By Bronson Pate, Client Relationships Manager, & Rubinaz Abbas, Project Manager, Tricord Consulting
Most CD Audits consist of four major components:
1) Method 21 Compliance (Comparative Monitoring and Technician Observations);
2) Field Review;
3) Document Review; and
4) Database Review.
What is Method 21 Compliance? How do You Prepare for it?
Comparative Monitoring and Technician Observations are intended to help determine how effective your facility is at using Method 21, from proper technique to finding leaks.
Technician Observations, as the name suggests, is watching technicians as they calibrate their instruments and monitor different types of components. Auditors will often ask questions to gauge understanding of Method 21 and applicable regulations as well.
For Comparative Monitoring, auditors will select a percentage of components at the facility and will randomly select components to monitor until they reach their target. The method of random selection can vary by auditor. While typically auditors will select three units for comparative monitoring based on historic leak rates and operations, some CDs require auditors pick specific units for each audit, and some newer CDs require all units have comparative monitoring conducted in every audit. The auditors will then generate a unit-specific Audit Leak Rate, determined by dividing the number of leaks found by the number of components monitored in each unit. They will then calculate a Leak Ratio by dividing the Audit Leak Rate by the site’s historical leak rate. While older CDs do not have this provision, newer CDs specify that a leak ratio greater than 3 requires corrective action and may be considered a deviation. Historic leak rates can range from four years to 12 months, depending on component types. Generally, historic leak rates for valves are determined based on the previous eight quarters of monitoring. There’s no magic last minute preparation that can be done to make sure leak rates are appropriate.
To prepare for this portion of the audit, regular reviews and checks are needed to ensure that Method 21 is being conducted correctly at a facility. On at least a quarterly basis, you, your contractor supervisor, or area manager should:
1) Review technician training.
• Most CDs require annual training for LDAR technicians.
• Make sure training is up-to-date, varied, and covers a field monitoring portion in addition to a computer-based training.
2) Conduct shadow monitoring on new technicians to make sure that they are monitoring appropriately.
Shadow Monitoring refers to the practice of remonitoring a route or a portion of a route within a few hours of a technician and checking that all leaks are captured and that monitoring readings are consistent between both people monitoring.
3) QA/QC monitoring data for monitoring pace, time between monitoring events, and suspicious patterns.
• Monitoring too fast, (i.e. too many components during a specified time slot) can often be the first indicator that Method 21 is not being properly conducted.
• Time between monitoring events is a good indicator of pace and can help pinpoint any mismonitoring if there is too little time between components that are too far apart.
• Suspicious patterns, like too many zeros in a row, are also cause for further investigation.
What do Auditors Look For During a Field Review?
Concurrent with comparative monitoring, or at another time during the audit, auditors will conduct a field review. During the field review, auditors will be looking for potential compliance issues like open-ended lines (OELs), components that are potentially in volatile organic compound (VOC) service but may have been overlooked from the LDAR program, appropriate tagging of components on Delay of Repair (DOR), sample station operation and flushing controls, difficult to monitor (DTM) and unsafe to monitor (UTM) component justification verification, etc.
Aside from running out into the field before the auditors to make sure all OELs are plugged, the following will help ensure you are prepared for a field review:
1) Involve your facility operators in the LDAR program.
Operators are the ones out in the field collecting samples, either from sample stations or bleeders with potential OELs. Involving them in the LDAR program for these two aspects can ensure that all OELs have caps, plugs, blinds, or double blocks and that sample stations are operated correctly and have flushing controls.
2) Have a robust Management of Change (MOC) process in place.
• MOC processes are key to making sure that all applicable components that may encounter VOCs are evaluated for inclusion into the LDAR program. Once these applicable components are identified, monitoring and recordkeeping can be conducted within required timeframes for those applicable components.
• A good MOC process with some help will allow you to keep track of modifications and changes to your facility to ensure you have not triggered applicability to a new regulation without realizing it.
3) Set your database up to ensure DTM and UTM justifications are appropriate.
Most LDAR databases have user fields that allow for entry of justifications for component status. Ensuring that justifications match regulatory definitions is a good way to make sure that no components are incorrectly labeled.
• Additionally, a review of location descriptions to make sure that DTM components are high enough to require a technician to be elevated greater than 2 meters in order to monitor them would also help prepare.
• For UTMs, document why they are unsafe in the LDAR plan along with a plan to monitor when safe.
Preparing for Document Review
Documentation review includes a review of instrument calibration records, instrument precision checks, instrument response time checks, DOR records and sign offs, LDAR written plan, highlighted P&IDs (if any), ensuring MOC and Quality Control (QC) processes in place, and semi-annual reports. It also includes checking for compliance with chronic leaker and low-leak requirements.
To prepare:
1) Have your documentation ready.
Keep your documentation filed and easily accessible. Auditors kept waiting too long may assume documentation does not exist, and without documentation, there is no proof of compliance.
2) Keep your LDAR written plan up to date.
Remember your LDAR written plan is also a binding document. Best practices written in the LDAR plan can be requirements. Review and revise it regularly to reflect the status of your program, and make sure there is nothing written in the LDAR plan that you do not comply with, regardless of if it is required by a regulation or not.
Many CDs require that the LDAR plan be reviewed and revised annually; keep a change log with review and revision dates as part of the plan as best practice.
LDAR Programs are typically managed in databases, as most CDs require electronic collection and storage of monitoring data. A database is often the backbone of the entire program as it is utilized to not only store components and monitoring data, but also to manage monitoring schedules, repair timelines, and follow-up requirements and generate regular reports, based on the regulations assigned to each component. Additionally, database audits are the easiest to request, as they do not require a fi eld visit, and they typically bring up a lot of questions and potential fi ndings. As a result, databases can provide information on the compliance status of most regulations as the records are all conveniently in one place in an electronic format. Finally, a database request meets the defi nition of ‘reasonable request’ under the Clean Air Act.
To run a database audit, auditors will request a *.bak fi le of your database. In essence, this is a copy of your entire database and recordkeeping system. The *.bak fi le can then be exported to a database management software like Microsoft Access where it can be manipulated or queried to verify compliance. Queries can be run to verify compliance with monitoring requirements, repair requirements, component status (DTM, UTM, etc), component justifications, and assorted other compliance requirements. There is limited room for argument over any compliance issues as they have been documented.
Once you receive a database request, there is not much you can do last minute. How do you prepare for an audit of the backbone of your program?
1) Ensure all regulations are set up correctly and all are applied appropriately.
Know your CD and pertinent regulations and ensure you’re complying with all applicable regulations.
2) Do not consolidate rules. The small differences in rules can impact compliance.
Complying with the strictest regulation ensures you will have complied with all regulations, but remember, a regulation may be more conservative in one aspect and less conservative for others.
3) Have procedural blockades that prevent compliance changes on components.
4) Know what data is not in the database.
• For example, if out of service history is managed outside the database make sure ‘missed inspections’ or the like match this data.
• Facilities generally opt to track their chronic leakers outside of the database, as the definition of chronic leakers varies by CD and most databases are not completely accurate while tracking those.
5) Run regular QC checks on your database to capture and correct potential errors before they develop into serious compliance issues.
In Summary
The best way to prepare for an audit is to conduct regular QC of your program, and to be involved in the program even if it is managed by a capable contractor.
Keep your documentation filed and easily accessible. Run monthly, or at the very least, quarterly QC on your database to make sure it’s functioning appropriately. Make sure you have a robust MOC program in place to include any new components that may contain VOCs in your LDAR program.
ABOUT THE AUTHORS
Rubinaz Abbas is a project manager/technical specialist with TRICORD Consulting, LLC. She has over fi ve years of project experience in air quality and LDAR, and has participated in and/or led over 20 third-party LDAR audits. She has also assisted with the implementation of LDAR programs for multiple facilities, including conducting detailed regulatory applicability determinations.
Bronson Pate is a Client Relationship Manager with TRICORD Consulting, LLC. Bronson is an LDAR Subject Matter Expert with more than thirteen years of professional experience within the industry. He has participated in and/or led over 275 third-party LDAR audits and has worked with multiple facilities to develop LDAR programs both domestically and internationally.