U.S. Department of Energy’s Consolidated Audit Program

1. U.S. Department of Energy’sConsolidated Audit Program Jorge FerrerManager, DOE Consolidated Audit Program Oak Ridge Office ASP Workshop 2010Seattle, Washington September 20-24, 2010 1

2. DOECAP’s Mission to Improve 2

3. Federal Leadership HSS Headquarters • Policy Direction/Guidance • Programmatic Oversight • Funding DOE Headquarters Points of Contact • Facilitate Program Implementation DOECAP Manager, Oak Ridge • Federal Management • Audit Participation/Direction 3

4. DOECAP Operations Team • Program Administration • Create and Maintain Programmatic Documents • Maintain Interface with POCs and Auditors • Maintain Audit and Programmatic Records • Maintain Electronic Database • Program Implementation • Recruit and Train Participating Volunteer Auditors • Schedule and Plan Audits • Implement Audits • Coordinate Audit Reports • Track Corrective Action Progress 4

5. DOECAP is an Integrated Participatory Program 5

6. Laboratory Audits in FY2010

7. Laboratory Audits in FY2010 7

8. Laboratory Audit Checklists • QA Management Systems & General Laboratory Practices • Data Quality for Organic Analyses • Data Quality for Inorganic Analyses • Data Quality for Radiochemistry Analyses • Laboratory Information Management Systems/ • Electronic Data Management • Hazardous and Radioactive Materials Management • Special Geochemical/Geotechnical Analyses • Special Biological Analyses and Aquatic Toxicity • Special Non-Destructive Assay (NDA) – (will be revised based on consensus requirements prior to FY2011 audits) • Laboratory Closure Audit

9. Laboratory Auditors FY2010 SITE TOTALAUDIT AREA TOTAL Oak Ridge 13 Lead 11 Livermore 5 Quality Assurance 32 Idaho 6 Organic Analyses 20 Hanford 7 (RL-3, PNNL-3, ORP-1) Inorganic Analyses 21 Nevada 4 Radiochemistry 17 Savannah River 5 LIMS 7 Albuquerque 4 Haz & Rad Mangt 13 Legacy Mangt 2 Aquatic Toxicity 1 Berkley 3 NDA 4 Paducah 2 Sandia 1 AITS Completed: 11 9

10. Analytical Laboratory Common Findings • Technical analytical processes or QC not performed or documented properly • Inadequate or incomplete SOP content • Practices do not match SOP direction • Performance Test failures • Electronic data security or training • Inadequate document control • Safety related issues 10

11. TSDFs Audited in FY2010 11

12. TSDF Audit Checklists • Quality Assurance Management Systems • Sampling and Analytical Data Quality • Waste Operations • Environmental Compliance and Permitting • Radiological Control • Industrial & Chemical Safety • Transportation Management • Regulatory Agency Review 12

13. TSDF Auditors FY2010 SITE TOTALAUDIT AREA TOTAL Oak Ridge 18 Lead 5 Savannah River 10 Quality Assurance 18 Idaho 5 Sampling & Analyses 11 Hanford 5 (RL-2, PNNL-1, ORP-2) Waste Operations 21 Nevada 1 Environ. Compliance 19 Brookhaven 2 Radiological Control 10 Pantex 1 Indust. & Chem. Safety 9 Los Alamos 4 Transportation 13 Berkley 1 Livermore 1 EMCBC 4 New Leads for Non-Rad TSDFs Headquarters 3 Gene Grohs, Joe Pardue Thomas Jefferson 1 Sandia 2 AITs Completed: 9 Paducah 1 13

14. TSDF Common Findings • Inadequate training of personnel • Incomplete documentation and records of training • Incomplete or inadequate SOP content • Practices do not match SOP direction • Inadequate labeling and posting (containers, placards, safety, etc.) • Inappropriate storage of chemical and equipment • Inadequate compliance with permits and regulatory requirements 14

15. TSDF Lessons Learned • First time audits at facilities are a learning experience for everyone; the facility, the auditors, and the Program • A more in-depth knowledge of actual DOE Contract and SOW information is needed • DOECAP TSDF checklists need to be revised and adapted for Non-Rad TSDF audits • Lack of adequate pre-audit materials from the audited facilities may warrant a 4 day audit 15

16. FY2010 Findings Review DOECAP conducted: 38 audits in FY2010 86% of all FY2009 audit findings were closed during FY2010: 88% of the Lab findings 82% of the TSDF findings New Findings Identified: FY2006 = 233 FY2007 = 340 FY2008 = 218 FY2009 = 273 FY2010 = 219 16

17. FY2011 Program Initiatives • Increase focus on auditor/lead auditor training through interactive on-line training opportunities • Organize and complete a comprehensive revision of the QSAS requirements document to incorporate and coordinate with new TNI Standard initiatives • Increase awareness/knowledge of DOE site contractual stipulations/requirements to assure their inclusion in audit activities • Establish and utilize a new EDS SharePoint platform to improve and update the system 17

18. FY2011 Program Initiatives • Clarify the use and application of Priority I Findings • Continue final audit report distribution to DOE field managers to increase awareness to the importance for continued oversight of environmental data quality and waste disposition • Increase focus toward pre-audit preparation and planning for both auditors and facilities • Mini-DOECAP audits, when warranted 18

19. DOECAP Operations Team Jorge Ferrer - DOE Oak Ridge Federal DOECAP Manager Phone: (865) 576-6638 E-mail:  ferrerja@oro.doe.gov Richard Martin – DOE Oak Ridge Nile Luedtke – Pro2Serve, Inc. Federal Deputy DOECAP Manager DOECAP Operations Team Leader E-mail: martinrw@oro.doe.gov Email: luedtkena@oro.doe.gov Joe Pardue - Pro2Serve, Inc. Todd Hardt - Pro2Serve, Inc. DOECAP Technical Operations Coord. DOECAP Qualification Coord. E-mail: parduegjjr@oro.doe.gov E-mail:  hardttl@oro.doe.gov Susan Aderholdt - Pro2Serve, Inc. Rhonda Jobe - Pro2Serve, Inc. DOECAP Corrective Actions Coord. DOECAP Document Coord. E-mail:  aderholdtsl@oro.doe.gov E-mail:  joberd@oro.doe.gov 19