Policy and Procedures For the Management of Asbestos

Policy and Procedures For the Management of Asbestos Version: 1.0 Ratified by: Health and Safety Committee Date ratified: 9 March 2009 Name of originator/author: NIFES Date issued: 20 April 2009 Review date: 20 April 2012 Target audience: All staff Asbestos Policy R1.0 09.04.09

Version Control Reference HS 5006 Date Approved 9 March 2009 Approving Body Health and safety committee (chairs action) Implementation Date 20 April 2009 Version 1 Supersedes New Policy Consultation Supporting Procedure See appendix 2 Review Date 20 December 2012 Lead Executive Author/Lead Manager Further Guidance Implementation Target audience Magda Moorey/Jane Shepherd NIFES/Jane Shepherd Health and Safety Policy All Staff Implementation plan in place? Tools for dissemination Yes Email, intranet, trust brief Date of dissemination April 2009 Monitoring Monitoring method audit incidents Frequency Bi-ennial quarterly report Responsibility NIFES Head of Quality Reporting Health and Safety Committee Health and Safety Committee Asbestos Policy R1.0 09.04.09

Equalities Impact Assessment Screening Grid Note: See equalities impact assessment guidance notes on PCT website at www.lewishampct.nhs.uk/eia before completion. Equality Group Race Disability Gender Age Sexual Orientation Religion or belief Deprivation Dignity and Human Rights Assessment of Impact No negative impact detected. No negative impact detected. No negative impact detected. No negative impact detected. No negative impact detected. No negative impact detected. No negative impact detected. No negative impact detected. Asbestos Policy R1.0 09.04.09

EXECUTIVE SUMMARY CONTENTS Page No. 1 INTRODUCTION 1 2 SCOPE 1 3 AIMS AND OBJECTIVES 1 4 GENERAL POLICY STATEMENTS 2 5 ROLES, DUTIES AND RESPONSIBILITIES 3 5.1 Chief Executive 3 5.2 Director of Finance 3 5.3 Head of Estates 3 5.4 FMS 4 5.5 Premises Managers 5 5.6 All Staff: FMS/Trust/Contractors 5 5.7 Trust Health & Safety Committee 5 6 ASBESTOS MANAGEMENT PLAN 5 7 PROCEDURES FOR WORKING IN AREAS CONTAINING ASBESTOS 9 8 ASBESTOS REGISTERS 10 9 INFORMATION 10 10 EMERGENCY PROCEDURES 11 11 SELECTION AND MONITORING OF CONTRACTORS 13 12 TRAINING 15 13 THIRD PARTIES 15 14 REVIEW 16 APPENDIX 1 - SENIOR STAFF 17 APPENDIX 2 - PRINCIPLE LEGISLATION & GUIDANCE 18 APPENDIX 3 - ASBESTOS : AN OVERVIEW AND DEFINITIONS 21 APPENDIX 4 - CONTROL LIMITS & AIR MONITORING 25 APPENDIX 5 - ASBESTOS MANAGEMENT PLAN PROCEDURES 26 APPENDIX 6 - METHOD STATEMENTS 32 Asbestos Policy R1.0 09.04.09

EXECUTIVE SUMMARY This document addresses the legal responsibilities of the Trust and its employees, the procedures, which shall be employed to fulfil these duties, hazards to health associated with asbestos and the arrangements in place to minimise these exposure risks. The Trust is required to comply with legislation protecting people in the workplace from hazards regarding the Asbestos. This policy sets out the requirements of the law regarding Asbestos and, provides guidance in the safe handling of Asbestos, and states how this will be implemented and monitored by the Trust. Authorship: Nifes Consulting Group Dr Simon Kempton and Mr Gareth Jones. Director,of Finance Tracey Easton Consultation Process: Nifes Consulting Group. Health and Safety Committee. January 2009. Configuration Management History: First issue. Asbestos Policy R1.0 09.04.09

1 INTRODUCTION 1.1 The Trust has legal duties and responsibilities as required within the scope of the Control of Asbestos Regulations 2006 (referred to as CAR henceforth), RIDDOR (1995), The Health and Safety at Work Act (1974) all current amendments, revisions, revocations, savings. 1.2 These require that asbestos in the workplace is properly managed and that the exposure of employees and others to asbestos is prevented. 1.3 This document addresses the legal responsibilities of the Trust and its employees, the procedures, which shall be employed to fulfil these duties, hazards to health associated with asbestos and the arrangements in place to minimise these exposure risks. 1.4 This document also details the structure of the asbestos management plan, AMP which forms the basis on how the Trust and designated dutyholders will manage the risk from asbestos exposure and procedures required. 1.5 These government Acts and Statutes are accompanied by approved codes of practice (ACoP) which will be used by the dutyholders to compile its literature and directives which shall enable it to fulfil these requirements. 1.6 The principle legislation and guidance relating to asbestos are outlined in Appendix 2 of this Policy. 2 SCOPE 2.1 This Policy and Procedures apply to all Trust staff and Contractors working on any of the Trust s sites including day to day activities and scheme works. 3 AIMS AND OBJECTIVES 3.1 To provide a guide and structure for Trust Managers and Officers to ensure that statutory requirements are complied with. 3.2 To prevent or reduce to the lowest reasonably practicable level the exposure of employees and contractors to fibres from Asbestos Containing Materials. 3.3 To ensure staff are aware of the Trust s commitment to the safe management of Asbestos Containing Materials. 3.4 To ensure that any Asbestos Containing Materials that are in a hazardous condition are adequately controlled and/or removed in an approved manner. 3.5 To ensure there is a coordinated approach to the management of risks from Asbestos Containing Materials. 3.6 To ensure that where necessary staff receive appropriate training. Asbestos Policy R1.0 09.04.09 Page 1 of 51

4 GENERAL POLICY STATEMENTS This section comprises general aspects/broad aims of the policy. More specific policy details are detailed in Sections 5-12. 4.1 The Lewisham Primary Care Trust has a duty to provide a safe and secure environment for staff, patients and others affected by its work activity. This duty includes the safe management of asbestos and asbestos based products. It is the policy of the Trust to comply with its legal duties and responsibilities as required within the scope of the Control of Asbestos Regulations 2006 (referred to as CAR henceforth), RIDDOR (1995), The Health and Safety at Work Act (1974) all current amendments, revisions, revocations, savings and associated Trust directives. 4.2 The Trust shall also establish procedures and safe working methods for the inclusion of Regulation 4 (Duty to manage asbestos in non-domestic premises, CAR). The Trust shall also endeavour to employ consultants, as they require, to aid in the application of this policy and the Trust s responsibilities under CAR, who shall operate to the European Standard EN ISO/IEC 17025 and who comply with Regulation 20 (Standards for analysis CAR). 4.3 The Estates Department and FMS shall attempt to prohibit the purchase and use of asbestos containing products where practicable. Where substitutes cannot be used, and asbestos containing materials remain in situ, they shall be labelled with proprietary signage, where practical in accordance with the AMP and CAR. The Estates Department shall remove, treat or prohibit access to asbestos containing materials, which provide a considerable risk to health in their current condition. 4.4 The Estates Department and FMS shall ensure that asbestos waste/raw asbestos is not stored, received, dispatched or distributed unless it is in a sealed container clearly marked, showing it contains asbestos, in accordance with CAR. 4.5 The Trusts Health and Safety Policy states that: an asbestos register will be maintained for all Trust sites; any asbestos found will be removed or put in a safe and manageable condition; areas containing asbestos will be examined on an annual basis and results recorded in the register. 4.6 It is the policy of this Trust that, wherever possible, asbestos will be left in a safe condition, appropriately managed and undisturbed until circumstances result in the need for its removal, when it will be stripped and disposed of in the correct manner, according to current / relevant legislation. Asbestos Policy R1.0 09.04.09 Page 2 of 51

4.7 These policies apply to all Trust premises and to all employees and contractors employed by the Trust involved in the maintenance, removal, handling and disposal of asbestos, and forms part of the Trust's General Risk Management and Health & Safety Policy. 4.8 The Trust shall employ methods to ensure that the legislation, documents and publications used are the most current. 4.9 The Trust shall endeavour to ensure that on building projects where over 25% of the GIA is to be affected, the PCT is then to remove all Asbestos Containing Material (ACM). 5 ROLES, DUTIES AND RESPONSIBILITIES The persons occupying senior roles & these positions, 3.1-3.4 are detailed in Appendix 1. 5.1 Chief Executive The Chief Executive has overall responsibility for the health, safety and welfare of staff and others affected by the work activities of the Trust and for the effective implementation of health and safety management policies and procedures. 5.2 Director of Finance The Director of Provider Services has delegated responsibility for the operational implementation and monitoring of health and safety management policies and procedures. The Director of Finance will oversee the implementation of this policy within the premises managed by the Trust, being the persons and managers defined in CAR as the duty holders in order to suitably dispense the Trusts responsibilities under the CAR; those responsible for repair, maintenance, construction, and purchase of items used for the aforementioned. 5.3 Head of Estates The Head of Estates will be responsible for: a) ensuring the Estates Department are informed of any Capital projects; b) ensure that the Asbestos register is referred to for all Capital projects; c) ensure that the Estates department are informed of any works which may compromise the integrity of asbestos in situ. The Head of Estates is responsible for all measures noted above, 3.3(a) and 3.5(d) to 3.4.1 with respect to any asbestos work undertaken within their area of responsibility.. Asbestos Policy R1.0 09.04.09 Page 3 of 51

5.4 FMS The FMS will be responsible for ensuring the day to day implementation of this procedure, and for bringing to the notice of the Estates Department details of any matters of concern requiring attention. In addition, Premises Managers will ensure that: a) where asbestos is located or is suspected of being present, the presence or otherwise of is established and the type identified; b) where asbestos is located it is clearly identified and clearly labelled; c) Risk Assessments and Method Statements are prepared before any Asbestos work is undertaken on site and copies are sent to the Health and Safety Advisor for the site. Guidance on information required by the HSE in a method statement is contained in Appendix 6; d) where asbestos has been disturbed or removed, exposure is prevented by the introduction of control methods other than respiratory protective equipment are implemented until such time as appropriate clearance tests have been undertaken to ensure that the area is safe; e) Specifications, plans and tender documents are properly prepared for removal or disturbance of asbestos. Contractors will be required to submit Method Statements prior to any asbestos work commencing on Trust premises; f) Adequate information, instruction and training are provided for all staff and others who are or are liable to be exposed to asbestos, or will be affected by any asbestos removal; g) Appropriate protective equipment and clothing is provided, maintained and properly used; h) Where employees are exposed to asbestos, air monitoring is carried out and records kept for at least 40 years; i) Where appropriate, employees significantly exposed to asbestos receive regular medical surveillance; j) Waste asbestos is disposed of correctly and in accordance with statutory requirements Hazardous Waste Regulation 2005; k) asbestos remaining 'in-situ' is inspected regularly, maintained in a good condition, the Asbestos Register is updated and all necessary steps are taken to ensure asbestos is left undisturbed, and that all persons entering the premises are aware of the potential hazard; Asbestos Policy R1.0 09.04.09 Page 4 of 51

l) Permits to work are issued and copies retained; m) Licensed contractors are supervised and monitored on a daily basis whilst on site. Monitoring should include witnessing smoke tests, ensuring clearance tests are carried out, inspection of work and reviewing contractor s compliance with the agreed method statement. 5.5 Premises Managers Premises Managers will ensure that any members of staff working in the area of asbestos removal work are given appropriate information about the work and the procedures in place for their safety. Premises Managers will ensure that all staff are made aware of the potential health and safety risks associated with asbestos and the reason for the procedures outlined in this policy. 5.6 All Staff: FMS/Trust/Contractors It is the responsibility of all staff to follow any safety procedures in place for their protection. This includes achieving compliance with Asbestos policy procedures, namely the Asbestos Management Plan, and adopting safe systems of work when undertaking activities involving asbestos. Employees must make full and proper use of any control measures, personal protective equipment or anything else provided by the Trust in order to comply with their statutory duties. 5.7 Trust Health & Safety Committee The persons appointed to the Trust Health and Safety Committee shall evaluate and aid in the implementation of procedures and arrangements required to fulfil this policy. They may also appoint further health and safety personnel to be given duties as the Trust and Committee sees fit. 6 ASBESTOS MANAGEMENT PLAN 6.1 It is the policy of the Trust to compile and implement an Asbestos Management Plan, or however named, which shall aid in fulfilling the general requirements of CAR 2006 and more specifically Regulation 4 - the duty to manage asbestos in non-domestic premises. 6.2 The purpose of this plan is to detail specific actions and responsibilities required by persons working for the Trust, and/or working within the confines of Trust property, in order to comply with the legal duties imposed by CAR. 6.3 In order to effectively manage risk, which is defined as the chance that persons will be adversely affected, the plan is divided into three stages, as follows. These stages form part of the continual process of management, as the information is likely to require regular updates and amendments. Asbestos Policy R1.0 09.04.09 Page 5 of 51

STAGE 1 - Identify Asbestos Containing Materials (ACM) Surveys for asbestos containing materials in Trust properties are to be undertaken by FMS. Due to the nature of occupancy the surveys undertaken have not been destructive but Type 2 sampling surveys, as detailed in MDHS 100 (surveying, sampling and assessment of ACM s). In some cases areas have not been investigated due to other hazards on site. Where areas have not been inspected, or noted as suspected to contain asbestos, they should be presumed to contain asbestos unless there is proof to the contrary. Further investigations will be required and shall be undertaken where more destructive building work and refurbishment projects are required. NO WORK WHICH EXPOSES OR IS LIABLE TO EXPOSE STAFF TO ASBESTOS MAY BE CARRIED OUT, UNTIL THE TYPE OF ASBESTOS INVOLVED IS IDENTIFIED AND ASSESSED IN ORDER THAT IT MAY BE DEALT WITH SAFELY. The Head of Estates must to sign off all works The details of surveys undertaken on Trust properties are securely held by the Estates Department in paper (text and drawings) and electronic formats which is updated by FMS. When asbestos is located or suspected of being present (and is not in the Asbestos Register), sampling must be undertaken to determine the asbestos type and content, or confirm the material is not asbestos prior to any work being present in the area. Once identified, the location and extent of asbestos must be noted in the Asbestos Register and the head of the relevant department informed. STAGE 2 - Assess and quantify the ACM (evaluate the risk) The risk presented by each item, or number of asbestos containing items found, is detailed in the survey reports. These codes can aid in deciding whether to retain or remove the asbestos. Remedial action may need to be taken first to make it safe, (e.g. labelling, sealing or painting etc.). The following points need to be considered. The items contained in these reports shall require regular re-evaluation, which can be undertaken by a specialist consultant or other Trust appointed personnel. The risk from ACM is based on a number of factors, and conditions affecting the ACM are subject to change: Location/Extent; Form/Friability; Condition/treatment e.g., is the asbestos prone to damage by vermin, people, traffic etc., or is the asbestos in bad condition causing more fibre release than if it was painted or sealed; Asbestos Policy R1.0 09.04.09 Page 6 of 51

Type/content e.g., asbestos with a high content of crocidolite is a greater hazard than that containing a low percentage of chrysotile; Likelihood of disturbance/position e.g., is the area occupied, sensitive or subject to frequent maintenance activities. The points for consideration when evaluating the risk shall include the following factors, as the level of risk presented by the ACM s is more likely to be great where: the material has a high asbestos content, increasing its friability and likelihood of asbestos fibre release/hazardous exposure eg., asbestos sprayed coatings release more fibres than asbestos cement; asbestos dust and debris in the surrounding area (likely to be ACM) surface of the material is exposed, damaged or scratched surface sealants or protective coverings are breaking off the material is becoming detached form its base (this is a particular problem with pipe and boiler lagging and sprayed coatings) the materials are being disturbed by occupants/air movements etc, or it will be damaged during refurbishment STAGE 3 - Management - Implementation of the Asbestos Management Plan (AMP) Management requires the allocation of specific duties to Trust staff to ensure that all persons likely to interfere with asbestos are made aware of its location in their environments, the associated health risks, that all exposure to asbestos is reduced to the lowest level practicable and that the asbestos management plan is adhered to. 6.4 The implementation of the Asbestos Management Plan will require the following procedures and actions. Information and distribution: This is the primary measure to ensure that persons who work for the Trust, or on Trust premises and who will be affected by the Trust s undertakings, are adequately informed about the presence of asbestos containing materials on Trust premises. Identification of ACM on site: As a secondary measure the asbestos bearing materials shall be labelled accordingly. High risk materials: Items given a high Risk Code are to be evaluated and priced for removal by licensed asbestos removal contractors. Establish programme for removal/treatment: The Estates Department will oversee or be informed of all projects that involve Asbestos Policy R1.0 09.04.09 Page 7 of 51

interference with the building structures through channels already in place within the organisation of the Trust. Control of staff/contractors: Inform them of their duties under CAR and their responsibilities to comply with the Estates Department. Training: This is imperative for all sections of staff who are likely to come into contact with asbestos containing materials, who are to operate within and who have an integral role in the implementation of this plan. Duties: The duties of management staff and personnel shall be clearly communicated and agreed by both parties to ensure that all persons can undertake their requirements under CAWR. These duties shall also extend to trust staff who do not work within the Estates Department, when they feel the condition of the ACM has deteriorated and requires treatment which had not been indicated during the previous audits/inspection programme due to other accidental and uncontrolled factors. Safety Representatives: These are persons whom work for the Trust and have been appointed under the Safety Representatives and Safety Committee Regs 1977. These persons shall aid and consult with the Estates Department in order that both parties fulfil their legal obligations under CAR and the HSW Act. Update and maintain the register/report: Only persons nominated by the Estates Department may update the register and reports with items removed/treated. Review and Monitor: Review and audits of this plan shall be done at frequent intervals and shall also be triggered when there is reason to suspect the plan requires amending or has obviously failed in its purpose. Risk assessments: The Trust shall attempt to provide contractors and persons working on the site with a standard set of risk assessments and working procedures, which can be applied in cases of repetitive works, which may cause interference, or run the risk of exposure to, asbestos containing materials. Arrangement for implementing proposals/instructions: The Estates Department shall establish a set of arrangements to implement this plan, which is to be communicated to all related parties. The suitability of these arrangements shall be reviewed and altered accordingly, where other person(s) are not able to complete the instructions given. Emergency arrangements: The Trust shall draft arrangements to deal with accidents, incidents and emergencies related to the use, removal or repair of asbestos containing materials in the workplace. 6.5 Air sampling should be used as appropriate as a means of reassuring staff that occupy or have to access an area containing asbestos material, when there is concern or doubt about the level of risk involved. Asbestos Policy R1.0 09.04.09 Page 8 of 51

6.6 The presence of airborne asbestos fibres above the current safe limit for occupation of an area, is a cause for concern, and remedial action should be taken immediately, to prevent exposure. 6.7 Where asbestos has to be removed or disturbed for any reason, (e.g. maintenance, emergency repairs, refurbishment, demolition or deterioration in condition) then assessment must be carried out by a competent person. The work will be undertaken by an approved, licensed Asbestos Contractor. The contractor will be requested to submit a detailed risk assessment and method statement for the work. Appendix 6 identifies the HSE criteria for a method statement. 7 PROCEDURES FOR WORKING IN AREAS CONTAINING ASBESTOS 7.1 Prior to any building work being undertaken in an area identified as containing asbestos, a permit to work must be completed and issued, and a written method statement prepared. This requirement applies to: (a) (b) (c) demolition; construction work; building maintenance work eg carpentry, plumbing, cabling, refurbishment; (d) work by external contractors which may affect the internal fabric of the building, eg IT installation, telecoms cabling, fire alarm installation etc 7.2 The method statement for asbestos treatment and removal should include those details listed in Appendix 6. The permit to work will address the following details: (a) (b) (c) (d) the nature and duration of the work; the address and location where the work is to be carried out; the methods to be used where the work could potentially disturb remaining asbestos; the characteristics of the equipment, including personal protective equipment, used for the: - (i) protection and decontamination of those carrying out the work; - (ii) protection of other people present on or near the worksite. 7.3 Leaving Asbestos in Place. The practicalities, safety issues and cost issues require ACM s to be managed in situ, not removed. In most cases, where the ACM is in a good condition and out of casual access, it is safest to leave in place. Where ACM remains 'in-situ' it must be protected either by physically wrapping the asbestos insulation with another material, or by sealing it in place. These materials then fall under the Asbestos Management Plan and shall be treated accordingly. Asbestos Policy R1.0 09.04.09 Page 9 of 51

8 ASBESTOS REGISTERS The Asbestos Registers are the prime source of information to assist in determining if Asbestos Containing Materials are present in a location and consequently the work method and personnel to be used. Any Asbestos removal works must be advised in writing by the Trust Supervising Officer to the relevant site based premises Manager and Asbestos Co-ordinator (FMS) (independent) to enable the Asbestos Register to be accurately maintained. The Asbestos Register held by FMS will be maintained and updated by the Asbestos Coordinator. When any Asbestos Containing Material is removed, treated or altered in any way the details will be updated in the Asbestos Register. The Asbestos Register will be updated by the Asbestos Co-ordinator (FMS) when any asbestos surveys are made and reference made to material identification or clearance certificates. To support the information provided in the Asbestos Register areas known to have Asbestos Containing Materials will be marked with an appropriate label. To avoid alarm or distress to patients, visitors or staff the labels will be worded appropriately to instruct people to contact the Estates Department before disturbing the fabric of the building or entering roof of floor voids. 9 INFORMATION 9.1 Employees and persons exposed or who are liable to be exposed to asbestos containing materials, including any contractor working for or on behalf of the Trust, are made aware of risk assessments and suitable plans of work, identified and suspected asbestos containing materials in their local environments, risks to health from asbestos exposure and suitable precautions. They shall be familiar with the register and shall inform site Estates Manager immediately of any changes. 9.2 The Estates Management shall ensure that the AMP is comprehensive and utilitarian, with procedures that can be implemented by all affected individuals, and is to include a process by which these individuals have recourse to the Estates Department when they require. 9.3 The duty holder shall also endeavour to ensure that the AMP is communicated to all persons whom it is likely to affect by whatever means it deems suitably fitting and appropriate. In communicating the details of the AMP the Trust will ensure that the responsibilities of all persons are clearly detailed and understood and that these persons aid in facilitating the requirements of the AMP and co-operating with the Estates Department. Asbestos Policy R1.0 09.04.09 Page 10 of 51

10 EMERGENCY PROCEDURES 10.1 It is in the event of an emergency affecting the engineering services that situations will usually arise where staff may be required to work with asbestos. Such a situation would probably occur outside normal working hours. Maintenance staff must be instructed in these circumstances to isolate the engineering services, until assistance can be obtained from specialist contractors. On no account should work be undertaken on asbestos materials or where asbestos materials may be damaged unless such time as a safe system of work is prepared and an approved contractor selected. For example emergency work on: (e) (f) asbestos insulation or coatings asbestos insulating board (g) asbestos cement, e.g, work on worn/crumbling/damaged products, or work with power tools; cleaning of old and weathered asbestos cement; machine sawing; and cutting operations etc 10.2 Where there is an unplanned exposure to the release of asbestos, through an accident or emergency, the Estates Department shall ensure that immediate steps are taken to mitigate the effects of the event, to restore the situation to normal, to review any safety drills which may have failed, to assess the level of risk to persons exposed and to inform those persons who may be affected. Records of these exposures shall be collected and retained, future exposures monitored and medical surveillance undertaken (at the cost and time of the Trust), where the exposure exceeds the control limit, in accordance with CAR. The steps that need to be taken if there is an unpredicted release of asbestos are the same whoever has responsibility for the safety of employees. Note: The CAR set control limits for asbestos exposure. In an emergency, it will not always be possible to carry out air monitoring to determine if the control limits have been exceeded. It is therefore necessary to treat all emergencies as though the limits have been exceeded. In an emergency the following steps must be taken. Immediately clear the area of all persons. If the emergency is contained in a single area, such as a room, isolate the room by closing all doors In the short term, give specific people the task of prohibiting entry, and subsequently suitably secure the area. Inform the Premises managers and FMS Asbestos Policy R1.0 09.04.09 Page 11 of 51

A specialist consultant should be called in to access the area and decide on further action. Carry out a risk assessment before determining the method of disposal, repair/sealing and clearance of any loose fibres. Carry out any remedial work, in accordance with legislative requirements. Keep the area clear of anyone who is not involved in remedial action until air monitoring has taken place and concentration levels reduced to an acceptable level. Finally it is necessary to review the original risk assessments following an emergency. The original relevant entries in the asbestos register may need to be amended and the effectiveness of the emergency plan should be reviewed in the light of the incident. Asbestos Policy R1.0 09.04.09 Page 12 of 51

11 SELECTION AND MONITORING OF CONTRACTORS 11.1 Under CAR 2006 an employer shall not undertake any work with asbestos unless he holds a license granted by the HSE. However a license is not required if: (a) (b) (c) (d) (e) Exposure of employees is sporadic and of low intensity. It is clear that exposure of any employee will not exceed the control limit. The work involves short non-continuous maintenance activities. The work involves removal of materials in which the asbestos fibres are firmly linked in a matrix. The work involves air monitoring or sampling. 11.2 Where work to asbestos containing materials is required the FMS Department shall employ the services of licensed asbestos removal in collaboration with Head of Estates contractors and/or ensure that a suitable plan of work, including an assessment of the risk, is drawn up and the persons required to undertake the work have suitable instruction, equipment and training to complete the task to the strict adherence of the requirements of CAR. 11.3 The FMS Works Services Manager will maintain an approved list of licensed specialist asbestos contractors, which have been checked according to the Trusts standard methods of approval, and also to ensure that they are: (a) suitably competent, trained and qualified, (guidance found in HSG 247 Asbestos: The licensed contractors guide). (b) (c) (d) experienced in the work to be undertaken holders of a current asbestos removal license are adequately insured to undertake the projects required 11.4 The FMS Works Service Manager will also maintain a list of contractors capable of analysing airborne and bulk samples and of visiting the site to check that all asbestos has been removed and to carry out clearance testing. The contractors must be accredited by the United Kingdom Accreditation Service (UKAS), and operate within the scope of ISO 17025 in order to fulfil the requirements of CAR 2006, Regulation 20. 11.5 All tenders for asbestos works should include: (a)work specifications/ plans identifying the extent of work. (b) Method statement, as detailed in Appendix. Asbestos Policy R1.0 09.04.09 Page 13 of 51

(c) (d) (e) Identification of the materials known to contain asbestos and type of asbestos contained when known. Requirements for asbestos air monitoring and analysis. These tests must be undertaken by an independent UKAS accredited laboratory. Where work on asbestos is to be undertaken, the specifications will be compiled by the department issuing the work order and/or a specialist consultant. These must be prepared in a manner which will assist the contractor in preparing comprehensive risk assessments and method statements. Where the type of asbestos cannot be adequately or practically assessed the most stringent safety measures shall be applied ie. An assumption that the material does not contain Chrysotile (white) asbestos alone. Any known additional hazards must also be identified, such as: - proximity to electrical equipment; - proximity to electrical equipment; - hazardous materials; - infectious materials; - confined spaces; - working at heights; - proximity to any ventilation plant, ducts, risers etc; - access restrictions to the area. 11.6 Prior to commencement of any work FMS and Head of Estates on or near asbestos by staff or contractors, the Project Manager or Head of Estates must be satisfied that the method statement and risk assessment have been properly prepared and adequately cover all the factors to be considered. A copy of the Method statement should be sent to the Health and Safety advisor at NIFES for approval. When all persons are satisfied that the risks have been adequately assessed and that the method statement contains all the required precautionary measures, then a permit to work may be issued. 11.7 The Works Manager or Capital Projects Co-ordinator will be responsible for ensuring that statutory procedures are complied with for the length of the contract. At any time the FMS Works Manager, Head of Estates or appointed monitoring laboratory/specialist consultant has the responsibility to stop the work when breaches of safety are identified, or deviation from the method statement. Asbestos Policy R1.0 09.04.09 Page 14 of 51

12 TRAINING 12.1 All persons who work with or may be exposed to asbestos must receive adequate information, instruction and training on the hazards of asbestos, the risk to health and the nature and purpose of any control measures. 12.2 Estates personnel who are responsible for monitoring compliance of the policy must receive appropriate training in order to fulfil their duties. 12.3 The Estates Department shall ensure that its responsibilities, and the objectives of this policy, are applied, shared and/or passed to persons and departments employed by the Trust who emulate in whole or part the role of the Estates Department as dutyholder as defined by CAR. 12.4 The Trust will endeavour to ensure that all persons responsible for, and affected by, the implementation of this policy, including persons who are not employed by the Trust, will co-operate with and have the sufficient means, which may include resources, training, equipment and information, in order to carry out their duties safely, and to carry out their responsibilities under CAR. This is to include, but should not be limited to, self-employed persons and the emergency services. 12.5 The Trust shall ensure that competent persons appointed by the Estates Department to dispense the AMP, shall have the authority and resources needed to carry out their duties. This shall include deputy positions where appropriate to identify, and organise the identification, of the occurrences of departures from the AMP, and to initiate actions to prevent and minimise future departures at all times. The deputies shall fulfil the roles of persons with integral positions to the maintenance of the AMP to ensure its implementation is not reliant on individual person(s) as far as reasonably practicable. 12.6 The competent persons employed to dispense tasks and oversee the implementation of the policy shall be free from undue pressure as far as reasonably practicable. 13 THIRD PARTIES 13.1 It is the policy of the Trust to co-operate with the requirements of representatives of the HSE, local environmental health officers and government organisations overseeing aspects of health and safety for any investigations and inspections of the systems and persons involved with the implementation of this policy and AMP. 13.2 The Estates Department shall ensure that its responsibilities, and the objectives of this policy, are applied, shared and/or passed to persons and departments employed by the Trust who emulate in whole or part the role of the Estates Department as dutyholder as defined by CAR. See section 3. Asbestos Policy R1.0 09.04.09 Page 15 of 51

13.3 The Trust requires co-ordination and input from other sources which affect its ability to maintain and implement this policy and AMP, it shall endeavour to communicate these needs and ensure that it requirements and procedures are understood. The Trust shall endeavour to ensure that the execution of this policy and AMP does not create a conflict of interest, which may reduce the effectiveness and application of this policy and AMP. 13.4 The dutyholder shall also impart information to third parties, who fall outside the scope of its control but may, though whatever means, affect the successful implementation of the AMP. 13.5 Should the AMP contradict or compromise any existing Trust directives the Estates Department shall, by process of consultation with the affected associated bodies, formulate procedures to ensure these requirements are met by other means, to the satisfaction of all concerned parties and with no compromise to its responsibilities under CAR. 14 REVIEW 14.1 The Trust will maintain resources to ensure that the arrangements of the Asbestos Management Plan (AMP) and this policy, can be implemented and regularly reviewed by appointed person(s). These person(s) shall be able to sufficiently assess and monitor the AMP s ongoing suitability, any amendments required through significant changes in the work place and/or when they suspect the AMP is no longer relevant, and through the passing of relevant legislation, directives and statutory instruments. 14.2 Audits and reviews of this policy and AMP shall form a cyclical program, which should address shortfalls and solutions until they are satisfactorily removed. The interval of review shall be decided by the dutyholder but shall by undertaken at regular intervals and subject to the details raised in point 10. 14.3 The dutyholder will ensure that any reviews/audits of the AMP will be undertaken in an objective manner and to a suitable level of frequency. Also that the findings from these reviews will be evaluated objectively by competent individuals and kept as records. Where these findings illustrate the need for any procedural or methodological changes to this policy and AMP, the Trust shall undertake revisions accordingly until suitable procedures can be implemented as the new standard. Revisions shall also fall within its audit schedule. Asbestos Policy R1.0 09.04.09 Page 16 of 51

APPENDIX 1 - SENIOR STAFF Chief Executive Gill Galleano Director of Finance - Tracey Easton Director of Provider Services Jane Shepherd Capital projects Co-ordinator - Jeff Moore Director of Projects FMS - Senior Premsies Officers - Pam Sebestyen Premises Officer Pauline Rowe Asbestos Policy R1.0 09.04.09 Page 17 of 51

APPENDIX 2 - PRINCIPLE LEGISLATION & GUIDANCE The following publications and their most recent amendments have been, and shall be referred to, when implementing and changing details within this policy. PRINCIPLE LEGISLATION 1. "Control of Asbestos Regulations 2006". 2. "Management of Health & Safety at Work Regulations 1992". 3. "Health & Safety at Work Act 1974". 4. "Hazardous Waste Regulations 2005". 5. RIDDOR Reporting of Injuries Diseases and Dangerous Occurrences Regulations 1995 PRINCIPLE GUIDANCE 1. EH57 - The problems of asbestos removal at high temperatures" 2. MDHS100 Surveying, sampling and assessment of asbestos containing materials 3. L73 A Guide to the Reporting of Injuries Diseases and Dangerous Occurrences Regulations 1995 4. HSR29 Guide to the notification and marking of sites on accordance with the Dangerous Substances (Notification and Marking of Sites) Regulations 5. HSE31 RIDDOR explained 6. MS13 Asbestos Medical guidance note 7. INDG233 Managing asbestos in workplace premises 8. INDG255 Asbestos dust kills keep your mask on 9. INDG288 Selection of Suitable Respiratory Protective Equipment for work with asbestos 10. INDG289 Working with asbestos in buildings 11. HSG189/2 Working with asbestos cement 12. DETR Asbestos and Man made mineral fibres in buildings Practical Guidance. Asbestos Policy R1.0 09.04.09 Page 18 of 51

13. HSG 213 - Introduction to Asbestos Essentials 14. HSG 210 - Asbestos Essentials Task Manual. 15. HSG 247 Asbestos: The licensed contractors guide. 16. L143 ACOP Work with materials containing asbestos. 17. HSG 248 Asbestos: The analysts guide for sampling, analysis and clearance procedures. 18. L127 The management of asbestos in non-domestic premises. 19. HSG 227 A comprehensive guide to managing asbestos in premises. 20. ISBN0717610756 Asbestos: Effects on health of exposure to asbestos. 21. WHO 1997 Determination of airborne fibre concentrations. A recommended method, by phase contrast optical microscopy (membrane filter method), WHO (World Health Organisation), Geneva 1997. Asbestos Policy R1.0 09.04.09 Page 19 of 51

Asbestos Policy R1.0 09.04.09 Page 20 of 51

APPENDIX 3 - ASBESTOS : AN OVERVIEW AND DEFINITIONS These notes are taken from guidance and reference publications listed in Appendix 2. OVERVIEW Asbestos is the name given to a group of naturally occurring fibrous silicate minerals, serpentine and amphibole. The three main types are: Crocidolite (Blue) Amosite Chrysotile (Brown) (White) All are dangerous but blue and brown are known to be more hazardous than white. Asbestos usually enters the body via the nose and mouth and it is the respiration of these fibres that causes disease. Although the body will get rid of most of the larger fibres, tiny fibres can pass through into the lower parts of the lungs. They can stay there for years and in some cases work their way through the lung lining. Asbestos related diseases generally appear more than twenty years after the first exposure. It is thought that occasional limited exposure to asbestos fibres do not lead to the following diseases. The body naturally gets rid of any asbestos fibres that may be taken in with food and liquids, and asbestos fibres cannot be absorbed through your skin. Breathing in asbestos fibres can eventually lead to a number of diseases, including: Asbestosis: this disease may result from exposure to high concentrations of airborne asbestos over several years. Some of the asbestos fibres inhaled may deposit in the lungs, resulting in thickening of the alveoli walls. If the exposure continues a greater proportion of alveoli will be affected, causing breathing difficulties and sometimes death in severe fibrosis. In addition, it can make the affected person more susceptible to other respiratory diseases. Pleural Plaques: a benign condition involving pleural thickening. Mesothelioma: this disease is significantly associated with asbestos, especially 'blue' and 'brown', and is a cancer of the lining of the lung (pleura) or bowel cavity (peritoneum), causing severe pain on breathing. It is untreatable surgically because the cancer forms a tree-like structure and is usually fatal. Bronchial Carcinoma: lung cancers caused by asbestos are indistinguishable from lung cancers caused by smoking and other agents, however the risk of lung cancer from exposure is higher among smokers. Diffuse pleural thickening: it may or may not be associated with asbestosis. It is usually asymptomatic and causes signs of restrictive lung disorders. Asbestos Policy R1.0 09.04.09 Page 21 of 51

ASBESTOS PRODUCTS The use of asbestos insulation and most types of asbestos based products is now banned, but thousands of tonnes of asbestos were used in the construction of buildings in the past. Much of this asbestos is still there and it is not easily identifiable by its appearance. Some of its common uses were: as a spray coating on steel work, concrete walls and ceilings for fire protection and insulation; as insulation lagging in buildings and factories, on pipe work, and for boilers and ducts. as insulating board sometimes called Asbestolux and Marinite, used as wall partitions, fire doors, ceiling tiles etc.; as asbestos cement products such as sheeting on walls and roofs, tiles cold water tanks, gutters pipes and in decorative plaster finishes. LIKELY LOCATIONS Asbestos has been used in the past in the following main materials: Sprayed asbestos and asbestos loose packing as fire breaks in ceiling voids. Moulded or preformed lagging for thermal insulation of pipes and boilers. Sprayed asbestos cement for fire protection in ducts, fire breaks, panels, partitions. Soffit boards, ceiling panels and around structural steelwork/ Insulating boards for fire protection, thermal insulation, partitioning and ducts. Ceiling tiles. Millboard, paper and paper products used for insulation of electrical equipment. Asbestos cement products such as corrugated roofing, wall cladding, gutters, pipes, and tanks. Textured coatings, oven door seals. Brake linings, clutch linings and gaskets/rope. Reasonable precautions should be taken when working with these materials. In addition asbestos is likely to be present if the building was constructed or refurbished between 1950 and 1980 and particularly if it has a steel frame and/or boilers with thermal insulation. Chrysotile (white) asbestos was banned in 1999 though may still be used for specialised plant/machinery. Asbestos Policy R1.0 09.04.09 Page 22 of 51

DEFINITIONS Major Work: Means any work with asbestos where worker exposure will exceed the control limit (0.1 fibres per cubic centimetre of air averaged over a continuous period of 4 hours. This involves any breaking, cutting, machining, any surface abrasion or any work on a suspended ceiling. These are nominal levels and in any case a risk assessment must be carried out to ensure staff have suitable training and equipment. Short Duration: Means the total time spent on such work by one person must not exceed 1 hour over a period of seven consecutive days. The total time spent by all persons must not exceed 2 hours. A suitable and sufficient risk assessment is also required to demonstrate that the control limit will not be exceeded and that any exposure will be sporadic and of low intensity. Asbestos Area: Means an area where the exposure to asbestos of an employee working in that area for all his working time, would exceed or be liable to exceed the control limit. These should be designated as respirator zones and marked by suitable warning notices. Asbestos Register: An Asbestos Register containing the following details will be maintained for all Trust premises. The survey reports must be read in conjunction to the register when investigating the details of ACM s in the premises in question. (a) exact location of asbestos; (b) type of asbestos; (c) date of analysis; (d) analysis reference number; (e) condition of asbestos; (f) date of most recent inspection; (g) priority to make safe or remove/risk code (h) site plans, marked to indicate location deposits. The Estates Department, as holders of the asbestos registers and survey reports, shall ensure that the information within is secure, updated and relevant, and shall initiate further investigations as they require to enable effective management of the risk from asbestos containing materials. This must be maintained under secure conditions and Estates Department Managers will ensure that the Asbestos Register is kept up to date and where changes occur, a new page is completed to replace the existing. All superseded pages must be retained for audit/inspection purposes. ACoP: Approved Code of Practice. EH: Environmental Hygiene series of publications. MDHS: Methods for the Determination of Hazardous substances. DETR: Department of the Environment, Transport and Regions. HSE: Health and Safety Executive. HSC: Health and Safety Commission. Asbestos Policy R1.0 09.04.09 Page 23 of 51

ACM: Asbestos containing materials. AMP: Asbestos Management Plan. reasonably practicable : this means that the degree of risk in a particular job or workplace needs to be balanced against time, trouble, cost, benefit and physical difficulty of taking measures to avoid or reduce the risk...it should not be used as an excuse to avoid taking safety measures, and if you are unsure you should err on the side of caution. L143 ACoP. dutyholder(s) : every person who has, by virtue of a contract or tenancy, an obligation of any extent in relation to the repair of non-domestic premises.. or where there is not such contract or tenancy every person who has to any extent control.. CAR 2006. Asbestos cement: this is predominantly a mixture of cement and Chrysotile and which in a dry state absorbs less than 30% water by weight. Specialist consultant : Refers to an approved Environmental Consultant who shall be UKAS accredited to undertake associated asbestos monitoring and analysis work, to have suitable experience to aid in asbestos removal project management and who shall comply with the requirements of ISO 17025. ISO 17025 : abbreviation for BS EN ISO/IEC 17025:2005 General requirements for the competence of testing and calibration laboratories. Asbestos Policy R1.0 09.04.09 Page 24 of 51

APPENDIX 4 - CONTROL LIMITS & AIR MONITORING Further and more specific regulations are triggered when exposure is liable to exceed the Control Limit. These are quantitive assessments of asbestos exposure, expressed in f/cm 3 over certain periods of time. In deciding whether the control limit is likely to be exceeded the assessments may be calculated from actual levels monitored, using 1997 WHO or likely expected figures calculated by person with suitable experience as recommended by the HSC. In either case the Trust has a duty to prevent the exposure of their employers to asbestos where it is reasonably practicable. This shall include the design and use of work processes, systems and controls to avoid or minimise the release of asbestos. Where this is not practicable the level of exposure and numbers of staff affected are reduced to the lowest level practicable, by means other than the use of respiratory protective equipment. The Trust shall take immediate steps to remedy the situation where it is likely that personal exposure to asbestos has exceeded the control limit, shall investigate their duties to report the incident under RIDDOR and apply the further special regulations required of CAR in each case. 1. The Control Limit Means a concentration of asbestos in the atmosphere when measured in accordance with 1997 WHO recommended method, or by a method giving equivalent results to that method approved by the Health and Safety Commission, of 0.1 fibres per cubic centimetre of air averaged over a continuous period of 4 hours. 2. Air Monitoring The publication which currently addresses the standard methods for asbestos air testing is 1997 WHO. Samples of the air are taken to determine air quality and the results presented in a quantitive format relating to current acceptable standards of airborne asbestos fibre levels. The measurement technique for air testing can be applied to various sampling situations as defined in 1997 WHO. In all cases an assessment of the air quality should be undertaken following asbestos removal and in most cases this requires air sampling to determine whether the atmosphere has a sufficiently low fibre concentration to allow general occupation. In this situation, the airborne fibre concentration is compared with the clearance indicator, <0.010f/cm 3. Asbestos Policy R1.0 09.04.09 Page 25 of 51

APPENDIX 5 - ASBESTOS MANAGEMENT PLAN PROCEDURES The contents of the plan are detailed in the policy document. This section addresses procedural aspects of implementing the plan. These tasks and actions are to be undertaken in a cyclical manner as the site details, plan structure and information alters and is re-evaluated accordingly. The order of events and priorities of actions will change following the temporary completion of various tasks, and the re-evaluation of the level of importance of each factor. The Estates Department, as the duty holders in this case, will evaluate each task as they see fit to ensure that each action aids in the overall compliance of their duties under CAR and the HSW Act. The Estates Department shall delegate specific roles to persons within its department, and other contacts as it sees fit, to ensure the successful implementation of this plan and adherence of the Trust s Control of Asbestos at Work Policy (2002). The main aim of these procedures is to outline the arrangements for ensuring the protection of patients, staff and other persons entering the Trust, by: 1. Information and Distribution The section/department managers are to be contacted with a standard Information Bulletin(s) which briefly details the Trust responsibilities, their responsibilities and how they can be achieved. This should also include evidence to support the receipt of documents issued which relate to the capacity of the Trust to fulfil its obligations under CAR. Documentation issued must be traceable not only to whom the document was issued but also document contents. Maintenance staff shall be given a copy of the flow chart, Are you about to interfere with the building structure and/or plant?, details of the permit to work system, to be arranged, and their responsibilities. Those staff who feel they still do not understand the health risk from asbestos and/or how to proceed with work on site, will need further training and information. These requirements shall be assessed by persons responsible for training, nominated by the Estates Department. The asbestos register needs to be available to anyone liable to work on it or disturb it ; the details of those persons liable must be maintained and also how the Estates Department has assessed those persons who fall within this category. The type of information issued may be duplicated to ensure that both the maintenance staff and heads of department/managers in each building sections are both vigilant and will request evidence that safe working methods are being followed. The type of information issued to each manager will be decided by the Estates Department. Asbestos Policy R1.0 09.04.09 Page 26 of 51

The distribution of information needs to be a two way process as staff nominated to check on the condition of the ACM s in their workplace need a method by which they can inform the Estates Department of changes in the condition and changes in risk that the ACM presents. This may be done by E- mail or other means that the Estate Department shall check and ensure the success and suitability of. 2. Identification of ACM on site These labels shall be standardised to either clearly state the material contains asbestos or shall warn persons not to proceed or interfere with the items to which the materials are attached, without first contacting the Estates Department. These labels may only be removed following removal of the asbestos containing materials to which they referred. They must not be hidden by other information or other coverings. Suitable wording may be similar to Do not remove. Inform estates department for risk evaluation code Where labelling for each item is not practical then a warning sign fitted to the entrance to areas containing asbestos items must be fitted, or other system of warning or prohibition shall be used. In essence the Estates Department must use all methods available to warn persons of asbestos containing materials when they may not have access to, or be informed of, the details of locations of ACM s on their premises. 3. High Risk Materials Where these may not be removed or treated for some time the Estates department is to ensure all persons who are likely to come into contact with these are to be notified to avoid these areas. The areas where occupants are likely to be exposed to or create a hazard level of exposure to items given Risk codes 1/2 in the survey reports, must be kept out of bounds and signed accordingly. Where regular inspections reveal damage to asbestos, urgent remedial action must be taken to ensure the release of asbestos fibres is eliminated, staff are protected from exposure and the register is updated to reflect a change in assessment/material treatment priority. 4. Establish Programme for Removal/Treatment Where identified asbestos is in a good condition, is not likely to be damaged and is not likely to be worked on, the safest course of action is to leave it in place and introduce a management system which ensures that its location is known and documented and its condition is maintained. Where this is not possible, i.e. if the asbestos has become damaged or refurbishment/building work that will interfere with the asbestos is being carried out, the asbestos will be removed. Asbestos Policy R1.0 09.04.09 Page 27 of 51

Any shortfalls to this procedure may require the establishment of new protocols, which will be distributed to those persons who oversee works in other departments or issue orders for such works. The details from planned projects shall be assessed for the likelihood of their interference with asbestos containing materials and as such the asbestos containing materials will be programmed for removal accordingly. The priority of items removed will depend on the risks they present, the order of planned projects and the severity of the risk codes given in the asbestos survey reports. The Estates Department shall also prioritise treatment to other asbestos containing materials due to any interim changes, which may arise from unplanned work or accidental/deliberate damage in Trust premises. The asbestos containing materials must be removed prior to the refurbishment project. Where the project reveals items suspected to contain asbestos these will be assessed and treated as a matter of urgency where required. The Trust shall make allowance for treating freshly damaged and/or emergency work, whether halting the project or changing the asbestos removal programme. The Trust shall ensure that all departments co-operate with the instructions of the Estates Department when work is requested to cease to allow for further investigations or emergency works. The programme for removal shall be dependant on safety, budget and time factors. The programme may require some changes in the priority of work undertaken within Trust premises as the Estates Department sees fit. 5. Control of Staff/Contractors They shall be issued with a set of procedures which shall cover how they will be issued work, the details for each job issued, how they can find out whether the materials contains asbestos and/or whether there is standard/special set of instructions and equipment they need to be aware of and follow. Also procedures to follow when they are issued work outside of any set protocols, what happens when their agreed plan of work has to be changed and to include any work orders raised or done under emergency conditions. The set of procedures shall cover those issuing orders and those undertaking work. General procedures may include: (a) (b) (c) (d) (e) Read text notes from the asbestos survey report on the building (numbered) they are to work on and the catalogue of repetitive/common items as found in Charing Cross Hospital Check register, Excel format Check highlighted areas on plans Section on miscellaneous items, fuse linings, gaskets etc. which may be hidden Assess whether the ACM will be disturbed and if so the level of risk and precautions to be taken Asbestos Policy R1.0 09.04.09 Page 28 of 51

6. Training Training for each role will vary and the suitability of training should be assessed by a competent person, who may also require training to fulfil this role, in accordance with the likely level of risk for each person(s). Supervisors in departments not related to the Estates Department should be made aware of their duties to the duty holder, namely the Estates Department. Specialist training for staff likely to work in close proximity to asbestos materials may be required and the need for this shall be discussed with the specialist consultant. 7. Duties Evidence of the allocations of duties and associated communications and feedback shall be kept and monitored by the Estates Department, who shall initiate further training etc. as required. This shall include an Information Bulletin for none maintenance personnel and more specific details for those persons carrying out refurbishment work, whether internal or externally supplied contractors. Contractors employed externally shall be given, as standard as information leaflet, the contents of which shall be decided by the Estates Department, but shall as a minimum standard warn the contractor that asbestos containing materials exist within Trust properties. Also that they have a responsibility to ask the work issuer if they are likely to interfere with asbestos containing materials in the undertaking the work they have been asked to do. Internally employed maintenance staff shall be issued information as given to the external/independent contractors and also copies of Management of Asbestos in Workplace Premises (INDG 223), Working with Asbestos in Buildings (INDG 289) clear instructions on how to access and use the asbestos database, and the following details as a minimum. Staff have a responsibility to: (a) (b) (c) (d) (e) Reduce exposure, prevent asbestos dust being released, including all dust. Ask whether there has been a check for asbestos where you are due to work, if not treat any insulation or insulating board as asbestos. If in doubt stop work and find out. Stop and ask if you are uncertain as to how to proceed. Protect their health and that of their workmates. If you think asbestos dust has been released inform your supervisor immediately and make sure it does not spread to affect other people. Follow procedures set out by Estates/Safety Dept. Use the safe work methods and equipment provided. Asbestos Policy R1.0 09.04.09 Page 29 of 51

(f) (g) (h) Control of tools and equipment you suspect may be contaminated/use for asbestos work, don t take overalls home etc. If you need to work with ACM follow the risk assessment and plan of work. If the nature of your job changes be sure that you will not interfere with ACM when using, reassessment of work required. Apply flowchart as attached. 8. Safety Representatives Shall also ensure that information regarding the safe working practices, and information relevant to H & S of workers, detailed in this plan are passed to the workers they represent. This shall also include the requirements for maintaining health records and any medical surveillance required. They may also provide an objective point of view for auditing the successful implementation of this plan and the suitability of any changes required. 9. Update and Maintain the Register/Report This shall include all forms of the register/report accessible to persons within and outside the Estates Department, and may include re-calling certain documentation. The frequency of updates will be dependant on the work done. Updates must clearly indicate the person altering the information, the date on which it was altered, reasons for any suspected materials changed or included in the report/register and where materials previously suspected to contain asbestos have since been proven not to. The validity of updates and the security of the register shall be included in the review program to assess it success. 10. Review and Monitor Competent persons, appointed by the Estates Department, who may require the aid of specialist consultants, shall undertake these reviews. The contents of these reviews shall be based on each section of part B - Plan Implementation. These must be viewed objectively and shall include feedback from staff who have been effected by the plan to evaluate its effectiveness. The results of the these reviews shall be kept along with the suitability of any required changes. The extent, content and frequency of reviews will be ascertained by the competent person who shall have a familiarity with the AMP. 11. Risk Assessments These standard methods shall ensure persons are fully protected and only undertake work which falls within the correct assessment/required specifications for their task. They shall employ the use of licensed asbestos removal contractors when advised by the specialist consultant or where they regard the level of training by their own personnel does not equip them to undertake the work safely. Asbestos Policy R1.0 09.04.09 Page 30 of 51

12. Arrangement for implementing proposals/instructions The contracts of persons employed to sustain the AMP may need to be redefined and should be mutually agreeable. In this way persons will be made aware of their responsibilities and standard procedures they will be expected to apply. They may then be in a position to request further information and/or training as required to enable them to fulfil their duties. The Estates Department shall establish a chain of command to avoid failures in the system which may occur through persons not being full aware of their roles, duplicating roles, reporting failures in the plan to the incorrect authorities, being unavailable through leave etc. The Estates Department shall also endeavour to communicate with other organisations who may effect its ability to successfully implement this plan, in order to agree the extent of responsibilities, flow of information and duties from each party concerned. They shall state where the relevant information can be accessed by persons they instruct to evaluate the risk of asbestos prior to work and ensure that it is comprehensive and current. 13. Emergency arrangements These may be based on past experience and may need to be considered in line with other hazards on site. Asbestos Policy R1.0 09.04.09 Page 31 of 51

APPENDIX 6 - METHOD STATEMENTS Before starting any work where asbestos is present CAR require you to make an assessment of the likely exposure of your employees, which may trigger further requirements such as notification, and to prepare a plan of work. The method statement prepared for the removal of ACM s shall be site specific and should cover in sufficient detail the following information: the scope of works as identified by a risk assessment; the address and location where the work is to be carried out; the methods to be used for the work with the asbestos or ACM as identified in the assessment, eg the prevention and control measures and the handling and disposal of the waste; the type of equipment, including PPE and procedures, used for the protection and decontamination of those carrying out the work, and the protection of other people at or near the work site. Positions for decontamination units and waste skips must be identified, and also the siting of Negative Pressure Units (NPUs) and ventilation ducting requirements. Any special requirements, such as negative pressure monitors, should also be stated. The Method Statement should identify the monitoring arrangements for the length of the contract. The specification must include reference to the role of a site Supervisor for the contractor. The initial risk assessment of the removal works should identify all the risks associated with the asbestos work. Guidance on what the risk assessment should include is set out in HSG247 Asbestos: The licensed contractors guide. Asbestos Policy R1.0 09.04.09 Page 32 of 51

Client Primary Care Trust Property Address Holding Address for Primary Management Plan & Contact Details Control of asbestos at Work Regulations ASBESTOS MANAGEMENT PLAN Regulation 4 - Site Document Please Tick Date Please Tick Date Pre Survey Document Post Survey Document The Company/ Dutyholder has adopted an open policy in its management arrangements for dealing with asbestos. Its health and safety arrangements acknowledge the importance attributed to the risks from asbestos and the requirement for strict legislation compliance in all operations that are affected by asbestos materials. Furthermore, explicit duties have been imposed upon the Company/ Dutyholder and it is their intention to comply fully with the requirements of Regulation 4 of the Control of Asbestos at Work Regulations 2002 and all other relevant legislation with regards to asbestos. ALL persons MUST give the necessary time to read this document BEFORE STARTING ANY works on the property Pay attention to the sections relevant to you (given overleaf) - This may result in you NOT being able to undertake the work that you have been asked to do. Do NOT start work until YOU ARE SURE the work will not disturb any asbestos materials. Asbestos Policy R1.0 09.04.09 Page 33 of 51

STOP!! CONTRACTORS AND/OR PERSONS ABOUT TO WORK on this property YOU MUST FOLLOW INSTRUCTIONS IN THE WHITE PAPER SECTIONS (SECTION 1 AND APPENDIX 1 & 2) If there is an ACCIDENTAL RELEASE OF ASBESTOS FOLLOW THE INSTRUCTIONS IN THE RED SECTION (SECTION 3) If you are an OCCUPIER, EMPLOYEE, or SECURITY STAFF READ THE GREEN SECTION (SECTION 2) in the first instance APPENDIX 1 Asbestos In this Property APPENDIX 2 Contractor Signing Page Asbestos Policy R1.0 09.04.09 Page 34 of 51

SECTION 1 CONTRACTORS AND PERSONS ABOUT TO WORK ON THIS PROPERTY YOU have legal responsibilities to protect yourself and those around you from asbestos risks. DO NOT Disturb or work on asbestos materials during your work - suspected or known - NO MATTER HOW SMALL DO BE ASBESTOS AWARE - always proceed with caution and if you discover any suspect or unidentified materials, stop work and speak to your site contact ABIDE BY UK ASBESTOS LEGISLATION and the rules and conditions set out within, at all times Seek advice if you are not sure Presume materials to contain asbestos and read thoroughly the asbestos information given in Appendix 1 and sign Appendix 2 If asbestos is accidentally disturbed, follow the RED section If you have any doubts - ask!! Sign Appendix 2 BEFORE STARTING WORK Asbestos Policy R1.0 09.04.09 Page 35 of 51

SECTION 2 Information for BUILDING OCCUPIERS/ EMPLOYEES/ SECURITY STAFF A1 Introduction Many Buildings within the UK are known to have asbestos materials used in their construction and assessment for asbestos has been carried out and is given in the asbestos register (Appendix 4) An asbestos register provides relevant information to individuals likely to disturb asbestos (workmen, contractors and in-house staff). The Register is a useful tool for managing the risks from ACMs and supports the ongoing development of policies and procedures outlining the dutyholders approach towards the management of asbestos. Occupiers Employers and Staff Staff and contractors are not expected to work with or be exposed to asbestos on this property and unauthorised activities which give rise to airborne dust (e.g. abrasion, breaking, sawing, cutting, drilling or machining) are NOT PERMITTED on asbestos materials. A2 'Duty to Manage' Requirements The dutyholders for this property have an asbestos management plan which will provide a long term and ongoing approach to asbestos and its risks. In the first instance, immediate actions have been undertaken and include the following preliminary procedures: take reasonable steps to find materials likely to contain asbestos presume materials contain asbestos, unless there is strong evidence they do not assess the risk of anyone being exposed to asbestos from these materials make a written record of the location and the condition of the Asbestos Containing Materials (ACMs) and/or presumed ACMs and keep it up to date provide information on the location and condition of ACMs to anyone who could disturb them as part of their work INFORM VISITING CONTRACTORS AND WORKMEN OF ASBESTOS BY PRESENTING THEM WITH THIS DOCUMENT Asbestos Policy R1.0 09.04.09 Page 36 of 51

Building Occupiers and Employees also share responsibility and are responsible for: ensuring that any activity that may disturb or damage asbestos containing materials is avoided reporting to their designated representative any suspect asbestos material where the material has been disturbed or damaged, or where staff are likely to undertake activities which may affect such material ensuring the Asbestos Management Procedures are abided by when activities are undertaken that may disturb asbestos containing materials Occupiers Employers and Staff A3 What Premises are Affected Regulation 4 of CAWR 2002 applies to non-domestic premises, irrespective of the type of business that is carried out in them. It also relates to common areas of domestic premises such as lift shafts, service risers, stairs and corridors. This site is assessed applicable to Regulation 4 of CAWR 2002. A4 Actions Undertaken Implementation of an asbestos management plan Conduct of desk top reviews to assimilate any information already known concerning asbestos containing materials that may be present. Prevent work on the premises that may disturb the building fabric and identify any damaged materials Keep under review the asbestos risk assessment and carry out Type 2 Asbestos survey where necessary Consolidate and review the management plan IF SUSPECTED ASBESTOS MATERIALS ARE ACCIDENTALLY DISTURBED, PLEASE REFER TO THE RED SECTION (SECTION 3) OF THIS DOCUMENT Asbestos Policy R1.0 09.04.09 Page 37 of 51

SECTION 3 Dealing with ACCIDENTAL RELEASE OF ASBESTOS FIBRES Emergency Procedure In the event of an uncontrolled release of asbestos fibres, the Control of Asbestos at Work Regulations (CAWR) require all persons to be kept away from the affected area. An adequate assessment is required and an emergency action plan should be followed. Emergency Procedure Asbestos Policy R1.0 09.04.09 Page 38 of 51

Step 1 Step 2 Step 3 Immediately clear the area of all personnel and isolate the area, such as a single room, by closing the door and taping all the doors. Seal off any air conditioning. Prohibit access to the area. Inform the designated person(s) below immediately: Emergency Contact For This Building Name Contact Details/ Emergency Number Name Contact Details/ Emergency Number Step 4 If the emergency contact is unavailable, inform the property representative, your Line Manager, Safety Officer, Building Manager or Client Representative. If these people are unavailable and/or you require advice urgently, please contact Thames Laboratories: If further advice is required please contact an asbestos competent organisation THAMES LABORATORIES Freephone 0800 085 2348 www.thameslabs.co.uk Step 5 The designated asbestos representative or its agent e.g. Thames Laboratories, will access the area using appropriate control measures and decide on a further course of action. Asbestos Policy R1.0 09.04.09 Page 39 of 51

APPENDIX 1 Asbestos Materials in This Property Asbestos Register Important Notice Certain asbestos surveys DO NOT identify ALL asbestos materials and ACMs concealed within the structure of the building may not be specified in the register Only type 3 surveys are suitable if you are carrying out refurbishment, other building improvements or demolition works. Other survey types given overleaf should be assumed limited in its scope to mainly surface materials only and excluding the building fabric. CONCEALED ASBESTOS MATERIALS SHOULD BE ASSUMED PRESENT Check the survey limitations and inaccessible areas in relation to your particular work area. If your work reveals any unknown but suspected ACMs, stop work immediately. Asbestos Policy R1.0 09.04.09 Page 40 of 51

Asbestos Register sample Known or Presumed Asbestos Materials Building Main Building Floor Location/ Description Room External to Building Material Type In House Asbestos Type:- Building Main Building Floor Location/ Description Room External to Building Material Type In House Asbestos Type:- Building Main Building Floor Location/ Description Room External to Building Material Type In House Key Information Asbestos Type:- A.C.M. - Asbestos Containing Material Crocidolite Blue Asbestos Chrysotile White asbestos Regulations Legal Requirements Amosite Brown Asbestos Sampling Collection & analysis of materials for asbestos Asbestos Insulation Board, Spray, Coatings Specialist laws apply here - only specialists are allowed to work on these materials Asbestos Policy R1.0 09.04.09 Page 41 of 51

Asbestos Register specimen Known or Presumed Asbestos Materials Building Main Building Floor Location/ Description Room External to Building Material Type In House Asbestos Type:- Building Main Building Floor Second Floor Room Rooms Location/ Description Material Type Thames Labs Asbestos Type:- Building Main Building Floor Second Floor Room Rooms Location/ Description Material Type Thames Labs Asbestos Type:- No Asbestos Detected Key Information A.C.M. - Asbestos Containing Material Crocidolite Blue Asbestos Chrysotile White asbestos Regulations Legal Requirements Amosite Brown Asbestos Sampling Collection & analysis of materials for asbestos Asbestos Insulation Board, Spray, Coatings Specialist laws apply here - only specialists are allowed to work on these materials Asbestos Policy R1.0 09.04.09 Page 42 of 51

Exclusions to the Survey These are SUMMARY findings of an asbestos survey inspection Consult the MAIN SURVEY REPORT if undertaking major work or further information is required Type 1 and Type 2 survey results should be assumed limited in scope to surface materials only - exclusions to the building fabric and other specific exclusions will apply. Examples of such limitations have been given overleaf in Additional Materials Found During a Type 3 Survey. General Limitations No access or attempts to gain access have been made where this would necessitate the use of specialist tools or equipment, or where it is believed damage to fixtures or fittings would occur. No inspections have been made of lift shafts, plant rooms or plant area where the attendance of specialist engineers is required No plant or equipment would have been dismantled during the inspection unless specifically addressed within the report. No inspections have been made to elements where this would necessitate the removal of fixtures, fittings or furniture unless specifically referenced within the report. Concealed spaces, unless specifically referenced within the report, should be regarded as having not been accessed. Where materials have been identified yet the sampling of these materials is considered to create an unnecessary danger to the surveyor, or materially affect the properties of the item to which the suspect material has been applied, then sampling of the product would not have been undertaken. For example, items will include gaskets, flange joints and electrical flash guards. A limited inspection would have been undertaken of any pipe work or vessel insulated with a nonasbestos product. Asbestos Policy R1.0 09.04.09 Page 43 of 51

The survey has been carried out with using step ladders to access materials that are generally beyond the reach of the surveyor. Accordingly, the survey is typically restricted to elements less than 3 metres in height (unless specifically noted) e.g. roofing elements. Inspections were not carried out in risers or other voids unless specified Asbestos Policy R1.0 09.04.09 Page 44 of 51

Asbestos Register Sketch Plans Please Note: Sketch plans given overleaf,where provided, support information to the asbestos register. However,the asbestos register must be consulted in its entirety to gain all critical information, and under some circimstances, the primary survey report will need to be reviewed, especially in relation to any major works disturbing the fabric of the building. Asbestos Policy R1.0 09.04.09 Page 45 of 51

Asbestos Register Areas which could not be accessed Site Building Floor Room/Space Description Reason Asbestos Policy R1.0 09.04.09 Page 46 of 51

Asbestos Register Additional Materials That Can be Found During a Type 3 Survey Concealed within ceiling voids - Asbestos insulation board packing behind I-beams Concealed above interlocking suspended ceiling grid asbestos insulation board fire break Hidden behind fibreboard wall partition asbestos felt damp proof membrane Asbestos floor tiles under applied carpet tiles Asbestos Policy R1.0 09.04.09 Page 47 of 51

Asbestos Register Additional Materials That Can be Found During a Type 3 Survey Asbestos lagging residues to pipe work within floor duct widespread loss of the insulation due to repeated flooding of this duct resulted in collection of extensive quantities under the boiler house Asbestos lagging found to pipe-work entering floor within a riser boxing Asbestos pipe lagging found in void within concrete floor slab Asbestos woven flashguards to fuseboxes Asbestos Policy R1.0 09.04.09 Page 48 of 51

Asbestos Register Additional Materials That Can be Found During a Type 3 Survey Asbestos cement debris to loft eaves revealed after lifting glassfibre insulation Loose fill insulation under floor boards in this case surrounding cabling/ pipes Asbestos insulation board lining to back of heater casings Asbestos insulation board firebreak within ceiling void Asbestos Policy R1.0 09.04.09 Page 49 of 51

Asbestos Register Equipment with Asbestos This is not an exhaustive list, and the presence of ACMs should be suspected in any equipment, especially where the properties of asbestos would be beneficial. Use of asbestos products were gradually stopped, but a comprehensive prohibition did not occur until 1999. Typical applications include : Insulation of pipes, boilers, pressure vessels, calorifiers etc. Heat insulation and Fire protection in switchgear. Electrical/Heat insulation of electrical equipment,wiring, ovens etc. Accoustic linings in air handling equipment; duct and pipe insulation. Lagging, jointing, packing materials for heat resistance or fire protection. Cloth used as thermal insulation and lagging, including blankets,mattresses, protective curtains, gloves, overalls (including aluminium coated). Gaskets and washers. Strings e.g. for sealinghot water radiators. Friction products e.g. brakes and clutch plates. Drive belts and conveyor belts. Laboratory worktops. Flue pipes, extractor hoods. Underseals. Asbestos gloves or those with asbestos lining. When working on equipment, further information may be required in addition to that provided within the asbestos register, and clarification should be sought. Asbestos Policy R1.0 09.04.09 Page 50 of 51

APPENDIX 2 Contractor Signing Page I have followed the WHITE sections in this document recognising my responsibilities while working within this building. I have read the document in relation to the proposed work area and my work activities will not affect asbestos materials. If I am not sure about how my work affects asbestos, I shall contact my supervisor, the property representative or their agent. If I find that my work does affect any identified or unknown, suspected asbestos material, I will stop work immediately and inform the site contact or my supervisor. Asbestos Contact For This Building Name Contact Details/ Emergency Number Name Contact Details/ Emergency Number Time Date Company Signature Print Name Asbestos Policy R1.0 09.04.09 Page 51 of 51

Contractor Signing Page (Continued) Time Date Company Signature Print Name Page Asbestos Policy R1.0 09.04.09 Page 52 of 51