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PETERBOROUGH UTILITIES SERVICES INC.

INTERNAL AUDIT REPORT #

12-01

AUDITOR

Patricia Skopelianos

AUDIT DATE
PURPOSE

December 12 & 19th, 2012

The purpose of the internal audit is to obtain objective evidence of the Municipality of
Trent Hills compliance to the Drinking Water Quality Management Standard (DWQMS)
as documented in the Operational Plan.
SCOPE
Elements 1-21
REFERENCE DOCUMENTS
Drinking Water Quality Management Standard - June 2007
Trent Hill Operational Plan Rev 5 July 2012
Standard Operating Procedures (SOP) as described
Previous Audits Reviewed TH11-01
STAFF AUDITED
Mike Rutter, Chief Administrative Officer (CAO)
Scott White, General Manager of Infrastructure Renewal & Public Works Admin.
Scott Campbell, QMS Representative
Todd Kerr, Operator
Paul Kelly, Operator
SUMMARY
The internal audit conducted on October December 12 & 19th, 2012 was the annual
audit for the DWQMS. The Operational Plan and associated SOP were well
documented and in accordance with the Standard. The understanding of the
procedures was extensive through the operational staff. There were a few areas of
non-compliance, which were mainly dealing with additional follow up required to
complete the entire process. With the completion of the corrective actions issued as a
result of the audit, the overall compliance is suitable and the implementation has been
effective.

PETERBOROUGH UTILITIES SERVICES INC.

Element 1

Quality Management System

Reference Documents:
Element 2

Element 3

Element 4

Element 5

Compliant

Operational Plan Section 4.0

Document & Record Control

Reference Documents:

Operational Plan Section 5.0

SOP-09 Documents and Records Control

Non-conformance

CAR 2012-01

Issued to:

Compliant

Operational Plan Section 3.0

Municipal Resolution #512

QMS Representative

Reference Documents:

Compliant

Operational Plan Section 2.0

Commitment and Endorsement

Reference Documents:

Compliant

Operational Plan Section 1.0

Quality Management System Policy

Reference Documents:

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QMS Representative

There is no evidence that the water regulations have been reviewed since 2010.
Paragraph 4.0 describes the process for change to documents but this process is not
performed as described. The approval is provided after the changes are made but
before they are posted rather than before they are made as described. The SOP
should be updated to describe actual practice.
Comment
paragraph 3.5.6 is seldom used and should be removed as it is not
required. The original signed version of the Operational Plan is kept at the
Campbellford WTP but it is not described where, at the time of the audit we could not
find it. The SOP should describe in greater detail where this document should be kept if
required.
Element 6

Drinking Water System

Reference Documents:
Element 7

Operational Plan Section 6.0

Risk Assessment Procedure

Reference Documents:

Compliant

Operational Plan Section 7.0

SOP-01 Risk Assessment

Compliant

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PETERBOROUGH UTILITIES SERVICES INC.

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Element 8

Risk Assessment Outcomes

Reference Documents:

Operational Plan Section 8.0

SOP-01 Risk Assessment
SOP-14 CCP Primary Disinfection
SOP-15 CCP Secondary Disinfection
SOP-16 CCP Filter Water Turbidity
SOP-17 CCP Coagulant

Non-conformance

CAR 2012-02

Issued to:

Water & Wastewater Operations Manager

The critical control point of back flow prevention has been previously identified as a nonconformance and it was described that the program was to be implemented. There is
still not a backflow prevention program for Trent Hills as required under element 8 of the
DWQMS.
Comment
Paragraph 2.6 should be updated to accommodate a greater range of
SCADA limits.
Element 9

Organizational Structure, Roles, Responsibilities

& Authorities

Reference Documents:

Element 10

Element 11

Operational Plan Section 10.0

SOP-11

Paragraph 4.0 contains an incorrect reference to SOP-12

Personnel Coverage

Reference Documents:

Element 12

Operational Plan Section 9.0

SOP-02 Personnel Coverage

Competencies

Reference Documents

Comment

Compliant

Operational Plan Section 11.0

SOP-02 Personnel Coverage

Communication

Reference Documents:

Compliant

Operational Plan Section 12.0

SOP-08 Communication

Compliant

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PETERBOROUGH UTILITIES SERVICES INC.

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Element 13

Essential Supply & Services

Reference Documents:

Operational Plan Section 13.0

SOP-13 Chemical Deliveries to the WTP
SOP-03 Essential Supplier and Services

Opportunity for Improvement

There is a process (work order) which requires staff to take an inventory level of
the chemicals. This is not described in this SOP as the process used to ensure
adequate essential supplies are maintained. Additionally there is no description
of the process to maintain the NSF certifications; this should be described in the
Document Control SOP.
Element 14

Review and Provision of Infrastructure

Reference Documents:

Element 15

Compliant

Operational Plan Section 14.0

SOP-12 DWQMS Infrastructure

Infrastructure Maintenance, Rehabilitation and

Renewal

Reference Documents:

Operational Plan Section 14.0

SOP-12 DWQMS Infrastructure

Opportunity for Improvement

The Flushing Record Form should be updated to include the CAP column as it
is manually added to each record.
Opportunity for Improvement
There is no description of the plant shut down test that is performed monthly.
This should be described as a maintenance program or as a critical control point.
Element 16

Sampling, Testing and Monitoring

Reference Documents:

Operational Plan Section 16.0

SOP-05 Procedure to Respond to Adverse Water Quality
Results
SOP-04 Sampling & Monitoring

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Opportunity for Improvement
There is a process that Operators follow for verifying the accuracy of online
monitors daily. If the Operators grab sample and the online read out are
different the operator will re-sample 3 times before adjusting or calibrating the
equipment. This process is not described but is a best practice and should be
included in this SOP.
Opportunity for Improvement
When the Operator are performing the work order on the calibration standards or
pillow packages, they should be documenting the lot numbers and expiry dates
of the standards to be able to verify if they are or were expired.
Opportunity for Improvement
Schedule log should also include the serial numbers of the portable units.
Comment
Element 17

Table 1 of SOP-05 should be updated to correct job changes.

Measurement & Recording Equipment Calibration
Maintenance

Reference Documents:

Element 18

Element 19

Operational Plan Section 17.0

SOP-04 Sampling & Monitoring Procedure

Emergency Management

Reference Documents:

Compliant

Operational Plan Section 18.0

SOP-13 Sampling & Monitoring Procedure

Internal Audit

Reference Documents:

Operational Plan Section 19.0

SOP-07 Internal Audit

Non-conformance

CAR 2012-03

Issued to:

Compliant

QMS Representative

The internal audit was scheduled beyond the required 12 months of SOP-07 and the
Standard.

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PETERBOROUGH UTILITIES SERVICES INC.

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Element 20

Management Review

Reference Documents:

Operational Plan Section 20.0

SOP-06 Management Review

Non-conformance

CAR 2012-04

Issued to:

QMS Representative

There is no evidence that actions items discussed at the recent Management Review
were described in the meeting minutes including the deficiencies, responsibilities,
resources and timelines for completions as per 5.0 of SOP-06.
Element 21

Continual Improvement

Reference Documents:

Operational Plan Section 21.0

SOP-10 Continual Improvement

CLOSING SUMMARY
Corrective Action Issued
4
Opportunities for Improvements 6
Comments
4

Compliant