U.S. Department of Energy Consolidated Audit Program (DOECAP) Fiscal Year (FY) 2013 Overview

1. U.S. Department of EnergyConsolidated Audit Program (DOECAP) Fiscal Year (FY) 2013 Overview Jorge A. Ferrer Manager, DOE Consolidated Audit Program Oak Ridge Office Analytical Services Program WorkshopAsheville, North Carolina September 23–26, 2013

2. Purpose of DOECAP • Eliminate/minimize audit redundancies • Standardize audit methodology, policies, and procedures • Communicate lessons learned • Reduce overall Department risks and liabilities

3. Why DOECAP? • DOE Order 435.1, Radioactive Waste Management, “DOE radioactive waste management activities shall be systematically planned, documented, executed, and evaluated.” • DOECAP conducts annual audits of commercial waste treatment, storage, and disposal facilities (TSDFs) and analytical laboratories that have contracts to provide services to DOE sites and projects. • Consolidated approach reduces redundancy and cost. • DOE Program Offices and sites participate voluntarilyby providing lead auditors, auditors, travel funds, and local points of contacts.

4. Benefits of the Program • Provides DOE environmental and waste managers confidence that • Audit and data quality are improved • Risks and liabilities are reduced • Continuous improvement is promoted • Regulatory acceptance is improved • Reduces inefficiency and ineffectiveness

5. Benefits of the Program (cont.) • Force multiplier • Consistent cost savings to the Department and the taxpayer through audit consolidation • It is estimated that DOECAP eliminates the potential for over 100 additional field audits, with a cost savings of $3.6Mper year.

6. DOECAP’s Mission is to Improve

7. Active DOECAP Participants

8. Laboratory Facilities (21) Radiological TSDF Facilities (7) Nonradiological TSDF Facilities (2) Laboratory Closure (1) FY 2013 DOECAP Laboratories and TSDFs

9. Laboratory Audits

10. Laboratory Audits in FY 2013

11. Laboratory Audits in FY 2013 (cont.)

12. Laboratory Auditors in FY 2013 SiteTotal Albuquerque 3Brookhaven 1 DOE HQ 4 Idaho 8 DOE Idaho: 1 CWI: 3 BEA: 4 LANL 1 LBNL 3 Legacy Mgmt. 3 LLNL 4 Oak Ridge 11 ORO: 4 ORNL: 1 UCOR: 5 Y-12: 1 SiteTotal Nevada 5 Paducah 4 Portsmouth 1 Hanford 8 PNNL: 2 WCH: 1 MSA: 1 DOE ORP: 1 WRPS: 3 Sandia 1 Savannah River 5 Audit AreaTotal Lead 14 QA 37 Organic 18 Inorganic 21 Rad 16 LIMS 6 HRMM 16 Geotech 1 Aquatic Tox 2 NDA 3 Total Lab Auditors:62 Total Audit Areas: 133 AITs to Schedule : 12

13. Distribution of FY 2013 Laboratory Findings

14. Common Laboratory Findings • Training not completed or not documented: • Technical demonstrations of capability (initial and continuing) • Ethics training • Laboratory information management system security training • Safety and personal protective equipment training • Radiation control training • Inadequate or incomplete procedure content • Practices not consistent with procedure direction

15. Common Laboratory Findings (cont.) • Deficiencies in sample receipt practices, particularly radiological screening practices • Performance test failures • Internal auditing deficiencies: • None performed • Schedule not established or maintained • No corrective action follow-up • Not reported to management

16. Common Laboratory Findings (cont.) • Calibration or calibration verification deficiencies • Logbook/notebook deficiencies • Waste disposal inadequate, or facilities being used for waste disposal not adequately reviewed

17. DOECAP TSDF Audits

18. TSDFs Audited in FY 2013

19. TSDF Auditors FY 2013 SiteTotal Brookhaven 6 EMCBC 4 DOE HQ 4 Idaho 5 DOE Idaho: 1 CH2M-Hill: 3 BEA: 1 LANL 5 LBNL 1 LLNL 2 Oak Ridge 18 ORO: 7 OREM: 1 ORNL: 4 ORAU: 1 UCOR: 1 Y-12: 3 TWPC: 1 SiteTotal Nevada 4 Pantex 1 Paducah 2 Portsmouth 3 Hanford 8 PNNL: 2 DOE RL: 2 PRC: 1 WRPS: 3 Sandia 2 Savannah River 7 Thomas Jeff. 1 Audit AreaTotal Lead 12 QA 23 DQ 13 Waste Ops 31 Env. Compliance 16 Rad 14 ICS 11 Transportation 18 Total TSDF Auditors: 73 Total Audit Areas: 126 AITs to Schedule: 12

20. Distribution of FY 2013 TSDF Findings

21. Common TSDF Findings • Incomplete or inadequate procedure content • Practices do not always match procedure • Inadequate personnel training • Incomplete training documentation and records

22. Common TSDF Findings (cont.) • Inadequate labeling and posting (containers, placards, safety, etc.) • Inappropriate storage of chemicals and equipment • Inadequate compliance with permits and regulatory requirements

23. FY 2013 Findings Review During FY 2013, DOECAP conducted: 9 TSDF Audits 21 Lab Audits 1Closure Audit 31 TOTAL AUDITS Percentage of previous year’s audit findings closed during the FY 2013 audits: 100% of the TSDF findings 98% of the Lab findings Number of New Findings Identified for Labs and TSDFs Since 2008: FY 2008 = 216 FY 2011 = 215 FY 2009 = 277 FY 2012 = 191 FY 2010 = 227 FY 2013 = 190

24. FY 2013 DOECAPAccomplishments • Requirement-based findings • Increased number of qualified Auditors and Lead Auditors: • TSDF Lead Auditors remained steady at 12 • TSDF Auditors from 63 to 73 (+11N–1L=+10) • Laboratory Lead Auditors from 12 to 14 (+2N–0L=+2) (R. Kemmerlin, R. Elkins) • Laboratory Auditors from 53 to 62 (+18N–9L=+9) • Began activities to transition the Electronic Data System to SharePoint, with expected completion in early 2014

25. FY 2013 DOECAPAccomplishments (cont.) • Initiatives to increase field participation • Memorandums to field managers • Meetings with field managers • 2012 ASP Annual Report

26. FY 2013 DOECAPAccomplishments (cont.)

27. FY 2013 DOECAP Accomplishments (cont.) • Completed integration of the DOE and Department of Defense (DoD) laboratory requirements documents into the new Quality Systems Manual (QSM) for Environmental Laboratories. DoD issued the manual in July 2013. DOE issuance expected in late September or early October. Audits to the QSM begin in November.

28. FY 2014 Program Challenges • Maintaining the strength of the program with reduced budgets throughout the DOE complex. • Different approaches to fulfill audit needs. • Obtaining accurate information regarding TSDF facility usage in order to appropriately prioritize audit schedules. • Diligent evaluation of the input data to make sound decisions.

29. FY 2014 Program Challenges (cont.) • Filling Audit Teams with Qualified DOECAP Auditors • Adding Qualified Auditors: • TSDF Disciplines:Sampling and Analytical Data Quality, Industrial and Chemical Safety, and Radiological Control • Laboratory Disciplines:Data Quality for Radiochemistry, Laboratory Information Management Systems, Hazardous and Radioactive Materials Management, and Aquatic Toxicity • Pairing Auditors-In-Training with Experienced Auditors

30. FY 2014 Program Challenges (cont.) • Cancelled one audit of a hazardous waste facility used by multiple sites due to lack of field participation • In some cases, there is limited audit scope, yet always address core disciplines: • QA • Waste Operations • Environmental Compliance • Frequency of audits given the forthcoming revision of DOE Order 435.1

31. DOECAP is an Integrated, Participatory Program = Urgent Need

32. Tentative Laboratory Audit Schedule for FY 2014

33. Tentative Laboratory Audit Schedule for FY 2014 (cont.)

34. Tentative TSDF Audit Schedule for FY 2014

35. Closing Remarks • DOECAP savestaxpayers significant amounts of money. • Voluntaryparticipation continues to be vital to the success and viability of the DOECAP Program. • Participation in the program includes the contribution of auditors and travel funds, as well as the identification of federal and contractor points of contact. • The immediate need is for auditors in the following disciplines: • Laboratory – Radiochemistry • Laboratory – Hazardous and Rad Materials Management • Laboratory – LIMS • TSDF – Sampling and Analytical Data Quality • TSDF – Radiological Control • TSDF – Industrial and Chemical Safety

36. DOECAP Contacts George E. Detsis – DOE, HSS, Office of Sustainability Support Analytical Services Program Manager Phone: (301) 903-1488 E-mail:george.detsis@hq.doe.gov Jorge Ferrer – DOE, Oak Ridge Office Federal DOECAP Manager Phone: (865) 576-6638 E-mail:ferrerja@oro.doe.gov Richard Martin – DOE Oak RidgeKaren Brown – Pro2Serve, Inc. Federal DOECAP Deputy Manager DOECAP Operations Team Lead E-mail: martinrw@oro.doe.gov E-mail: brownkc@oro.doe.gov Joe Pardue – Pro2Serve, Inc. Todd Hardt – Pro2Serve, Inc. DOECAP Laboratory Lead DOECAP TSDF Lead E-mail: parduegjjr@oro.doe.gov E-mail:  hardttl@oro.doe.gov Rhonda Jobe – Pro2Serve, Inc. Susan Aderholdt – Pro2Serve, Inc. DOECAP Doc. Control Coordinator DOECAP Corrective Actions Coordinator E-mail:  joberd@oro.doe.gov E-mail:  aderholdtsl@oro.doe.gov

37. Questions? ? ?