APPENDIX Y. Audit Closeout Memo. Revision History

Transcription

1 APPENDIX Y Audit Closeout Memo Revision History Revision Date Approval Reason 0 12/19/11 Original 1 05/19/16 M. Esquer Addressed 2013 Audit Findings 2 06/30/16 M. Esquer Addressed 2015 Audit Findings

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3 ORANGE COUNTY SANITATION DISTRICT Memorandum DATE: SUBJECT: Closing Out the 2015 Audit of OCSD s Sewer System Management Plan On July 31, 2015, Orange County Sanitation District (OCSD) received the audit findings from an independent auditing firm, RMC, of the Sewer System Management Plan (SSMP). The audit reviewed the period between January 1, 2013 and December 31, 2014 and found OCSD to generally be in compliance with all Provisions of the WDR. The table below summarizes the findings: Non-Compliance 1 Major Deficiency Non-Conformance 1 Major Deficiency Non-Conformance 15 Minor Deficiencies Opportunities 15 All non-compliance and non-conformance findings have been corrected or adopted. Several opportunities and best practice recommendations were suggested. Staff will review these items during the first half of the 2016/17 fiscal year. The following section summarizes OCSD s response and action for each compliance and deficiency finding. For additional information on the referenced regulatory section and corrective action completion date, a more detailed spreadsheet is available. Non-Compliance 1. The SSMP was last certified in March The amended Monitoring and Reporting Program (Order No. WQ EXEC) requires documentation of SSMP updates. Records are not attached to the SSMP documenting all changes made to the SSMP since its last certification indicating when subsections were changed or updated and who authorized the change or update. Created log of changes to the SSMP that have occurred since the amended Monitoring and Reporting Program went into effect in 2013 for Volumes I and II. This log will be incorporated as part of the cover page of each section, appendices, and/or chapter as appropriate. Non Conformance Major Deficiency 1. In October 2014, the MS Access CCTV database exceeded the size limit and would not accept any new records. The District is in the process of creating a Request for Proposals to purchase an off-the-shelf CCTV software to serve as the future repository of CCTV inspection data. In the meantime, CCTV data collected is being summarized for each inspection and loaded into a spreadsheet. According to staff, almost all CCTV data collected is coded using PACP standards. A quick review of the MS Access CCTV database tables indicates the table structure and database format is not currently in PACP database format. OCSD will need to transform that data into a format that can be migrated into the future CCTV repository database. OCSD is purchasing a CCTV software package. Procurement is scheduled to be completed by September 19, 2016.

4 Page 2 of 6 Non Conformance - Minor Deficiencies 1. The SSMP Organizational Chart is missing three OCSD staff responsible for key elements of OCSD s SSMP Program. Updated the SSMP Organizational Chart to include OCSD staff responsible for key elements of the SSMP Program. 2. CIWQS lists four OCSD staff an Onsite Manager also referred to as Legally Responsible Officials (LRO). Update the SSMP, as appropriate; to identify who in the organization is designated as a Legally Responsible Official in the CIWQS database. The SSMP Organizational Chart and Organizational Narrative were updated to reflect the LROs in CIWQS that can certify SSOs. 3. Several of the title descriptions on staff identified in the SSMP Program Organizational Chart are dissimilar from the title descriptions in the Organizational Narrative creating confusion when linking the two documents together. Similarly, the role designations on the SSMP Program Organizational Chart do not always align with the SSMP Responsibility on the Organizational Narrative. Consistency between title descriptions in the SSMP Organizational Chart and Organizational Narrative were addressed. 4. An additional position (i.e., Engineering Supervisor, Collection Facilities Division or designee of the LRO) is included in the Appendix C - Organizational Narrative that is not included in the SSMP Program Organizational Chart. This position is the WDR Subject Matter Expert as defined in the District s Environmental Auditing Procedure TS-ECRA-SOP-011 included as Appendix X1 of the SSMP and is responsible for managing the WDR/SSMP audit. The Organizational Narrative and Organizational Chart were updated with positions responsible for key elements of the SSMP Program. 5. The Organizational Narrative incorrectly identifies the Principal Environmental Specialist Management Services Team as responsible for the SSMP audit, yet this position is only responsible for updating the status of the audit in ECAP. The District should update the Organization Narrative and SSMP Program Organizational Chart to reflect these responsibilities. The Organizational Narrative and SSMP Program Organizational Chart were updated with positions responsible. 6. Update Appendix P2 and Appendix P3 to reflect changes in monitoring and reporting requirements amended on July 30, Appendix P2 and Appendix P3 were updated on March 23, 2016 and were posted to the OCSD SSMP documents external web page. 7. The OCSD website posts a Sewer Spill Estimation Guide that contains a more comprehensive set of spill volume estimation methods along with a more detailed narrative description for how to utilize these methods. Updated Appendix R with the Sewer Spill Estimation Guide dated May 15, 2014.

5 Page 3 of 6 8. The 870-GEN SSO response procedures are referenced but not included in the SSMP. Added the 870-GEN SSO to Volume II, Appendix Q2. 9. The SSMP Chapter 7 does not reference notification procedures and response protocols for sewer overflows caused by contractors working for the District. The District requires contractors to develop a Spill Prevention and Countermeasure Control Plan (SPCC Plan), which is not mentioned in the SSMP. The SSMP has been updated. The OCSD Master Specification for Temporary Handling of Sewage constrains language on how to respond to sewage spills in the Collections System. Contractors are made aware of this language during meetings and are provided a copy of the document. 10. SSMP describes the District s periodic master planning process, but does not describe the process used by District staff to review major development proposals, apply the model as needed to evaluate impact on hydraulic capacity, and update the model and its flows as new information becomes available. Describe the District s ongoing modeling and capacity analysis process in the next update of the SSMP. OCSD will describe the ongoing modeling and capacity analysis process in the next update of the SSMP. 11. References and design criteria information provided in the SSMP are not current. Update the narrative and dates of reference documents for documents that have been revised. OCSD will update the Design Criteria narrative provided in the SSMP in the next update of the SSMP. 12. Based on the work performed for the 2009 Facilities Plan, some of the capacity projects recommended in 2006 have been eliminated or deferred indefinitely on the basis of revisions to flow projections or corrections/changes to the modeled network. However, some projects that were determined in 2006 to present a likelihood of overflow under current development conditions during a 10-year wet weather event have been deferred indefinitely, even though subsequent modeling analysis has confirmed the original hydraulic deficiency. Although the 2009 Facilities Master Plan calls for those potential deficiencies to be monitored, there is no documentation that any monitoring is being performed. OCSD s Engineering Department is starting a master plan update that includes a large monitoring program. The estimated start is in November 2016 through April Once this effort has been completed and the data used to calibrate the hydraulic model to present day flows, OCSD staff will consider an on-going flow monitoring program. Type and placement of monitors will depend on numerous factors, including value of the data, on-going construction efforts, and operations and maintenance concerns. 13. SSMP and referenced documents such as the 2006 Strategic Plan Update, the 2009 Facilities Plan, and Fiscal Year Budgets describe capital improvement projects for capacity enhancement. Some of the identified projects have been completed and others deferred for a variety of reasons. It is not easy to determine the status of each project because the information is contained in various documents. Update table in Appendix M. OCSD will update Appendix M, as appropriate.

6 Page 4 of The Audit Closeout Memo in Appendix Y was not updated after the 2013 WDR Audit. It is not clear whether or how the audit findings from the previous audit were addressed. Update the Audit Closeout Memo in Appendix Y to reflect the decisions and changes resulting from this 2015 WDR Audit. If the District chooses not to update the Audit Closeout Memo then the District should consider updating the SSMP to remove the previous Audit Closeout Memo. Updated the Audit Closeout Memo in Appendix Y to reflect the decisions and changes resulting from the 2013 WDR Audit. Appendix Y will be updated with the decisions and changes resulting from this 2015 WDR Audit. The following section includes the 15 Other Findings and Opportunities not linked directly to issues of compliance or conformance with the WDR. 1. Section 4.1 (c) of the SSMP discusses access for maintenance, inspection, or repairs for portions of the lateral owned by OCSD. This section misses an opportunity to clearly state that the District does not own and is not responsible for maintenance of the laterals connecting private buildings to local sewers and therefore does not require access for maintenance, inspection, or repairs of those laterals. Legal counsel advised against addressing OCSD's lateral ownership in the SSMP for the following reasons: 1) OCSD is a REGIONAL service provider, 2) OCSD is only a few months away from divesting themselves of the vast majority of local sewers, 3) OCSD does not permit direct lateral connections. Counsel states that it is a moot point to discuss ownership or lack thereof in the SSMP. 2. Internal Stakeholder Meetings did not occur after the last audit. In the past, these meetings served to support increased accountability for addressing WDR audit deficiencies and updates to the SSMP. 3. Over the past four years, OCSD has collected multiple data points for every asset in the local sewer system. Four or more recent completed cleaning work orders with maintenance feedback indicating type and severity of material found during cleaning. One CCTV inspection focused on condition assessment and potentially a second inspection for cleaning quality control. 4. During interviews staff indicated that trouble spot pipe schedules are regularly added, removed, or modified as conditions warrant. For example, if a trouble spot pipe routinely comes back dirty (based on contractor input or data), staff may consider cleaning it more often. Conversely, if the pipe routinely comes back clean, staff will consider cleaning it less often.

7 Page 5 of 6 5. Some of OCSD s internal goals have changed and are now more aggressive than those documented in the SSMP. For example, OCSD s pipe inspection goal has changed from 7 years to 5 years and goals for manhole inspections are now set at 2 years. 6. OCSD does not currently have a means to continuously update collection system risk as new CCTV data is collected. This has evolved from being a best management practice to becoming a standard industry practice. For example, NASSCO recently incorporated a risk assessment methodology into the PACP standard. Also, off-the-shelf software with risk assessment functionality is readily available in the wastewater industry marketplace. 7. OCSD currently evaluates the maintenance and renewal needs of sewer pipelines on a caseby-case basis. 8. The District has utilized an assumption for asset deterioration to generate long-term refurbishment and replacement cost projections. These projections are the basis for future refurbishment and replacement funding for capital investment. 9. OCSD has collected CCTV inspection data for almost all collection system gravity mainline assets. 10. The District is considering changing how specifications are assigned to design staff to improve the update process. The process will enable staff to send comments on specifications to both custodian and owner. 11. Contractors are required to perform a quality assurance/quality control inspection of pipelines after construction work is completed. In the past, the District would then perform a baseline CCTV inspection. On some projects, the District is having the contractor perform the baseline inspection. According to staff, OCSD s specification for the contractor (Spec 2730) does not require a PACP inspection.

8 Page 6 of It is difficult to determine which SSOs reported to CIWQS were related to the local system versus the regional system. It appears this information may be determined from the City field, yet this is not clear. 13. The District has invested significant funds to assist member agencies with their I/I reduction efforts, but does not monitor the effectiveness of those efforts or attempt to quantify trends in I/I over time. It is important to the District that peak I/I be controlled by the member agencies. Significant increases in peak I/I could result in additional hydraulic deficiencies that have not yet been identified in the District s trunk sewers, as well as in the District s treatment plants and ocean outfalls. OCSD will partially comply; An I/I assessment will be completed as part of the Collection Capacity Evaluation Study (start date October 2016); however, the potential date for completion of this task is unknown at this time. If Orange County experiences a good rainfall event during the wet weather season then this analysis will be completed after April of next year. If drought conditions persist, then the analysis will hopefully be completed following the wet weather season of At this time, OCSD does not intend to formally document I&I improvement efforts by member agencies. 14. Appendix I1 of the SSMP entitled Preventative Maintenance Program, specifies collection system maintenance output goals. These goals are summarized in Table 8. Staff indicated verbally that these commitments are being achieved, yet at the time of the audit data was not readily available to validate this. 15. ECAP is sending notifications to staff requesting review and update of SSMP sections. It is not clear who the administrator is for the WDR in ECAP and whether these notifications are staying updated. Management will review and decide if this needs to be completed. This is not a compliance requirement.