities necessary to meet DOE necessary to meet DOE requirements for the storage, requirements for the storage, handling, transportation, processing handling, transportation, processing and final disposition of DOE waste.and final disposition of DOE waste.

Percent Distribution of Percent Distribution of FY 2008 TSDF FindingsFY 2008 TSDF Findings

15%

7%

9%

23%13%

13%

20%

Quality Assurance (8)

Sampling and DataQuality (4)Waste Operations (5)

EnvironmentalCompliance (12)Radiological Control (7)

Industrial and ChemicalSafety (7)Transportation (11)

Percent Distribution of Percent Distribution of FY 2008 TSDF ObservationsFY 2008 TSDF Observations

6%

16%

7%

22%15%

22%

12%

Quality Assurance (4)

Sampling and DataQuality (11)Waste Operations (5)

EnvironmentalCompliance (15)Radiological Control (10)

Industrial and ChemicalSafety (15)Transportation (8)

TSDFs Audited in FY08TSDFs Audited in FY08

• Diversified Scientific Services, Inc. (DSSI), Kingston, TN

• Energy Solutions, LLC, Oak Ridge, TN

• Energy Solutions of Utah, Clive, Utah

• Materials and Energy Corporation, Oak Ridge, TN

• Perma-Fix Northwest, Richland, WA

• Perma-Fix of Florida, Gainesville, FL

• Waste Control Specialists, Andrews, TX

Common TSDF Findings Common TSDF Findings by Audit Discipline (FY 08)by Audit Discipline (FY 08)

Quality Assurance Management Systems:Quality Assurance Management Systems: Follow-up on corrective actionsFollow-up on corrective actions SOP reviews are not currentSOP reviews are not current Training records are not completeTraining records are not complete Document control is inadequateDocument control is inadequate

Sampling and Analytical Data Quality:Sampling and Analytical Data Quality: Waste Analysis Plan DiscrepanciesWaste Analysis Plan Discrepancies Incomplete SOPsIncomplete SOPs

Waste Operations:Waste Operations: Excessive quantities of aged waste on siteExcessive quantities of aged waste on site Actual work practice not consistent with SOP Actual work practice not consistent with SOP

or Planor Plan

Common TSDF Findings by Common TSDF Findings by Audit Discipline (FY 08) cont’dAudit Discipline (FY 08) cont’d

Environmental Compliance/Permitting:Environmental Compliance/Permitting: Container label, designation or storage condition Container label, designation or storage condition

inadequateinadequate Shipment receipt verification incompleteShipment receipt verification incomplete Area inspections and documentation inadequateArea inspections and documentation inadequate Performing a waste size reduction process without Performing a waste size reduction process without

having regulatory approval (one instance)having regulatory approval (one instance) Radiological Control:Radiological Control:

Radiological work permit briefing and training Radiological work permit briefing and training inadequateinadequate

Inappropriate monitoring instruments for alphaInappropriate monitoring instruments for alpha Visitor monitoring and training inadequateVisitor monitoring and training inadequate Inadequate posting or signageInadequate posting or signage

Common TSDF Findings by Common TSDF Findings by Audit Discipline (FY 08) cont’dAudit Discipline (FY 08) cont’d

Industrial and Chemical Safety:Industrial and Chemical Safety: Inadequate Health and Safety Plans or Inadequate Health and Safety Plans or

delinquent reviewsdelinquent reviews Postings for confined space incompletePostings for confined space incomplete Incompatible chemical storageIncompatible chemical storage Inadequate chemical labelingInadequate chemical labeling

Transportation Management:  Transportation Management:        Lack of trainingLack of training Records Management not included for all Records Management not included for all

documentsdocuments Evaluation of sub-tier contractor incompleteEvaluation of sub-tier contractor incomplete Incomplete shipping/receiving documentation Incomplete shipping/receiving documentation

TSDF TSDF AccomplishmentsAccomplishments

Completed 7 TSDF audits; 1 on-site Completed 7 TSDF audits; 1 on-site scoping of non-radiological TSDFscoping of non-radiological TSDF

Approved 7 TSDF Corrective Action Approved 7 TSDF Corrective Action PlansPlans

Tracked 86% of FY2007 Corrective Tracked 86% of FY2007 Corrective Actions to completion (57 FY2007 Actions to completion (57 FY2007 findings closed out of 66 identified)findings closed out of 66 identified)

Updated all Program audit checklistsUpdated all Program audit checklists Increased number of qualified auditors Increased number of qualified auditors

and lead auditors and lead auditors Continued interagency partnering with Continued interagency partnering with

EPA, State Agencies, and DoDEPA, State Agencies, and DoD

DOECAP ChallengesDOECAP Challenges

Increase Federal team leadersIncrease Federal team leaders Increase auditor poolIncrease auditor pool

Radiological controlRadiological control Industrial and chemical safetyIndustrial and chemical safety

Improve POCs active participation -- Improve POCs active participation -- HQ/field HQ/field

Improve localized/regional auditor Improve localized/regional auditor participation to reduce travel costsparticipation to reduce travel costs

Improve program ownership/responsibilityImprove program ownership/responsibility Increase incorporation of DOECAP Increase incorporation of DOECAP

language into contractslanguage into contracts

ASP Program Contact InformationASP Program Contact Information

George Detsis, George Detsis, Analytical Services Program (ASP) Analytical Services Program (ASP) ManagerManagerPhone: (301) 903-1488Phone: (301) 903-1488E-mail:  E-mail:  George.Detsis@hq.doe.gov

Carolyne Thomas - Carolyne Thomas - DOECAP Manager, DOECAP Manager, DOE Oak Ridge DOE Oak Ridge

Phone: (865) 576-2690Phone: (865) 576-2690E-mail:  E-mail:  thomascf@oro.doe.gov

Guy MarletteGuy Marlette, , MAPEP Coordinator, MAPEP Coordinator, Idaho National LaboratoryIdaho National LaboratoryPhone: (208) 526-2532Phone: (208) 526-2532E-mail: E-mail: marletgm@id.doe.govmarletgm@id.doe.gov

Brent PulsiferBrent Pulsifer, , VSP Coordinator, VSP Coordinator, Pacific Northwest National LaboratoryPacific Northwest National LaboratoryPhone: (509) 375-3989Phone: (509) 375-3989E-mail: E-mail: Brent.Pulsipher@pnl.govBrent.Pulsipher@pnl.gov