UNIVERSITY HOSPITALS OF LEICESTER NHS TRUST POLICY FOR THE MANAGEMENT OF ASBESTOS

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1 UNIVERSITY HOSPITALS OF LEICESTER NHS TRUST POLICY FOR THE MANAGEMENT OF ASBESTOS APPROVED BY: UHL H&S Committee and UHL H&S Committee TRUST REF: B27/2005 DATE APPROVED: March 2008 ORIGINATOR: Glyn Lambley - Senior Statutory Compliance Manager REVIEW DATE: March 2010

2 CONTENTS Section Title 1.0 Asbestos Policy Statement 2.0 Scope 3.0 Definitions 4.0 Organisational Responsibilities 5.0 Arrangements 6.0 Asbestos Labelling 7.0 Monitoring the Condition of Asbestos Materials in Known and Accessible Locations 8.0 Purchasing of Asbestos and Asbestos Products 9.0 Research 10.0 Contractor Procurement 11.0 Encountering Asbestos During Maintenance Work 12.0 Procedure for Uncontrolled Fibre Release 13.0 Training 14.0 Asbestos Removal 15.0 Asbestos Work by Licensed Contractors 16.0 Notification of work with asbestos 17.0 Disposal Arrangements 18.0 General Contractors 19.0 Audit of Asbestos left in-situ 20.0 Monitor and Review of Asbestos Management Arrangements 21.0 Associated Policies and Documents APPENDIX I Flowchart guidance for suspected asbestos Page 15

3 Summary of the Main Changes Arising from the March 2008 Review; 2.0 Scope amended to reflect the consolidation of Asbestos Regulations 3.0 Definitions New Asbestos control limits 4.0 Organisational Responsibilities Nominated Manager Appointment 8.0 Prohibitions statement 12.0 Procedure for Uncontrolled Fibre Release Guidance on personal exposure Asbestos Removal Added Guidance 16.0 Notification of work with Asbestos 18.0 General Contractors Responsibilities of all UHL Project Managers and General Managers 21.0 Revised Guidance and UHL Contact points for Asbestos. Appendix I Flowchart - discovered or damaged materials that could contain asbestos, including suspected personal exposure to asbestos.

4 1.0 Asbestos Policy Statement The objective of the Policy is to provide guidance to ensure that all appropriate steps are taken to comply with their Duty to Manage Asbestos within the University Hospitals of Leicester (UHL), NHS Trust and to comply with asbestos related legislation, approved codes of practice, guidance and relevant standards. In particular it will seek to prevent exposure, or where this is not reasonably practicable, to minimise the exposure of all persons. 2.0 Scope This Policy applies to all UHL premises and to all employees and contractors involved in the construction, management, design, upgrading, refurbishment, extension, maintenance and operation of plant, equipment, buildings and services. The Control of Asbestos Regulations 2006 came into force on 13 November 2006 (Asbestos Regulations - SI 2006/2739). These Regulations bring together the three previous sets of Regulations covering the prohibition of asbestos, the control of asbestos at work and asbestos licensing. The Regulations require mandatory training for anyone liable to be exposed to asbestos fibres at work (regulation 10). This includes maintenance workers and others who may come into contact with or who may disturb asbestos (eg cable installers) as well as those involved in asbestos removal work. When work with asbestos or work which may disturb asbestos is being carried out, the Asbestos Regulations require employers and the self-employed to prevent exposure to asbestos fibres. Where this is not reasonably practicable, they must make sure that exposure is kept as low as reasonably practicable by first considering measures other than the use of respiratory protective equipment. The spread of asbestos must be prevented or contained. The Regulations specify the work methods and controls that should be used to prevent exposure and spread. 3.0 Definitions Worker exposure must be below the airborne exposure limit (Control Limit). The Asbestos Regulations have a single Control Limit for all types of asbestos of 0.1 fibres per cm 3.

5 A Control Limit is a maximum concentration of asbestos fibres in the air (averaged over any continuous 4 hour period) that must not be exceeded. In addition, short term exposures must be strictly controlled and worker exposure should not exceed 0.6 fibres per cm 3 of air averaged over any continuous 10 minute period using respiratory protective equipment if exposure cannot be reduced sufficiently using other means. "adequate" means adequate having regard only to the nature and degree of exposure to asbestos and "adequately" shall be construed accordingly; "appointed doctor, means a registered medical practitioner appointed for the time being in writing by the Executive for the purpose of these Regulations; "approved" means approved for the time being in writing by the Health and Safety Commission or the Executive as the case may be; "asbestos" means the following minerals; crocidolite, amosite, chrysotile, fibrous actinolite, fibrous anthophyllite or fibrous tremolite or any mixture containing any of those minerals; "control limit" means one of the following concentrations of asbestos in the atmosphere when measured or calculated by the reference method described in Annex I to Council Directive 83/477/EEC or by a method giving equivalent results to that reference method approved by the Health and Safety Commission: "control measure" means a measure taken to prevent or reduce exposure to asbestos (including the provision of systems of work and supervision, the cleaning of workplaces, premises, plant and equipment, the provision and use of engineering controls and personal protective equipment); "personal protective equipment" means all equipment (including clothing) which is intended to be worn or held by a person at work and which protects that person against one or more risks to his health, and any addition or accessory designed to meet that objective; 4.0 Organisational Responsibilities Where asbestos is found on UHL premises, the primary Management responsibility rests with the Facilities Department. The Facilities Department will maintain an up-to-date Asbestos Register for each site, listing the location, type and condition of asbestos identified. A nominated Manager, with line management responsibility (e.g. Building Maintenance Manager/Engineering Maintenance Manager) shall be appointed for each UHL site to co-ordinate the management of asbestos and maintain and update the site Asbestos Register.

6 5.0 Arrangements Asbestos must be dealt with on a priority basis, based upon the risk presented by the material. This shall take into account the potential for fibre release, and the condition of the material, its location and the likelihood of the material being damaged or disturbed. Asbestos listed in the Asbestos Register will be assigned a risk classification in order to prioritise the risk. Progressive removal, or substitution of asbestos materials will take place on a priority basis in areas where they are likely to be regularly worked on, disturbed or receive damage. Asbestos materials which are not considered to be creating a significant risk may be left in-situ to be considered for removal as part of a planned programme for removal. Asbestos materials will be sealed in accordance with best practice. Whenever they receive minor damage they will be resealed or removed if the damage is considered to be significant. When buildings are shut down for major refurbishment, or a change of occupancy, the possibility of more extensive replacement programmes should be considered. Any areas where an asbestos survey has not been carried out will be subject to a precautionary approach. This will entail assuming that all materials contain asbestos, unless there is strong evidence to indicate that they do not. 6.0 Asbestos Labelling This applies where asbestos has been assessed as satisfactory to leave intact i.e. it does not require removal. Where reasonably practicable, these areas should be labelled. 7.0 Monitoring the Condition of Asbestos Materials in Known and Accessible Locations The Facilities Department will ensure that a system for the visual monitoring of asbestos is put in place and maintained. All staff have a duty to report any damage to asbestos materials or to materials suspected of containing asbestos to their Manager.

7 8.0 Purchasing of Asbestos and Asbestos Products In accordance with the regulations prohibiting the supply, import and use of asbestos and asbestos based products, the UHL will not purchase any such products or materials. 9.0 Research An exception in relation to the use of asbestos for the purposes of research is permitted. Such use is subject to the UHL Local Rules and project approval relating to carcinogens Contractor Procurement The UHL Control of Contractors Policy provides the framework for procuring contractors. All contractors should be engaged through the Facilities Department in order to provide the required Professional and Technical interface and to ensure that asbestos issues are taken into consideration at the earliest stage. Contractors work activities that may unexpectedly encounter asbestos include: Lighting Electrical wiring installations Security systems IMT installations Installation of scientific/medical equipment and associated pipe work Ventilation ducting Demolition Installation of windows, curtains and blinds 11.0 Encountering Asbestos During Maintenance Work a. The area in which staff, or contractors are working should be checked against the Asbestos Register. If any hidden material or dust which is suspected to contain asbestos is uncovered work must stop and be reported immediately to a Supervisor. b. For work which will involve asbestos materials, a risk assessment must be carried out and a method of work proposed and accepted by the responsible UHL manager, prior to starting work.

8 Maintenance work which may involve encounters with asbestos, includes: lagging on pipes and boilers insulation board in walls, on doors and ceilings asbestos cement for roof and walls covering pipes and tanks in some decorative plaster fire proofing in ducts and voids Insulation in electrical and telecommunication installations Insulation behind wall mounted heaters fire protection around window, skylight and door frames Gaskets, rope and seals plus many other applications where asbestos has been used as a primary agent, or as an additive to other substances (i.e. cement) Procedure for Uncontrolled Fibre Release Prior to starting planned asbestos works, the risk assessment should consider the risks arising from an uncontrolled release. This will include emergency procedures to contain the fibre release and will include how to close doors, windows and isolate ventilation systems to prevent the movement of the fibres. Where an incident occurs, which results in an uncontrolled release of asbestos into the work place at a concentration that is likely to exceed the appropriate control limit, e.g. removing pipe lagging subsequently revealed to be asbestos, the following procedures should be implemented: The affected area(s) should be immediately evacuated and steps taken to secure the area from re-entry of unauthorised persons. Any persons who may be contaminated with asbestos fibres should minimise disturbance to any fibres on their person/clothing to protect themselves and others from inhaling asbestos fibres. An Estates Manager or Estates worker with asbestos training, or a UHL H&S Advisor should be called immediately to advise what actions to take to mitigate the risk in the particular circumstances of the fibre release. The flowchart in Appendix I of this document lists the Health and Safety Executive s guidance for a suspected asbestos fibre release. The Facilities Department, or Switchboard must be notified as soon as possible. Steps should be taken to isolate other areas which may be affected (i.e. close doors/windows, isolate ventilation systems) The cause of the uncontrolled release should be established.

9 Specialist contractors will then be employed to thoroughly clean all visible debris and dust wearing appropriate personal protective equipment which will include suitable respiratory protection. Any necessary measures to seal damaged sources or remove the asbestos material will be taken in accordance with the UHL Special Waste Procedures. Air sampling is finally carried out to confirm that the remedial measures taken have been successful. Only when clearance has been given can people return Training Asbestos Awareness training courses will be provided to all Facilities staff who have involvement with asbestos works and those who have been identified by their Manager as being at risk of encountering asbestos (e.g. building/maintenance staff). The need for further training will be subject to constant review, and provided as appropriate Asbestos Removal Bulk, or high risk Asbestos removal and major work involving asbestos containing materials shall only be carried out by licensed contractors engaged through the Facilities Department, who shall be responsible for their supervision and ensuring that the work is carried out in accordance with the legal requirements and HSE codes of practice. Other Low Risk asbestos works may be carried out by experienced staff, subject to a suitable and sufficient risk assessment, method statement and a permit-to-work. Prior to the commencement of work by a licensed contractor, the Facilities Contract Manager shall notify the Facilities Statutory Compliance post holder, consult with the Department concerned, and ensure that arrangements for HSE notification, permits-to-work, environmental monitoring and clearance certificates are in place. Asbestos survey reports must be made available to the contractor by the responsible Facilities Contract Manager. They are to be checked beforehand to identify those jobs which may have an asbestos involvement. After the satisfactory completion of the works, the Contract Officer must ensure that all asbestos related information from the project is given to the Asbestos Register Nominated Person to ensure that the register is amended. Most asbestos removal work must be undertaken by a licensed contractor but any decision on whether particular work is licensable is based on the risk. Work is only exempt from licensing if: the exposure of employees to asbestos fibres is sporadic and of low intensity (but exposure cannot be considered to be sporadic and of low intensity if the concentration of asbestos in the air is liable to exceed 0.6

10 fibres per cm 3 measured over 10 minutes); and it is clear from the risk assessment that the exposure of any employee to asbestos will not exceed the control limit; and the work involves: short, non-continuous maintenance activities. Work can only be considered as short, non-continuous maintenance activities if any one person carries out work with these materials for less than one hour in a seven-day period. The total time spent by all workers on the work should not exceed a total of two hours. removal of materials in which the asbestos fibres are firmly linked in a matrix, Such materials include: asbestos cement; textured decorative coatings and paints which contain asbestos; articles of bitumen, plastic, resin or rubber which contain asbestos where their thermal or acoustic properties are incidental to their main purpose (eg vinyl floor tiles, electric cables, roofing felt) and other insulation products which may be used at high temperatures but have no insulation purposes, for example gaskets, washers, ropes and seals. encapsulation or sealing of asbestos-containing materials which are in good condition, or air monitoring and control, and the collection and analysis of samples to find out if a specific material contains asbestos. Under the Asbestos Regulations, anyone carrying out work on asbestos insulation, asbestos coating or asbestos insulating board (AIB) needs a licence issued by HSE unless they meet one of the exemptions above Licensed Asbestos Contractors Asbestos works presenting a significant risk should only permitted if they are carried out by Licensed Contractors. The work usually involves: Constructing and working within a temporary ventilated enclosure ("tent"). All air which leaves the enclosure is filtered through HEPA filters. Testing the "tent" for leaks before work can commence. Testing the air outside the "tent" for asbestos fibres during the work. Testing the air and conditions within the "tent" before it can be taken down. Testing the air and giving a "clearance certificate" after the tent has been taken down, before normal use of the area can resume. special safety provisions for workers within the "tent" and special disposal arrangements for the waste asbestos. arrangements whereby workers wear "dirty" workwear inside the tent and

11 "clean" workwear outside Notification of work with asbestos This regulation applies to work at the premises of the employer in which an employee is or is liable to be exposed to asbestos unless - the extent of that exposure neither exceeds nor is liable to exceed the action level; or the work is work to which the Asbestos (Licensing) Regulations 1983 apply. An employer shall not carry out work for the first time unless he has notified the enforcing authority at least 14 days before commencing that work using form FOD ASB 5. Where an employer has notified work and there is a material change in that work which might affect the particulars so notified (including the cessation of the work), the employer shall forthwith notify the enforcing authority of that change Disposal Arrangements Licensed contractors carrying out work which generates asbestos waste or contaminated articles will be responsible for the collection, secure storage and disposal of the waste. All asbestos waste generated, including used protective clothing must be double bagged, clearly identified and securely stored. Labelling of packaged and unpackaged products containing asbestos must include one of the following methods of hazard identification: an adhesive label firmly affixed to the product or its packaging, a tie-on label firmly attached to the product or its packaging, or direct printing onto the product or its packaging, as the case may be General Contractors Contractors engaged by the Facilities Department to carry out other work in the proximity of asbestos must also be informed of the location of asbestos materials so as to prevent inadvertent contact. Where asbestos cannot be confirmed, or urgent reactive work is required, there should always be the presumption that materials contain asbestos, unless there is strong evidence to suggest it does not. All UHL Project Managers and General Managers must ensure that no intrusive works (including drilling, or inserting screws/nails) are carried out on the fabric of the buildings or building services without the permission of the Facilities Department.

12 19.0 Audit of Asbestos left in-situ A written asbestos management action plan must be produced and where asbestos materials are to be left in place: Those affected are informed of its condition and location Regular checks are carried out to assess its condition (at least annual, or as appropriate) Review and revise the action plan, as appropriate The Statutory Compliance Post Holder for each site shall ensure that an annual, or as appropriate, schedule of audit is put into place to measure performance against this policy and the site asbestos action plan. A main (annual) audit should be carried out each year Monitor and Review of Asbestos Management Arrangements The results of the asbestos audit should be forwarded to the Nominated Asbestos Duty Holder on site (the Line Manager who has the designated management function for managing asbestos on the site), the Head of Facilities and the Statutory Compliance post holder, in order to monitor and review performance and formulate asbestos management strategy for the site Associated Policies and Documents UHL Control of Contractors Policy DMS Document No: References

13 Control of Asbestos Regulations 2006 Work with Materials Containing Asbestos ACOP and Guidance 2006 The Management of Asbestos in non-domestic premises, HSE publication. Health and Safety at Work etc Act 1974 (c. 37) Safety representatives and safety committees L87 A guide to the Health and Safety (Consultation with Employees) Regulations Consulting employees on health and safety: A guide to the law Leaflet INDG232 HSE Books 1996 Construction (Design and Management) Regulations 2007 Asbestos: The analysts' guide for sampling, analysis and clearance procedures HSG248 Asbestos essentials task manual: Task guidance sheets for the building maintenance and allied trades HSG210 Surveying, sampling and assessment of asbestos-containing materials MDHS100 Management of health and safety at work. Management of Health and Safety at Work Regulations Approved Code of Practice and guidance L21 Asbestos: The licensed contractors' guide HSG247 Working with asbestos cement HSG189/2 HSE Books 1999 Health and safety in roof work HSG33 (Second edition) HSE Books 1998 Control of substances hazardous to health (Fifth edition). The Control of Substances Hazardous to Health Regulations 2002 (as amended). Approved Code of Practice and guidance L5 (Fifth edition) HSE Books 2005 PAS 60-1: 2004 Equipment used in the controlled removal of asbestos containing materials. Controlled wetting of asbestos-containing materials Fit testing of respiratory protective equipment face pieces OC 282/28 PAS 60-3: 2004 Equipment used in the controlled removal of asbestos containing materials. Operation, cleaning and maintenance of class H vacuum cleaners. Code of practice British Standards Institution PAS 60-2: 2004 Equipment used in the controlled removal of asbestos containing materials. Negative Pressure Units. Specification British Standards Institution BS EN ISO : 2004 Protective clothing for use against solid particulates. Performance requirements for chemical protective clothing providing protection to the full body against airborne solid particulates (type 5 clothing) British Standards Institution BS EN ISO/IEC 17020: 2004 General criteria for the operation of various types of bodies performing inspection British Standards Institution BS EN ISO/IEC 17025: 2005 General requirements for the competence of testing and calibration laboratories British Standards Institution Safe work in confined spaces.

14 Confined Spaces Regulations Approved Code of Practice, Regulations and guidance L101 HSE Books 1997 Carriage of Dangerous Goods and Use of Transportable Pressure Equipment Regulations 2004 SI 2004 No 568 The Stationery Office For more information go to the HSE Asbestos Microsite: University Hospitals of Leicester, NHS Trust Emergency Contact Arrangements: Facilities Helpdesk (GGH & LGH) Serco Helpdesk (LRI) Duty Manager, available through Main Switchboard for out of hours (all sites) APPENDIX I (Extract from HSE Guidance note ref: em 1)

15 RPE = Respiratory Protective Equipment PPE = Personal Protective Equipment

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