UNIVERSITY OF LEICESTER ESTATES & FACILITIES MANAGEMENT DIVISION ASBESTOS MANAGEMENT PLAN

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1 UNIVERSITY OF LEICESTER ESTATES & FACILITIES MANAGEMENT DIVISION ASBESTOS MANAGEMENT PLAN Revision Date Nature of Revision Prepared by Approved by 0.2 Jul 2013 Initial draft for comment Jon Fahie 0.3 Sep 2013 Revised draft following comment Jon Fahie 0.4 Jan 2014 Revised Draft to reflect changes to process & organization Jon Fahie 1 (Final) May 2014 Final Draft Jon Fahie Estates H&S Cttee Final June 2014 Jon Fahie University H&S Cttee This, the University of Leicester Asbestos Management Plan was approved by the University Health and Safety Committee on 9 June 2014

2 ASBESTOS MANAGEMENT PLAN CONTENTS Contents POLICY STATEMENT INTRODUCTION PURPOSE SCOPE DEFINITIONS ABBREVIATIONS REFERENCES ROLES & RESPONSIBILITIES Council The Health and Safety Committee The Director of Estates Deputy Director Estates The Appointed Person (& Deputy) Asbestos Heads Departments, Heads of Schools and Heads of Divisions Project Managers ASBESTOS MANAGEMENT Asbestos Surveys Management Surveys Refurbishment or Demolition Survey Areas Where the University of Leicester is Not the Duty Holder Asbestos Records Risk Assessment Management Removal Encapsulation or Seal Monitor Periodic Re-inspection Restrict Access Change of Use Information and Instruction Revision 1 Page 2 of 15

3 5.6 Training EMERGENCY PROCEDURE AND INCIDENT REPORTING Emergency Procedure Incident Reporting MONITORING & REVIEW Revision 1 Page 3 of 15

4 POLICY STATEMENT The University declares that high standards of safety and health are an integral part of the proper conduct of its affairs. The University also believes that statutory duties and requirements are the minimum standards to be met, and that it may be desirable for such standards to be exceeded. In compliance with this general principle the University will:- Prevent, as far as is reasonably practicable, the exposure of staff, students and others to the health risks associated with asbestos. Identify and monitor Asbestos Containing Materials (ACMs) in University buildings, equipment and areas under its control, assess the level of risk, maintain an asbestos register and carry out a proactive ongoing programme of monitoring, removal or containment. Promote awareness of asbestos and the Asbestos Register. Provide information and appropriate training on asbestos. Regularly review the Asbestos Management Plan. Revision 1 Page 4 of 15

5 1.0 INTRODUCTION Asbestos is the term used for the fibrous forms of several naturally occurring minerals. The three main types of asbestos are: 1) Crocidolite (blue) 2) Amosite (brown) 3) Chrysotile (white) Asbestos has been the subject of gradual voluntary and statutory bans since By 1999 the importation, supply and use of all forms of asbestos had been banned in the UK. Asbestos fibres can be found in the atmosphere in Great Britain, therefore the general public is exposed to very low levels of fibres. However, a key factor in the risk of developing an asbestosrelated disease is the total number of fibres breathed in. Working on or near damaged asbestoscontaining materials or breathing in high levels of asbestos fibres, which may be many hundreds of times that of environmental levels could increase the chances of getting an asbestos-related disease. There are four main diseases caused by asbestos; 1) Mesothelioma 2) Lung cancer 3) Asbestosis 4) Diffuse pleural thickening If ACMs are kept in good condition and left undisturbed, fibres will not be released into the air where they can be breathed in; therefore the presence of asbestos containing material does not in itself constitute a danger, however it is hazardous when disturbed or damaged and must be adequately managed. 1.1 PURPOSE The purpose of this Asbestos Management Plan is to; Demonstrate the University of Leicester s commitment to comply with current Asbestos Legislation Clearly identify the responsibilities of the Duty Holder. Detail the mechanism by which the University of Leicester will prevent the exposure of staff, students and others to asbestos and prevent the spread of asbestos to the lowest level reasonably practicable. 1.2 SCOPE There are currently in excess of 300 buildings within the University estate; these are a mixture of academic and residential buildings as well as shared spaces in hospitals. Revision 1 Page 5 of 15

6 Where the University of Leicester owns controls or maintains the building, the University of Leicester is the Duty Holder for ensuring compliance with Asbestos Legislation Those buildings currently outside the scope for the University as the Duty Holders are those buildings for which the University Estates and Facilities Management Division are not maintaining these include; NHS Trust buildings. Leasehold buildings where the University of Leicester do not have maintenance or repair obligations. As the University of Leicester has members of staff and students using these buildings there is a duty of care to ensure that the Duty Holder in those buildings has an adequate process in place for complying with the Control of Asbestos Regulations and any ACM information is available for review by the University of Leicester. 2.0 DEFINITIONS Duty Holder The person or organisation that has clear responsibility for the maintenance or repair of nondomestic premises through an explicit agreement such as a tenancy agreement or contract. Management Survey This is the survey required for all building constructed pre 2000, its purpose is to locate, as far as reasonably practicable, the presence and extent of any suspect ACMs in the building which could be damaged or disturbed during normal occupancy, including foreseeable maintenance and installation. Refurbishment and Demolition Survey This survey is needed before any refurbishment or demolition work is carried out. This type of survey is used to locate and describe, as far as reasonably practicable, all ACMs in the area where the refurbishment or demolition work will take place. 2.1 ABBREVIATIONS ACMs Asbestos Containing Materials AMP Asbestos Management Plan CAR Control of Asbestos Regulations 2012 HSE Health & Safety Executive UKAS United Kingdom Accreditation Services Revision 1 Page 6 of 15

7 RIDDOR Reporting of Injuries, Diseases and Dangerous Occurrences Regulations MICAD Estates asbestos management information system The Asbestos Register EFMD Estates & Facilities Management Division The Appointed Person Asbestos This shall mean the Asbestos Officer The Appointed Person (Deputy) This shall mean the Head of Planned Maintenance. 3.0 REFERENCES Control of Asbestos Regulations 2012 HSG264 - Asbestos: The Survey Guide 2012 RIDDOR - Reporting of Injuries, Diseases and Dangerous Occurrences Regulations ROLES & RESPONSIBILITIES 4.1 Council Council is the governing body of the University. It is there to ensure that the University is being managed effectively and legislative commitments are being met, as such it has the ultimate responsibility for health and safety. 4.2 The Health and Safety Committee The Health and Safety Committee of the Council is established with the delegated authority to approve Health and Safety Policy. 4.3 The Director of Estates The Director of Estates has overall responsibility for the strategy and resource allocation (within the limits of the approved budget) of financial and other resources for the control of ACMs at the University of Leicester. 4.4 Deputy Director Estates The Deputy Director Estates has the responsibility for ensuring the strategy is delivered via his team. This will include nomination of both an Appointed Person and Deputy for the day-to-day management of ACMs and to ensure those staff who manage or supervise projects and activities that could disturb ACMs are aware of their responsibilities under this plan and competent to undertake the work. 4.5 The Appointed Person (& Deputy) Asbestos The Appointed Person Asbestos has specific duties for the day-to-day management of ACMs in the University buildings, equipment and areas under its control which include: Revision 1 Page 7 of 15

8 Ensure processes are in place to maintain of the integrity of the asbestos register (MICAD database); Arrange for asbestos surveys where necessary; Arrange for periodic re-inspections of known ACMs and the revision of the MICAD Asbestos Register database; Provide information and advice about ACMs to Estates and departmental project managers involved in works that may disturb ACMs within the University buildings; Provide information and advice about ACMs to other persons, designated by project managers, who are involved in works that may disturb ACMs within the University estate; Arrange for the removal or containment of ACMs as part of the on-going asbestos management program; Monitor the removal of ACMs from the University of Leicester properties to ensure it is only undertaken by licensed asbestos contractors with approved method statements; Provide and arrange for asbestos awareness courses for staff who carry out or manage work that may disturb ACMs at the University; Establish emergency procedures to deal with any unplanned / uncontrolled disturbance of ACMs at the University of Leicester; Request and incorporate asbestos survey/register information for all new property acquisitions; Provide asbestos register information for all property disposals. 4.6 Heads Departments, Heads of Schools and Heads of Divisions Heads of Department must; Arrange for any construction, installation and refurbishment work required within departmental premises to be carried out with the co-operation and permission of the Estates and Facilities Management Division so that the management of ACMs is considered at the planning stage. Arrange for the removal or containment of known ACMs within departmental equipment. Ensure departmental project managers or supervisors of activities that may disturb ACMs are aware of their responsibilities under this Plan and have (as a minimum) attended an asbestos awareness course. 4.7 Project Managers Project Managers includes any member of staff responsible for people involved in general refurbishment, maintenance work, engineering projects, security systems, cable runs, minor work, Capital Work Projects, Pre-Construction Work, enabling works, work involving penetrations in to the fabric of any building, disturbance of materials above ceilings or in service ducts from any department including Estates Development, AVS, IT Services, RACS, Fire Alarms, Electrical and Maintenance. Revision 1 Page 8 of 15

9 Project Manager s Responsibilities Responsibility for compliance with Asbestos Management Legislation throughout the entire project lifecycle (design, planning and implementation) rests with the Project Manager. Consult the appointed person to view the Asbestos Register for details of known or suspected asbestos in the building concerned and additionally to gain an understanding of any other current work with asbestos in the area of their project. To meet the requirements of current asbestos legislation the project manager undertaking major building work e.g. refurbishments, extensions, major repairs, rewiring etc. will arrange for a Refurbishment and Demolition Survey to be carried out in all areas likely to be affected by the works. This survey will assist the project manager to meet the requirements of other legislation relating to building works namely: 1 CDM Regulations which require the Client and designer to make contractors aware of known hazards. 2 Management of Health and Safety at Work Regulations, which requires the University to assess and control all risks to employees and other persons affected by its operations. Current HSE published guidance documents and approved code of practice publications also require the University to use competent consultants and contractors. A list of these can be obtained from the appointed person. Either pass a copy of the survey report to the Principal Contractor/CDM Coordinator for notifiable projects falling under the Construction Design and Management Regulations Or inform the contractor/in house tradesmen of the presence of Asbestos Containing Materials (ACMs). Where work is to be done via the Appointed Person, obtain costs and time span for the removal of all items affecting the works from the Appointed Person, and include this in the project estimates and programme. Project managers need to be aware that most asbestos has a 14 day statutory notification to the HSE and therefore a minimum of three weeks should be allowed for its removal, possibly longer dependent on the extent of the work. Where asbestos removal/encapsulation work is not being organised by the Appointed Person include within the Main Contract tendering documentation for the removal/encapsulation works by approved asbestos removal contractors. When letting the work as part of the main contract arrange via the Appointed Person for the appointment of an analyst to undertake the analytical/supervisory work relating to the asbestos works. Upon completion of the work under the main contractor provide to the appointed person full details of all asbestos removal work carried out including sample results and Clearance Certificates. Revision 1 Page 9 of 15

10 Halting work, notifying contractors and staff and seeking advice from the Appointed Person, if suspect materials are discovered during the course of the works. Forward to the Principal Contractor for inclusion in the Health and Safety File a copy of the completion documentation (Certificate of Reoccupation) provided by the Appointed Person. Ensure full and complete records of all works with Asbestos are passed to the Appointed Person for inclusion in the central Asbestos Register. 5.0 ASBESTOS MANAGEMENT The following section details how the University of Leicester meets its duties to manage asbestos: 5.1 Asbestos Surveys Where a property was built before 2000 it must be presumed that ACMs are present unless the asbestos survey confirms otherwise. Where a property was built post 2000 then it is assumed that there is no asbestos containing materials within the building. Note - This depends on the whole of the building being built post Checks should be made if there are any areas built pre before making this assumption. Surveys at the University are carried out by a licensed and UKAS accredited asbestos survey contractor. Surveys and re-inspections are carried out to standards set by current legislation Management Surveys The University takes reasonable steps to establish if there are materials containing asbestos in its buildings by undertaking asbestos management surveys (previously referred to as Type 2 Surveys ) of those buildings where the University of Leicester is the duty holder. The purpose of the survey is to identify the location of ACMs, the amount, what condition it is in and to conduct a risk assessment, evaluating the likelihood of asbestos release and the likelihood of human exposure. This risk assessment forms the basis for the ongoing Asbestos Management Plan Refurbishment or Demolition Survey Refurbishment or demolition surveys (previously referred to as Type 3 Surveys ) must be undertaken prior to demolition works or refurbishment works that are likely to penetrate the fabric of the building or services. This type of survey is used to locate as far as is reasonably practicable, all ACMs in the building and will involve destructive inspection where necessary to gain access to all areas. A full sampling programme is undertaken to identify ACMs and its content. For a refurbishment or demolition survey to progress the area must be unoccupied and fully Revision 1 Page 10 of 15

11 accessible to the surveyor, with furnishings and equipment removed Areas Where the University of Leicester is Not the Duty Holder The Appointed Person Asbestos will monitor where the University is not the Duty Holder to ensure that the building Duty Holder has arranged for the identification and monitoring of ACMs, including asbestos surveys, the compilation of an asbestos register and periodic re-inspections of known ACMs. 5.2 Asbestos Records The University of Leicester is required to make, and keep up-to-date, a record of the location and condition of the asbestos containing materials - or materials which are presumed to contain asbestos. An Asbestos Management System (MICAD) The Asbestos Register - is maintained by the Estates Division and supplemented with additional information gained during monitoring, investigation or periodic re- inspection, and kept up to date to reflect the gradual removal of Asbestos Containing Material from University premises. MICAD is a computerised database system stored on the University s network managed by the Appointed Person Asbestos. This database is accessible, with a log-in obtained from the Appointed Person, via the following link Asbestos Register When asbestos removal or encapsulation works take place via a project manager at the University, the Appointed Person Asbestos will be provided with documentation from the project manager via the asbestos removal company or analyst to confirm the removal has taken place; this may include a waste consignment note, Certificate of Reoccupation/Four stage clearance and air monitoring records. The Asbestos Register will be updated to reflect removal works that have been undertaken, however the original record of ACMs in an area will remain on the database. 5.3 Risk Assessment The risk assessment on MICAD takes into account a number of factors when assessing the risk of anyone being exposed to the fibres; Material Assessment: Product type - composites, boards, insulations. Extent of damage / deterioration - good condition, damaged. Surface treatment composite materials, sprayed, sealed, encapsulated or unsealed. Asbestos type Chrysotile, Amphibole, Crocidolite. Revision 1 Page 11 of 15

12 Priority Assessment: Normal occupancy level rare user, low disturbance, high levels. Location, accessibility & extent. Human Exposure Potential number of occupants, frequency of use, average time in the area. Maintenance activity type of maintenance activity / frequency of activity. This risk assessment forms the basis of the Asbestos Management Plan and determines the removal of ACMs or actions necessary to reduce the risk to its lowest practicable level. High Priority This indicates ACMs that require urgent attention. In some circumstances immediate plans for removal of the asbestos concerned should be implemented, or at least the rapid sealing and restriction of the affected area. Medium Priority Indicates ACMs which require some action, encapsulating, sealing, enclosing or labeling. This asbestos would be removed as part of a phased programme. Low Priority Indicates ACMs in good / fair condition, no significant health risk if left undisturbed during maintenance and work activities. Materials within the category will be inspected on a periodic basis to ascertain any change in circumstances which could require reassessment of priority rating. 5.4 Management The risks identified via the asbestos management surveys, must be managed to reduce them to an acceptable level as low as reasonably practical. The levels of management will be dependent on the risk that the ACMs presents. The University has and uses the following management options; Removal ACMs are removed as a result of one or more of the following: Identified as part of the on-going prioritised ACMs removal programme; ACMs made accessible as part of a construction or refurbishment project; ACMs made accessible because of areas vacated and where the removal is reasonably practicable; Revision 1 Page 12 of 15

13 To enable other works to proceed (e.g. refurbishment and maintenance works); Discovery of damaged or high risk ACMs not identified as part of an asbestos survey; Arrangements for the removal of ACMs must be agreed by the Appointed Person Asbestos and the Project Manager with responsibility for the works involved. The Appointed Person Asbestos must review and approve the Safe System of Work before work commences on site. The removal of ACMs shall be considered a high risk operation that must be carried out by a licensed asbestos contractor. The ACMs removal works must be managed by a competent person, time must be allowed for the planning and removal stages of the works and must take account of: Agreement on the scope of the works; Contractors quotation, agreement of costing and assessment of method statement; Statutory HSE notification period (14 days ); Vacation of the work area (departmental staff, furniture and equipment); Isolation of services as required for safe working; Arrangements and services for the contractor: parking, area for de-contamination unit, supply of water and power, security arrangements etc; Liaison and provision of information for departments affected by the works Encapsulation or Seal ACMs that have deteriorated may be encapsulated to contain and reduce the risk of ACMs releasing fibres. Arrangements for the encapsulation of ACMs must be agreed with the Appointed Person Asbestos or an appointed competent person, who will make the arrangements for the work and liaise with the departments involved Monitor Periodic Re-inspection ACMs that are in good condition can safely be left in-situ and monitored. To monitor and review the condition of identified ACMs the Appointed Person Asbestos is responsible for ensuring periodic reinspections are carried out by the University of Leicester approved contractor, the MICAD Asbestos Register database is updated with any alterations to drawings, data or risk assessment and any prioritised actions are completed. For asbestos products, such as asbestos gaskets in plant rooms or mastic pads in kitchens, the University of Leicester will reduce the inspection period to a 3 yearly re-inspection Restrict Access The University has the right to restrict access to an area should asbestos containing materials be Revision 1 Page 13 of 15

14 identified that are high risk. The area will be restricted until remedial works can be planned and undertaken to make the area safe Change of Use Where an area has been identified as at risk of damaging the asbestos, it is possible to consider a change of use for the area so that we reduce the risk of damage and reduce the occupancy level to minimise the risk. 5.5 Information and Instruction The University has a duty to provide information on the location and condition of the materials to anyone who is liable to work on or disturb them. The University carries out this duty in several ways; The MICAD Asbestos Register database web based version is available to the University members of staff and students with an appropriate University address and password. The MICAD information and drawings are available to EFMD Team members via the Asbestos Register. Controlling building maintenance activities all work tickets issued to internal staff or contractors have a step built in that ensures the Asbestos Register is checked and notes added to the job instruction prior to issue of the job. The Appointed Person Asbestos will supply information from the Asbestos Register to contractors and consultants with the agreement of the appropriate Project Officer. 5.6 Training Two levels of training will be provided for staff, students and others depending upon their potential level of interaction with ACMs: 1. For staff whose work could involve work on or near ACMs (maintenance staff, IT staff, project managers, contractors) an asbestos awareness course is delivered to highlight the types of materials, typical locations and to raise awareness of what to do in event of a potential incident. 2. Appointed Persons (and deputy), project managers, maintenance managers and anybody authorised to instruct and manage works on the estate of a size that could lead to affecting significant ACMs should complete both the asbestos awareness course and a recognised training course in asbestos management. Records for all training delivered (internally or via external organization) will be forwarded to the EFMD Training Officer for inclusion on staff s personal training records. Revision 1 Page 14 of 15

15 6.0 EMERGENCY PROCEDURE AND INCIDENT REPORTING 6.1 Emergency Procedure 1. STOP THE WORK IMMEDIATELY 2. Windows and doors should be closed if it is possible to do so without further disturbance to the damaged material and additional risk of inhalation of fibres. 3. All persons should leave the area 4. Post an out of bounds notice, seal up doorways using tape 5. Reported to one of the following: a. The Project Manager / Organiser of the work b. Estates Appointed Person Asbestos c. Estates Project Manager d. Head of Department e. Safety Services 6. THE AREA MUST REMAIN UNOCCUPIED UNTIL INVESTIGATION BY THE APPOINTED PERSON ASBESTOS OR A COMPETENT PERSON. 7. The Appointed Person Asbestos or the competent person attending will assess the situation and make suitable arrangements. This may involve air monitoring, sampling and analysis of the suspect material or arrangements for the removal of the material and a clean of the area. Suspect contaminated areas must remain out of bounds until cleared by the Appointed Person Asbestos or the competent person attending. In a situation where a competent person is unavailable a licensed asbestos contractor should be contacted to attend and manage the situation. 6.2 Incident Reporting If it is found or suspected that persons have been exposed to airborne asbestos fibre (normally taken to mean a level that exceeds 0.01 fibres per ml of air) an Incident Report must be completed and sent to Safety Services. Where exposure occurs in an area under the control of a Principal Contractor the reporting will be the contractor s responsibility. Following the investigation the Appointed Person Asbestos will supply Safety Services with additional information for the incident report that will include the nature of the exposure, the type of asbestos material/fibre content and copies of any analytical or air test records. Safety Services will assess the requirements to report under RIDDOR Regulations. Where it is suspected that University staff or students may have been exposed to asbestos fibres Revision 1 Page 15 of 15

16 they will be referred to Occupational Health for advice about possible health risks and actions that may be required. Copies of the incident report will be kept by Safety Services, Occupational Health and a copy provided to the person involved. Source: HSE Asbestos Essentials EM1 7.0 MONITORING & REVIEW This plan and arrangements will be annually reviewed, at changes in legislation or to include changes to the procedures to ensure they remain up to date. Revision 1 Page 16 of 15

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