POLICY ON THE CONTROL OF ASBESTOS AT WORK Review date: 27/10/2018 Reviewer: Compliance Officer Circulation for comment: Technical Services Manager Works Supervisor Building Supervisor Data Coordinator Compliance Officer Uist and Barra Hospital Saint Brendan s Hospital Health and Safety Adviser 1
1.0 INTRODUCTION 1. The Western Isles NHS Board has adopted a policy on the control, including identification, handling and disposal, of ACMs in the workplace. The objective of the policy is to ensure that proper arrangements are made for the health, safety and welfare at work of all persons who may come into contact with substances known or thought to be of asbestos origin. 2.0 STATUTORY REQUIREMENTS 2.1 The policy is in accordance with the provisions of a. Health and Safety at Work etc. Act 1974 b. Management of Health & safety at Work Regulations 1999 c. Workplace (Health, Safety and Welfare) Regulations 1992 d. Control of Asbestos at Regulations 2012 e. Control of Substances Hazardous to Health Regulations 2002 2.2 The policy is also in accordance with the HSE Approved Code of Practice on the Control of Asbestos at Work 2002. 3.0 POLICY ON ASBESTOS CONTAINING MATERIALS IN HEALTH BOARD PROPERTIES 3.1 All reasonably practicable steps will be taken to ensure that Health Board employees, tenants and sub-contractors working of behalf of the Health Board will not be exposed to hazards associated with Asbestos Containing Materials (ACMs). 3.2 A systematic programme of surveying all Health Board-owned or occupied property by the Estates Department for the presence of ACMs is in plcae. 3.3 All survey information should be supplemented and amended as necessary after any subsequent survey, removal or treatment of ACMs. 3.4 It is presumed that materials suspected to contain ACMs should be treated as such, unless there is strong evidence to suppose they do not. 3.5 Risk assessments will be undertaken to assess the risk of the likelihood of anyone being exposed to asbestos from these materials. 3.6 The Health Board will maintain an Asbestos Register for all its premises highlighting premises where ACMs is found and its condition. The Asbestos Register will be made available to all interested parties on request. 3.7 No asbestos-based materials shall be purchased, used in construction, treatment or repair of any Health Board-owned property. 3.8 Approved licensed asbestos removal contractors accredited by the United Kingdom Accreditation Service (UKAS) will carry out all work involving ACMs. 2
3.9 All work involving ACMs will be carried out in accordance with current legislation, guidance notes and codes of practice issued by the Health and Safety Executive. 3.10 All work involving ACMs will be notified to the Estates Department and the person in charge of the premises. An assessment will be required for all work with ACMs. If however the work is of a repetitive nature, one assessment will be suitable. Assessments require approval by the Estates Department prior to the start of any work with ACMs. The Authorised Person who will undertake the work will be issued with an appropriate Estates Permit to Work. 3.11 Health Board tenants employees and anyone who will be affected by the work will be formally notified before any contract for the removal of ACMs is undertaken. 3.12 An effective system of vetting the suitability of applicants for inclusion on Health Board s standing list of contractors will be operated, along with a suitable monitoring scheme for recording contractor performance. 3.13 All monitoring and sampling shall be carried out at an accredited UKAS laboratory. 3.14 The Health Board policy will be made available to employees and information on ACMs will be made available when requested. 3.15 All information held by the Health Board in connection with ACMs in Health Board owned premises is available to the occupiers of such premises and also to any contractors employed by the Health Board. 4.0 TRAINING 4.1 The Health Board undertakes to provide training for all new employees who may encounter ACMs in the course of their duties and regular refresher training for all employees who may encounter ACMs. 5.0 ARRANGEMENTS FOR DEALING WITH ACMs OR MATERIAL THOUGHT TO CONTAIN ASBESTOS 5.1 The arrangements for dealing with ACMs or materials thought to contain asbestos in Health Board-based property are as follows. a. When the Estates Department (with the assistance of the Health & Safety Adviser) are asked for advice relating to materials thought to contain asbestos, the advice given will vary according to the circumstances, but will largely follow the under noted pattern: (i) (ii) Working with or on the suspect material must be suspended until the situation is investigated. Samples must be taken by a Competent Officer, or on certain occasions, by an Asbestos Removal Contractor. 3
(iii) (iv) The sample will then be submitted for analysis. The condition of the material, whether "hard", "fragile" or already in a "powdery" state if found to contain asbestos will be considered before action is taken either to: protect/enclose; seal/encapsulate; repair remove; label or colour code the ACMs. (b) The results of the analysis will be studied and when asbestos is present, licensed Asbestos Removers may, if thought necessary, be contacted for advice as to treatment or removal. When the work is put out to tender the Contractors must submit Work Method Statements. Notification to the Health and Safety Executive may be required before work commences. (c) These arrangements will be carried out by the Estates Department as the lead Department on behalf of the Health Board. (d) Clearance tests must be carried out on completion of the ACMs treatment or removal exercise and before the area concerned can be considered 'safe' or 'clean'. (e) Arrangements for disposal of the ACMs waste must be made by the Asbestos Removal Contractor with the approval of the Health Board as producer of the waste. All ACMs waste requires to be deposited at a landfill site licensed to receive same. (f) Where required, clearance testing, both by visual inspection and by air sampling, should be carried out by the Estates Department, with the assistance of an accredited UKAS laboratory. 6.0 ARRANGEMENTS FOR IMPLEMENTATION OF POLICY 6.1 The arrangements detailed below consist of a series of procedures which are intended to safeguard persons who may encounter the possibility of discovering ACMs in the course of their work and to ensure the safety of any premises occupants who may be affected by any associated works which may involve the disturbance of material containing asbestos fibres. 7.0 RISK ASSESSMENT 7.1 Risk assessment procedures require to be used to identify and control any possible exposure to ACMs fibres. It is important to note that unlike other risk assessments, removal of the material may present a greater hazard than leaving it in situ and undisturbed. 4
7.2 Asbestos in any form represents a potentially serious risk to health and it is important that staff are aware of the correct methods to be carried out to: a) Source information on premises with identified ACMs on site b) Consider the content of risk assessment information c) Arrange for surveys where appropriate to determine the presence of ACMs prior to undertaking alteration works. d) Arrange for the taking and analysing of (suspected) ACMs samples. e) Arrange for tenders to encapsulate or remove ACMs. f) Include for appropriate supervision of removal works where necessary. g) Record and distribute results of ACMs related information. 8.0 Safe Systems of Work 8.1 Use of competent staff. 8.2 Surveys to be undertaken by people with appropriate accreditation /certificate. 8.3 For ACMs removal, appoint an approved contractor. 8.4 Produce a risk assessment. 8.5 Manage the risk. 9.0 Action sequence for works where ACMs may be encountered. 9.1 Conduct a Risk Assessment. 9.2 Inform line manager and post notice on suspect material. 9.3 Arrange for Survey / Samples. 9.4 Record results of analysis. 9.5 Issue written notification of result to line manager. 9.6 Decide action Encapsulate, Remove, Leave undisturbed. 9.7 Exclude work activity / evacuate occupants from area, if urgently required. 9.8 Seek tenders for ACMs related works form approved contractors only. 9.9 Receive plan of work and issue acceptance to (Licensed) Contractor. 9.10 Notification to HSE before removing any ACMs. 5
9.11 On completion of works, update asbestos register. 6
10.0 ACMs PROCEDURES FLOWCHART (From issue / receipt of Notification of ACMs pro - forma) Initial Risk Assessment Check Asbestos Register ACMs Likely Post Notices Carry out Risk Assessment Inform Line Management Invitation Letter Acceptance Letter Survey Sample Analysis Record Information Asbestos Register ACMs Action Diary ACMs Known Quotation to Tender Acceptance letter Issued Carry out work & Update Register ACMs plan of work agreed Assessment by Asbestos Licensed Contractor HSE Approval 7
11.0 ACMs SURVEY PROCEDURE 11.1 Objective 11.1.1 The objective of this procedure is to ensure persons who may encounter ACMs during the course of their work are aware of the tasks to be implemented to ensure a safe system of work. Also to set out the methods of safe working practice to avoid or minimise risks to health and safety when an ACMs survey is to be undertaken. 11.1.2 Competent persons will only undertake survey work and analysis of samples will only be undertaken by a UKAS accredited laboratory. 12.0 ACMS SAMPLING PROCEDURE 12.1 Objective 12.1.1 The objective of this procedure is to ensure that any sampling of ACMs or suspected ACMs is carried out using a safe system of work to avoid or minimise risks to health and safety. 12.2 Control Measures 12.2.1 Sampling will only be undertaken by competent persons and only in conditions where it is safe to do so. 13.0 ASBESTOS REGISTER AND RECORDING PROCEDURE 13.1 Objective 13.1.1 The objective of this procedure is to ensure that persons encountering ACMs during the course of their work are aware of the communication and recording procedures. The register will be readily accessible so it can be consulted prior to the authorisation of maintenance or remedial work. 13.1.2 The location, description and condition of all known ACMs in Health Board owned or occupied premises are to be made available in an Asbestos Register. 13.2 Control Measures 13.2.1 The Estates Manager shall act as a single point of contact to receive information on ACMs in respect of all Health Board owned or occupied properties. 13.2.2 Measures are stated within this procedure to confirm and control the format of information in the Asbestos Register. No entries shall be made in the register unless the minimum information required has been completed. 8
13.2.3 Maintenance contractors and others who may encounter ACMs on Health Board premises will be reminded on a periodic basis of the necessity to report the presence of ACMs to ordering / supervising officers. 13.3 ACMs Recording Procedure. 13.1 The circumstances giving rise to the necessity to record ACMs information can arise from: a) Emergency incidents. b) Discovery of ACMs during pre-planning examinations, surveys or construction/repair works in progress. c) Deterioration of condition of currently known ACMs. d) Programmed removal/encapsulation of ACMs. e) Variations to instructed work related to ACMs removal. 14.0 ASBESTOS REGISTER 14.1 The register will show the following details: a) UKAS accredited laboratory sample identifier b) Property type c) Location of ACMs d) Type of ACMs e) Condition. f) Minimum action required g) Priority 14.2 Availability of use 14.2.1 The master copy of the register will be maintained and updated by the Estates Department. A complete set for Uist and Barra properties will be retained at Uist and Barra Hospital, Balivanich and Saint Brendan s Hospital, Isle of Barra. 14.2.2 Where a building on the register is in multiple occupancy, a copy of the entry will be sent to person in control of premises. 14.3 Procedure for changes 14.3.1 All updates will be carried out by the Estates Department. 14.3.2 Refer to other policy and procedures for management of Hard Copy information. 9
14.4 Monitoring arrangements 14.4.1 All actions concerning ACMs related work and procedures are to be recorded. 14.4.2 Where work has been instructed to be carried out, the Estates Department will monitor progress and ensure that proper procedures are followed and all recording points have been actioned. 15.0 INFORMATION FOR CONTRACTORS 15.1 Where ACMs have been identified on any site, the details of the ACMs and precautions to be taken will have been given to the responsible person in charge. 15.2 Where Contractors come on to site, they are under standing instructions to report their presence and identify the tasks that they are to carry out to the responsible person in charge. 15.3 Where the work is being carried out in the vicinity of known ACMs the responsible person in charge will ensure that the appropriate Permit to Work notice for that location is issued to the contractor. 15.4 Where the repair work is liable in any way to cause breakage or disturbance to known ACMs, the Property Person in Charge raising the requisition will ensure that a copy of a Hazard Notification is issued along with the Works Order and will record the details of the works order. 15.1 Contents 15.1.1 The hazard notification will show the following details: a) ACMs position b) ACMs form c) Condition. d) Guidance 15.2 Monitoring arrangements 15.2.1 All actions concerning ACMs related work and procedures are to be recorded. 15.2.2 Where work has been instructed to be carried out, the Estates Department will monitor progress and ensure that proper procedures are followed and all recording points have been actioned. 15.2.3 Estates Officers will be contacted on a periodic basis to ensure contractor compliance with reporting procedures. 10
16.0 ASBESTOS LICENSED CONTRACTOR SELECTION PROCEDURE 16.1 Objective 16.1.1 The ensure that the selection of Licensed Asbestos Contractors is made by considering the competence and experience of the Licensed contractor in relation to the complexity and extent of work with ACMs proposed to be undertaken. 16.2 Procedure 16.2.1 The initial preliminary selection of contractors will be made from the Standing Approved Lists of Contractors. Experience has shown however that the circumstances of contractors can alter significantly from the time of their initial incorporation on Standing Lists. 16.2.2 Contractors selected for the provisional list of tenderers will be asked to produce the following documentation before being confirmed on the final proposed list. a) Current HSE Licence Registration details b) Licensed Waste Carrier Registration details c) Confirmation of availability of medical records of personnel d) Institution / Organisation memberships. e) Contact details for two current referees f) A copy of a recent method statement for work of a similar nature. 11