Policy for the Management of Asbestos

CARDIFF AND VALE NHS TRUST YMDDIRIEDOLAETH GIG CAERDYDD A R FRO Policy for the Management of Asbestos Author Keith Jones Estate Controls Assurance Officer / Environmental Management Co-ordinator Policy ratified by Trust Board Date : September 2004 Responsible Officer (Lead of Group) Director of Corporate Management Peter Welsh Classification Health and Safety Date Issued : October 2004 Area Applicable Trust wide Review Date : October 2007 Ref No: 114 Version No: 1 Disclaimer When using this document please ensure that the version you are using is the most up to date either by checking on the Trust database for any new versions or if the review date has passed please contact the author. OUT OF DATE POLICY DOCUMENTS MUST NOT BE RELIED ON Ref: 114 Page 1 of 13 Version No: 1

- CONTENTS - Section Title Page No. 1. INTRODUCTION 3 2. LEGAL REQUIREMENTS : 4 2.1 Employers General Duties 4 2.2 Employers Specific Duties 4 2.3 Employees General Duties 5 2.4 Employees Specific Duties 6 3. TRUST RESPONSIBILITY 6 4. DELEGATED RESPONSIBILITY 6 5. MAIN SAFETY OBJECTIVES 7 6. MONITORING OF PERFORMANCE 8 7. RESOURCES 9 8. TRAINING REQUIREMENTS 10 9. REFERENCE SOURCES AND GUIDANCE 11 Appendix 1 : ASBESTOS - Organisational Relationships 13 Ref No: 114 Page 2 of 13 Version No. 1

1. INTRODUCTION Asbestos fibres are a potentially harmful substance found throughout the work place. It is a general term for a variety of silicates of iron, magnesium, calcium, sodium and aluminium which naturally exist in fibrous form. The Asbestos (Licensing) Regulations 1983, Control of Asbestos at Work Regulations 2002 define Asbestos as any of the following minerals or any mixtures containing any of them - crocidolite, amosite, chrysotile, fibrous anthophyllite, fibrous actinolite and fibrous tremolite. Asbestos is considered as a notable occupational health hazard. The health risks involved are associated with the inhalation of fibrous dust and its dispersion within the lungs and other parts of the body and are enhanced when the Asbestos dust is combined with air borne pollutants such as those absorbed by the body when smoking. Unlike many other occupational diseases, Asbestos - related disease manifest themselves over a long latent period of around forty years. As a consequence of that, the present numbers of disease and deaths are attributable to past control methods and to dust levels which obviously were injurious and much too high. In the light of the knowledge of the harmful effects of exposure to Asbestos fibrous dust, industry has been galvanised into producing safer alternatives but unfortunately asbestos is still around in large quantities in the form of cladding, sheet boards and pipe-work insulation which can be found throughout hospitals and other health care premises. This Asbestos Policy and supportive Asbestos Operational Procedure and specific local house rules are the Trust s response to meet the requirements of providing a safe system to manage asbestos within the Trust s properties. An Asbestos Register is maintained which identifies all known locations where asbestos containing material are present. Ref No: 114 Page 3 of 13 Version No. 1

2.0 LEGAL REQUIREMENTS 2.1 EMPLOYERS - General duties under the Health and Safety at Work etc., Act 1974 (HSWA) The general duty of employers under the Health and Safety at Work etc., Act 1974 applies generally to working with Asbestos as it applies to other kinds of work. The act places a duty on every employer to ensure so far as is reasonably practicable, the health, safety and welfare at work of all his employees (HSWA 2(1)) moreover all employers must: a). b). c). d). e). Provide and maintain plant and systems of work that are, so far as is reasonably practicable, safe and free from health risks (HSWA 2(2)(A)). Make arrangements for ensuring, so far as is reasonably practicable, safety and absence of health risks in connection with the use, handling, storage and transportation of articles and substances. (HSWA 2(2)(B)). Provide such information instruction, training and supervision as is necessary to ensure so far as is reasonably practicable, the health and safety at work of their employees [HSWA 2(2)(C)]. Provide a safe working environment [HSWA 2(2)(E)]. Those in control of premises must ensure that they are safe and that any plant or substances do not endanger health (i.e. of patients, staff or visitors etc.,) HSWA. sect.4. 2.2 Employers - Specific legal requirements - The Control of Asbestos at Work Regulations 2002 ( Regulation 4 ) No employer shall carry out work which exposes, or is liable to expose their employees to asbestos containing materials - ACMs unless first : a) Take reasonable steps to find materials likely to contain asbestos b) Presume materials contain asbestos, unless there is strong evidence to suppose they do not. Ref No: 114 Page 4 of 13 Version No. 1

c) Assess the risk of the likelihood of anyone being exposed to asbestos from these materials. d) Make a written record of the location and the condition of ACMs and presumed ACMs and keep it up to date. e) Repair or remove any material that contains or is presumed to contain asbestos, if necessary, because of the likelihood of disturbance, and its location or condition. f) Prepare a plan to manage that risk and put it into effect to ensure that : Information on the location and condition of ACMs is given to people who may disturb them during work activities Any material known or presumed to contain asbestos is kept in a good state of repair. g) Monitor the condition of ACMs and presumed ACMs. h) Review and monitor the action plan and the arrangements made to put it in place. (Other legal requirements are laid down in other related regulations to be found in Section 8 - Reference Sources and Guidance) 2.3 Employees - General duties under the Health and Safety at Work etc., Act 1974 By virtue of Section 7 of the Health and Safety at Work Act, employees are under a duty to take reasonable care of their own and others 'safety' when handling and using substances hazardous to health as well as during any other work activity. Employees must also co-operate with their employer so far as is necessary to enable that employer to comply with any statutory duty or requirement, e.g. by following safe systems of work and by using and/or wearing personal protective equipment. Ref No: 114 Page 5 of 13 Version No. 1

2.4 Employees - Specific legal requirements - The Control of Asbestos at Work Regulations 2002 1. Every employee exposed to asbestos above "action level" must: a) Make full and proper use of any control measures, personal protective equipment or other facility provided by the employer. b) Report any defect in personal protective equipment or control measure to the employer. 2. Not enter/remain in asbestos areas or respirator zones unless their work permits them to do so. 3. When required by their employer, present themselves, during working hours, for medical examination/checks. 3.0 TRUST RESPONSIBILITY The Trust acknowledges and accepts its responsibility to implement in full the safe management of asbestos containing materials in Trust premises. It is the policy of the Trust to treat all asbestos as hazardous and to remove or control that hazard in accordance with statutory regulations in force. That removal will be undertaken by licensed specialist contractors, and in only exceptional emergency situations that maintenance staff will become involved in handling asbestos. In such a situation, the handling would be carried out under adequate supervision, by trained members of the maintenance staff properly equipped to do so safely. 4.0 DELEGATED RESPONSIBILITY The Trust delegates to the Chief Executive, responsibility for the safe management of asbestos. In practice, the responsibility is designated to the Chairperson of the Trust s Health and Safety Committee, who has responsibility for Health and Safety / Risk Management within the Trust. Ref No: 114 Page 6 of 13 Version No. 1

The Chairperson of the Trust s Health and Safety Committee will appoint an Asbestos Co-ordinator, from whom advice and information on asbestos can be sought. [An organisational chart for the management of Asbestos is illustrated in Diagram 1 on page 13] The Asbestos Co-ordinator person will act on notification that asbestos has been located or is suspected of being present and will: a) Establish the presence or other wise of asbestos; b) Will carry out a risk assessment; c) Will arrange to remove or adequately control the hazard; d) Will review the assessment periodically or sooner if there is valid reason to do so; e) Will maintain records and a register of asbestos where removal has not been carried out; f) Will keep management and accredited staff health and safety representatives informed on matters concerning asbestos. 5.0 MAIN SAFETY OBJECTIVES a) To protect patients, staff and the general public from all known deposits of asbestos containing materials on the Trust's premises and sites. b) To monitor the condition and to keep safe from all persons all known deposits of asbestos of the Trust's premises and sites. Ref No: 114 Page 7 of 13 Version No. 1

c) To ensure, that when it is essential and necessary for continuing patient care, then only competent persons, adequately protected with safety equipment are exposed safely to asbestos. d) To maintain a register of asbestos containing materials complete with its location and analytical identification of the types of asbestos on each site. e) To maintain a register of approved asbestos removal companies. f) To provide regular up to date training for all competent staff who may have reason to work on or near asbestos in the event of an emergency arising in the interests of continuing patient care. 6.0 MONITORING OF PERFORMANCE The Asbestos Co-ordinator shall ensure: a) That only approved contractors with medically fit staff will be allowed to interfere or remove asbestos from the site. b) That no disturbance of any of the asbestos deposits occurs unless it is essential for continuing patient care. d) That safe and reliable equipment is readily available at all times so that only competent persons can work with or near asbestos in a safe manner. e) That all staff whose duties may incur exposure to asbestos containing materials have regular up to date asbestos awareness training. f) That the register of known deposits of asbestos and plan of each of the Trust's sites showing the locations of asbestos is regularly up dated when either asbestos is removed or new deposits are discovered. Ref No: 114 Page 8 of 13 Version No. 1

g) When asbestos deposits are removed from site by competent approved contractors, then an air test certificate must be completed and kept on file showing that the location of removed asbestos is now free from asbestos. The name of the authorised refuse tip to which the removed asbestos is deposited must be retained on file. 7.0 RESOURCES In order to meet the full obligations of the Control of Asbestos at Work Regulations 2002, with respect to the introduction of premises holders duty to manage from May 2004, the Trust has put in place the following initiatives in order to effectively manage asbestos containing materials - ACMs within Trust premises. a) In partnership with asbestos consultants manage asbestos data base utilising a bureau type system, with requests for information on ACMs only from authorised Trust / College personnel. b) Provide requisite on-going training seminars in support of the above for all authorised database access personnel c) Carry out periodic re-surveys of all known ACMs in Trust/College premises to ensure database is up to date. d) Update database with information received via site personnel, where ACM s have been removed, or other changed circumstances etc., utilising an agreed updating protocol. The revenue costs associated with provision of the above are of the order of 50k per annum, which is to be funded via the estate maintenance revenue allocation. Ref No: 114 Page 9 of 13 Version No. 1

8.0 TRAINING REQUIREMENTS Cardiff and Vale NHS Trust Training must be given to competent staff so that they can action the following: a) That they are capable of using the safety appliances in such a manner that they do not expose themselves and all others to the asbestos fibrous dust when they have reason to work on or near known deposits of asbestos. b) That they are capable of supervising the work of the approved asbestos removal contractors and ensuring that strict observance and adherence is made to the Trust Asbestos Operational Procedures and Protocols Manual. c) That they are capable of planning the duties involved when essential work must be actioned on or near asbestos containing materials. They must ensure adequate precautions are in place or effected, prior to work being performed on or near asbestos containing materials. That the necessary authorisation (i.e. HSE and operational Staff Managers) is obtained prior to the work being undertaken. They must be capable of monitoring and supervising the work on or near asbestos in a safe manner. They must be aware of their duties when the work is completed in that they must ensure that the asbestos is removed in appropriate bags safely from site, the disposable equipment is also removed properly, the re-usable equipment is thoroughly cleaned and safely stored for further use. An airborne dust sample of the location from whence the asbestos was removed is required. Ref No: 114 Page 10 of 13 Version No. 1

9.0 REFERENCE SOURCES AND GUIDANCE Legal provisions EEC 91/382 Protection of workers from risks related to exposure to asbestos at work. Health and Safety at Work etc. Act 1974 HMSO ISBN 0 10 543774 3 The Asbestos (Licensing) Regulations 1983 SI 1983/1649 The Asbestos (Licensing) (Amendment) Regulations 1998 SI 1998/3233 Control of Asbestos at Work Regulations 2002 SI 2675 Asbestos (Prohibitions) Regulations 1992 SI 1992/3067 Asbestos (Prohibitions) (Amendment) Regulations 1999 SI 1999/2373 Asbestos (Prohibitions) (Amendment)(N o 2) Regulations 1999 SI 1999/297 Asbestos (Prohibitions) (Amendment) Regulations 2003 SI 2003/1889 Approved Codes of Practice Work with asbestos which does not normally require a licence: Control of Asbestos at Work Regulations 2002 Approved Code of Practice 2002 (fourth edition) L27 Work with asbestos insulation, asbestos coating and asbestos insulating board: Control of Asbestos at Work Regulations 2002 Approved Code of Practice 2002 (fourth edition) L28 The management of asbestos in non-domestic premises Regulation 4 of the Control of Asbestos at Work Regulations 2002 L127 Managing construction for health and safety. The Construction (Design and Management) Regulations 1994. Approved Code of Practice HSG224 2002 Safe Work in Confined Spaces - Confined spaces Regulations 1997 Approved Code of Practice, Regulations and Guidance L101 1999 HSE Guidance Documents and Information A comprehensive guide to managing asbestos in premises HSG227 2002 Guide to the Asbestos (Licensing) Regulations 1983 (as amended) L11(second edition) 1999 Asbestos: exposure limits and measurement of airborne dust concentrations EH10 1995 (Seventh Edition) Asbestos fibres in air: sampling and evaluation by phase contrast microscopy (PCM) under the control of Asbestos at Work Regulations MDHS 39/4 2000 Training operatives and supervisors for work with asbestos insulation and coatings EH50 2001 Provision, use and maintenance of hygiene facilities for work with asbestos insulation and coatings EH47 May 2002 (Third Edition) Surveying, Sampling and Assessment of asbestos-containing materials MDHS 100 July 2001(First Edition) Asbestos in Bulk materials: Sampling and identification by polarised light microscopy MDHS77 2000 Ref No: 114 Page 11 of 13 Version No. 1

Enclosures provided for work with asbestos insulation, coatings and insulating board EH51 2002 The problems of asbestos removal at high temperatures EH57 1993 Controlled asbestos stripping techniques for work requiring a licence HSG189/1(Second Edition) 1999 Working with asbestos cement HSG189/2 (Second Edition) 1999 Introduction to Asbestos Essentials HSG213 2001 Asbestos Essentials: Task Manual HSG210 2001 Health & Safety in Roof Work HSG33 1999 (Second Edition) Health & Safety in Construction HSG150 1996 Asbestos Alert - A Workers Information Card for building, maintenance, repair and refurbishment workers IND(G)188(P) 1995 Asbestos Dust - The Hidden Killer: Essential advice for building maintenance, repair and refurbishment workers IND(G)187(L) 1995 Construction Information Sheet No 39 Construction (Design and Management) Regulations 1994: The role of the client Selection of suitable respiratory protective equipment for work with asbestos INDG288 1999 HSE Books Substitutes for Chrysotile (white) Asbestos MISC155 A short guide to managing asbestos in premises, INDG223 2002 The Selection, Use & Maintenance of respiratory protective equipment - a practical guide HSG53 Fit Testing of Respiratory Protective Equipment used for Controlling Exposure to Asbestos Fibres Information Document HSE 282/28 2000 Successful Health & Safety Management HSG65 2000 (Second Edition) Management of Health & Safety at Work ACOP & Guidance 2001 (Second Edition) Managing Asbestos in Premises INDG 223(Rev2) 2002 Working with Asbestos in Buildings INDG289 2001 Having Construction Work Done? Duties of clients under the Construction (Design & Management) Regulations 1994 MISC193 2000 Asbestos: Medical guidance note MS13 (Third edition) 1999 Other Guidance and Publications Department of Environment. Paper 18. Asbestos Wastes - Technical memorandum on arisings and disposal, including a code of practice Asbestos and man-made mineral fibres in buildings, a practical guidance DETR 1999 (Fourth Edition), ISBN 0 7277 2835 0 Operational Procedures and Protocols for the Management of Asbestos [Internal Trust document] Ref No: 114 Page 12 of 13 Version No. 1

ORGANISATIONAL CHART FOR THE MANAGEMENT OF ASBESTOS Appendix 1 TRUST BOARD EXECUTIVE BOARD EXECUTIVE RISK MANAGEMENT COMMITTEE FACILITIES SERVICE GROUP [ Estate Maintenance ] DEVELOPMENT DIRECTORATE [ Monitoring & Capital Works ] EXTERNAL ASBESTOS CONSULTANT ASBESTOS CO - ORDINATOR SUPERVISING OFFICER(S) OCCUPATIONAL HEALTH DEPARTMENT CONSULTANTS AND CONTRACTORS LICENCED ASBESTOS REMOVAL CONTRACTOR(S) ESTATE MAINTENANCE STAFF STAFF OF THE TRUST Denotes functional responsibility Denotes health surveillance responsibility Liaison /Advisory function with external Asbestos Consultant Ref No: 114 Page 13 of 13 Version No. 1