Document facilitator: Facilities Manager
Senior document owner: General Manager Corporate Services
Document number: 1.103612
Issue Date 9 April 2018
Review Date 9 April 2021
Version 1
Type:
Plan
Name:
Asbestos management plan
Purpose
The Capital and Coast District Health Board (CCDHB ) Asbestos Management Plan
provides information on how to identify, assess and control any potential health
hazard caused by the presence of asbestos identified in a building.
CCDHB is a person conducting a business or undertaking (PCBU) under the Health
and Safety at Work Act 2015 (Act). The primary duty of care in the Act requires a
PCBU to ensure the health and safety of workers as far as is reasonably practicable.
Scope
This plan applies to CCDHB workers, visitors, patients, students and contractors
engaged to work at CCDHB
Definitions
Policy content and guidelines
Asbestos Facts Asbestos1 is the name used for a group of naturally occurring minerals that are made
up of many small fibres. These fibres are very strong, and highly resistant to heat,
fire, chemicals and wear due to friction. These properties made it an extremely
popular and widely used building material throughout the 20th century.
Asbestos products are generally classed into two groups: friable and non-friable.
Friable Materials Friable materials are those that, when dry, can be crumbled, pulverized or reduced to
powder using moderate hand pressure. The use of friable materials in construction is
banned today but due to its widespread use in the past, these materials are still
present in many of our older buildings.
Non Friable Materials Non Friable refers to ACM in sound condition. Left undisturbed; it presents negligible
risk to building occupants and the general community. Therefore removal of ACM
may not be immediately necessary. However, our surveys also take into
consideration immediate health risks based on the location and condition of the ACM.
1 Asbestos is defined as a fibrous form of silicate minerals. There are two major groups of asbestos:
Serpentine - Chrysotile (White Asbestos)
Amphibole - Amosite (Brown), Crocidolite (Blue) and three other minor forms not commercially used in building materials
(Actinolite, Anthophylite and Tremolite).
Asbestos Management Plan
Page 1 of 27
ID 1.103612
Regard printed versions of this document as out of date – The CapitalDoc
document is the most current version
Document facilitator: Facilities Manager
Senior document owner: General Manager Corporate Services
Document number: 1.103612
Issue Date 9 April 2018
Review Date 9 April 2021
Version 1
The condition of any remaining ACM (such as fibre cement cladding to buildings) is
monitored and regularly inspected (at least annually) by an independent assessor.
Reasonably practical steps are taken to implement any recommendations to
eliminate or minimise health risks from these ACM
Potential Health Effects of Asbestos Asbestos has been recognized as a health hazard linked to serious, debilitating and
often fatal diseases as a result of respiration of asbestos fibres
Although the mechanism of asbestos related diseases is still not fully understood, it is
known that there is normally a long waiting (latency) period between the time of
exposure and the occurrence of disease. This latency period can typically be
between ten to over forty years. Asbestosis, Mesothelioma and Lung Cancer are the
diseases most commonly associated with asbestos exposure, although several other
diseases have been linked to asbestos exposure.
The health risk of contracting an asbestos related disease is negligible for ’office’
building workers, however the risk for maintenance workers is higher. This is
because maintenance workers are more likely to come into contact with and disturb
ACM in the normal course of their work.
Regulatory Requirements
The Asbestos Regulations require a PCBU with management or control of the
workplace (in this case CCDHB in respect of its workplace and in some cases
together with other parties) to ensure:
so far as is reasonably practicable, that all asbestos or ACM giving rise to a
risk at the workplace is identified;
the presence and location of asbestos or ACM identified at the workplace are
clearly indicated;
the Asbestos Management Plan for the workplace is prepared and that the
information in the Asbestos Management Plan is kept up to date;
and the plan is reviewed and revised
Provision for re-inspection and re-evaluation of all identified asbestos or ACM
that are isolated or encapsulated on a regular, scheduled basis.
The CCDHB Asbestos Management Plan
Overview
The Asbestos Management Plan includes:
Processes to identify asbestos or ACM including the establishment of an
electronic asbestos register which identifies the materials that contain or are
presumed to contain asbestos across all CCDHB sites
A decision-making and risk management framework about work with
asbestos or ACM
Work procedures, general work practices and training to facilitate the
implementation of the Plan, including procedures for accessing the Asbestos
Register and managing incidents or emergencies involving asbestos or ACM
at the workplace
The establishment of the position of Asbestos Management Officer to
implement the plan
Information about the workers who carry out work involving asbestos
Asbestos Management Plan
Page 2 of 27
ID 1.103612
Regard printed versions of this document as out of date – The CapitalDoc
document is the most current version
Document facilitator: Facilities Manager
Senior document owner: General Manager Corporate Services
Document number: 1.103612
Issue Date 9 April 2018
Review Date 9 April 2021
Version 1
The CCDHB Asbestos Management Plan contains three parts:
Part 1 - Strategy
The strategic component of the plan outlines the responsibilities of the Asbestos
Management Officer in regards to management, response, worker safety and
monitoring and reporting activities related to asbestos or ACM
Part 2 - Communications
This part outlines responsibilities and objectives in relation to the management of
information about asbestos, and how that information is communicated internally and
externally. It includes
The Asbestos Register
Internal communications
External communications including past workers and external agencies
The Asbestos Management Plan is a live document that should achieve the following
outcomes
Giving workers and contractors the best available information in order for
them to make the best possible decisions.
Providing a framework and processes for information to flow from source to
user in a timely and useful way
Part 3 - Operations
This part outlines procedures for identifying, inspecting and resolving matters of
unidentified and potentially asbestos containing products that may be encountered
during maintenance activities. It includes:
Safe work procedures
Worker awareness training
Ensuring Workers at risk have appropriate training.
Emergency work procedures.
Waste management
Asbestos Management Plan
Page 3 of 27
ID 1.103612
Regard printed versions of this document as out of date – The CapitalDoc
document is the most current version
Document facilitator: Facilities Manager
Senior document owner: General Manager Corporate Services
Document number: 1.103612
Issue Date 9 April 2018
Review Date 9 April 2021
Version 1
Definitions
Asbestos containing materials (ACM)
Products that are known to be built from
material containing asbestos.
Asbestos
The asbestiform varieties of mineral
silicates belonging to the serpentine or
amphibole groups of rock forming
minerals, including the following:
a) Actinolite asbestos
b) Grunerite (or amosite) asbestos (brown)
c) Anthophyllite asbestos
d) Chrysotile asbestos (white)
e) Crocidolite asbestos (blue)
f) Tremolite asbestos
g) A mixture that contains 1 or more of the
minerals referred to paragraphs (a) to (f)
of The Health and Safety at Work
(Asbestos) Regulations 2016
Asbestos Exposure Database
The Asbestos Exposure Database is a
register held by Worksafe NZ to record
anyone who has been exposed to
asbestos fibres.
Asbestos Register
The database held by CCDHB to record all
occurrences of asbestos containing
material in its premises.
Friable
Asbestos material that is in a powder form
or able to be crumbled, pulverised, or
reduced to a powder by hand pressure
when dry.
Harm
Illness, injury or both, including physical or
mental harm caused by work-related
stress.
Non-Friable
Bonded ACM that cannot be crumbled by
hand pressure alone
Protective Clothing
Specifically designed protective clothing
(including coveralls, gloves, underclothing
and boots) that is to be used or is used in
association with asbestos work that will
limit the spread of asbestos contamination
to the wearer, any other person or other
environment.
Person Conducting a Business or
A person conducting a business or
Undertaking
undertaking, whether the person conducts
a business or undertaking alone or with
others; whether or not the business or
undertaking is conducted for profit or gain.
Does not include:
A person to the extent that the
person is employed or engaged
solely as a worker in, or as an
Asbestos Management Plan
Page 4 of 27
ID 1.103612
Regard printed versions of this document as out of date – The CapitalDoc
document is the most current version
Document facilitator: Facilities Manager
Senior document owner: General Manager Corporate Services
Document number: 1.103612
Issue Date 9 April 2018
Review Date 9 April 2021
Version 1
officer of, the business or
undertaking:
A volunteer association.
An occupier of a home to the
extent that the occupier employs
or engages another person solely
to do residential work.
A statutory officer to the extent
that the officer is a worker in, or an
officer of, the business or
undertaking.
A person, or class of persons, that
is declared by regulations not to
be a PCBU.
Personal Protective Equipment (PPE)
Anything used or worn by a person
(including clothing) to:
Minimise risks to the person’s
health and safety
Reasonably Practicable
That which is, or was, at a particular time,
reasonably able to be done in relation to
ensuring health and safety, taking into
account and weighing up all relevant
matters, including:
The likelihood of the hazard or the
risk concerned occurring; and
The degree of harm that might
result from the hazard or risk; and
What the person concerned
knows, or ought reasonably to
know, about:
-
The hazard or risk; and
-
Ways of eliminating or minimising
the risk; and
-
The availability and suitability of
ways to eliminate or minimise the
risk; and
-
After assessing the extent of the
risk and the available ways of
eliminating or minimising the risk,
the cost associated with available
ways of eliminating or minimising
the risk, including whether the cost
is grossly disproportionate to the
risk.
Respiratory Protective Equipment
Air- supplied respiratory equipment such
(RPE)
as respirators and filters that comply with
AS/NZS 1716 - Respiratory protective
devices
Asbestos Management Plan
Page 5 of 27
ID 1.103612
Regard printed versions of this document as out of date – The CapitalDoc
document is the most current version
Document facilitator: Facilities Manager
Senior document owner: General Manager Corporate Services
Document number: 1.103612
Issue Date 9 April 2018
Review Date 9 April 2021
Version 1
Restricted Asbestos Work
Work in one or more of the following
categories:
Work involving asbestos, if the
asbestos concerned is friable and is,
or has been used in connection with
thermal or acoustic insulation, or fire
protection, in buildings, ships,
structures or vehicles.
Work involving asbestos, if the
asbestos concerned is friable and is,
or has been used in connection with
lagging around boilers, ducts,
furnaces or pipes.
The demolition or maintenance of
anything containing friable asbestos.
The encapsulation of material
containing friable asbestos.
The use on asbestos cement or other
bonded product containing asbestos
of:
o A power tool with any kind of cutting
blade or abrasive device, except when
use with dust control equipment; or
o Any other equipment whose use
may result in the release of asbestos
dust except when it is used with dust
control equipment
o Dry sanding of floor coverings
containing asbestos.
Worker
An individual who carries out work in any
capacity for a PCBU, including work a:
An employee; or
A contractor or subcontractor; or
An employee of a contractor or
subcontractor; or
An employee of a labour hire company
who has been assigned to work in the
business or undertaking; or
An outworker (including a
homeworker); or
An apprentice or a trainee; or
A person gaining work experience or
undertaking a work trial; or
A volunteer worker; or
A person of a prescribed class.
WorkSafe NZ
The Regulator of health and safety legislation
in New Zealand.
Asbestos Management Plan
Page 6 of 27
ID 1.103612
Regard printed versions of this document as out of date – The CapitalDoc
document is the most current version
Document facilitator: Facilities Manager
Senior document owner: General Manager Corporate Services
Document number: 1.103612
Issue Date 9 April 2018
Review Date 9 April 2021
Version 1
Part 1 - Strategy
To ensure the plan outcomes are achieved, CCDHB will create the position of
Asbestos Management Officer to carry out the following strategic functions.
To provide an on-going review process of the asbestos management plan
and system, and to provide feedback to key stakeholders
Identify and manage emerging risk areas and provide evidence of active
management
Review, endorse and support strategies to prevent asbestos incidents
To review responses to external enquiries and audits
Actively collaborate with other DHBs and encourage information sharing
In addition the Asbestos Management Officer will ensure that identification,
management, response review and worker safety of asbestos or ACM follows
regulatory requirements.
Identification
To implement the programme of works including asbestos surveys and
asbestos labelling and to provide monitoring data
Identify and manage emerging risk areas
Management
Ensure that the location and presence of suspected asbestos or ACM
throughout CCDHB properties are documented in the (online) Asbestos
Register
To ensure that ACM has been assessed for the condition, friability and
accessibility of asbestos to determine the potential for fibre release
Communicate with staff and contractors to ensure that their activities are not
disturbing asbestos or ACM
Promote that clinical and non-clinical managers undertake asbestos
awareness training
Response
To prepare and implement standardised procedures and communications
pertaining to potential health issues for incident management where exposure
to staff or contractors may have occurred
Implement a process to manage complaints or concerns in relation to
asbestos issues and the management of the communication process both
internally and supporting the communications team in external requests
Manage critical / unplanned works to achieve safe work environments
To assist in managing stakeholder expectations in relation to project delays
due to following required asbestos procedures
Develop a strategy to ensure that damaged or deteriorated asbestos or ACM
are be promptly removed, isolated or encapsulated to prevent the release of
airborne asbestos fibres.
Co-ordinate incident and accident/emergency response.
Investigate enquiries or concerns immediately and take immediate action
Asbestos Management Plan
Page 7 of 27
ID 1.103612
Regard printed versions of this document as out of date – The CapitalDoc
document is the most current version
Document facilitator: Facilities Manager
Senior document owner: General Manager Corporate Services
Document number: 1.103612
Issue Date 9 April 2018
Review Date 9 April 2021
Version 1
Worker safety
Implement and manage safe work policies, procedures and practices with
regard to working around asbestos for CCDHB workers and assist contractors
in doing the same
Ensure that the induction process for all contractors includes confirmation of
any asbestos hazard in the areas where they plan to work
Ensure that the Asbestos Register is readily available to maintenance
personnel as well as contracted trades so that they are informed about the
presence and location of asbestos or ACM
Ensure that relevant information from the Asbestos Register is provided to
CCDHB workers in a timely fashion on request
Develop and maintain written work procedures for service and maintenance
activities which may involve contact with asbestos or ACM including a
process for emergency works involving asbestos.
Manage and coordinate all asbestos removal, handling and sampling to
ensure that it is carried out by a licensed and qualified agency in accordance
with the Asbestos Regulations
Monitoring and review
Develop and implement an inspection programme to monitor the condition of
asbestos or ACM throughout the sites.
Develop a programme to formally re-evaluate any remaining ACM at regular
intervals (at least every five years). This will include reassessment of the
potential hazard, remedial action as required, an update of the Asbestos
Management Plan (if required) and Asbestos Register based on the findings
of these inspections.
Monitor and review work performed by maintenance personnel, including
contracted trades, to ensure that their work activities are not disturbing
asbestos or ACM and that any identifying tags are not being inadvertently
removed, damaged or painted
Asbestos Management Plan
Page 8 of 27
ID 1.103612
Regard printed versions of this document as out of date – The CapitalDoc
document is the most current version
Document facilitator: Facilities Manager
Senior document owner: General Manager Corporate Services
Document number: 1.103612
Issue Date 9 April 2018
Review Date 9 April 2021
Version 1
Part 2 – Information and Communications
Information about asbestos or ACM is only useful if it reaches workers, contractors or
members of the public before an incident occurs. In order to achieve the outcomes of
the plan, information must be accessible in a timely fashion.
The foundation of the information and communications part of this plan is the CCDHB
Asbestos Register, further information tools are all aimed at ensuring potential users
become aware of the ACM.
The CCDHB Asbestos Register
CCDHB’s Asbestos Register is document that contains accessible detailed records of
all surveyed locations and identified and assumed asbestos or ACM. The Register is
intended as a tool to assist trades in the identification and effective management of
asbestos across our sites. The Asbestos Register will be reviewed and updated a
minimum of once every three months by the Asbestos Management Officer.
CCDHB requires contractors, maintenance personnel and project managers to
consult the Asbestos Register prior to starting work all buildings and/or in which
asbestos or ACM has been identified or is likely to be present.
CCDHB aspiration is to develop an online-based register as part of the
implementation of this management plan. The form of the register, then, will vary
over time and it is the Asbestos Management Officer’s role to ensure version and
medium control of the Asbestos Register.
Internal communications
The Asbestos Management Officer will develop a DHB wide communication plan to
assist in raising staff awareness of asbestos and its management at our campuses.
This plan shall include:
Information Booklet
An information booklet will be produced and circulated via the intranet for all staff to
read. The booklet contains information regarding:
General facts about asbestos and its uses
The actual risk to workers / visitors / contractors at our campuses
Exposure limits
Ways to access to the CCDHB Asbestos Register
As the foundation of all asbestos management activity, the CCDHB Asbestos
Register must be accessible. CCDHB will make the Asbestos Register available to
all:
workers that carried out work at the workplace in the past;
workers currently working at the workplace;
workers intending to do work at the workplace; and
people representing workers that worked; are currently working or intend to
work at the workplace.
Emergency Services who may enter the workplace
Asbestos Management Plan
Page 9 of 27
ID 1.103612
Regard printed versions of this document as out of date – The CapitalDoc
document is the most current version
Document facilitator: Facilities Manager
Senior document owner: General Manager Corporate Services
Document number: 1.103612
Issue Date 9 April 2018
Review Date 9 April 2021
Version 1
The register is available in the following locations and formats
-
CCDHB Intranet (digital copy)
-
CCDHB maintenance management software (BEIMS) (digital copy)
-
CCDHB Facilities Management office (Helpdesk) (physical copy)
-
Contractor’s health and safety inductions (physical copy)
-
CCDHB Health and Safety Service (physical copy)
Requests by employees (including previous employees) for inspection of data held
within the Asbestos Register will be actioned as follows:
Current Employees
The CCDHB Health & Safety Policy
**DOCUMENT CONTROLLER TO INSTALL
LINK TO THIS DOCUMENT VIA INTRANET**requires that any staff member who
believes that they have been exposed to a hazard in the workplace, reports this to
their manager using the worker incident reporting system. (SQUARE)
The report must include a description of the incident leading to the potential
exposure. This is so that CCDHB has an opportunity to understand the health and
safety risk being reported and can ensure that the worker’s health is managed
appropriately. Once CCDHB has the requested report, it will provide any relevant
information from the Asbestos Register to the current employees within five business
days.
Previous Workers
It is extremely difficult to assess potential past exposures without any evidence of the
circumstances around the event.
Review of potential exposures should include:
Records of any historic incident / occurrence reports relating to potential
exposure from the previous worker who carried out work at the workplace in
the past.
review of the CCDHB Asbestos Register to determine identification
testing and ACM in area identified
review of any removal process undertaken
It will also confirm to previous workers that all asbestos removal works undertaken at
CCDHB over the years have been conducted in accordance with the relevant health
and safety regulations and recommend that if the person believes they may have
been exposed to airborne asbestos fibres, they contact their GP for an assessment
and register their details on the National Asbestos Exposure Register held by
WorkSafe NZ.
http://www.worksafe.govt.nz/worksafe/notifications-forms/asbestos/asbestos-
exposure-registration WorkSafe NZ states that
“exposure does not need to be related to paid work. If you
register on the Asbestos Exposure Database, you will receive an article on asbestos
and its associated health-related problems. If you indicate you have a family doctor,
they will be notified you are on the register. They will also be sent information about
asbestos”.
Asbestos Management Plan
Page 10 of 27
ID 1.103612
Regard printed versions of this document as out of date – The CapitalDoc
document is the most current version
Document facilitator: Facilities Manager
Senior document owner: General Manager Corporate Services
Document number: 1.103612
Issue Date 9 April 2018
Review Date 9 April 2021
Version 1
Part 3 – Operations
3.1 Asbestos Surveys As a PCBU, CCDHB has a responsibility to ensure that any asbestos or ACM on its
sites is identified and managed in an appropriate manner in accordance with the
requirements of the Asbestos Regulations.
Asbestos Management Surveys The standard asbestos surveys conducted at CCDHB owned and operated sites are
known as Asbestos Management Surveys and are carried out by an appropriately
qualified person2.
The survey purpose is to locate, as far as reasonably practicable, the presence and
location of any identified or assumed asbestos or ACM in a building which could give
rise to a risk of exposure to respirable asbestos fibres. For example, this includes
ACM that could be damaged or disturbed during normal occupancy, or foreseeable
maintenance and installation work.
Asbestos surveys and due diligence are undertaken on all leased and rented
properties to ensure that any asbestos is identified and adequately managed. As part
of the duty to co-operate and consult, CCDHB will contact its landlords and property
managers regarding asbestos, asking if they are aware of any potential asbestos or
ACM.
Demolition and Refurbishment Surveys More invasive Demolition and Refurbishment Surveys are to be completed prior to
demolition or refurbishment works if these works are likely to disturb any known or
presumed ACM. This typically involves the partial removal of walls, ceilings and floor
coverings etc. to enable the licensed asbestos assessor to gain a clear picture of the
volume of ACM that may need to be removed prior to demolition or refurbishment
works.
All ACM's identified during a refurbishment or demolition survey that are likely to be
disturbed during the works must be removed prior.
The contracts for any new building work will specifically state that asbestos and ACM
are not to be used. Any products that traditionally contained asbestos and have not
been manufactured in New Zealand or Australia will be accompanied by an IANZ or
NATA accredited laboratory certificate showing a negative result prior to being
installed. If asbestos is found in any new building material supplied then the contract
will state that the replacement and / or removal will be at the contractors cost,
including any ACM management / decontamination costs.
The results of all surveys, sample analysis, remedial work and clearance inspections
and certificates are recorded within the CCDHB Asbestos Register.
The Asbestos Regulations prohibit the carrying out, directing or allowing work
involving asbestos or ACM outside the requirements of the Asbestos Regulations.
2 There is no formal license or qualification for surveyors in NZ as of yet. A licensed assessor inspects removals, conducts
monitoring and completes clearance procedure post removal.
An appropriately qualified or competent person is allowed to complete surveys, this may not include assessors as they may not
have surveying experience
Asbestos Management Plan
Page 11 of 27
ID 1.103612
Regard printed versions of this document as out of date – The CapitalDoc
document is the most current version
Document facilitator: Facilities Manager
Senior document owner: General Manager Corporate Services
Document number: 1.103612
Issue Date 9 April 2018
Review Date 9 April 2021
Version 1
Therefore no Workers can be instructed by CCDHB to undertake any work involving
asbestos without having the relevant license, supervision or training.
Appendices A and B of this Plan set out procedures for bulk sampling and visual re-
inspection and re-evaluation.
3.2 Asbestos Identification Program (Labelling)
All work conducted on ACM must be undertaken in such a manner as to minimise
health risks.
Based on the CCDHB and Asbestos Survey Information, the Asbestos Management
Officer will initiate a labelling programme to ensure Asbestos or ACM is clearly
labelled. In this manner, we will prevent asbestos disturbance due to lack of
knowledge.
The outcome of the labelling programme is that all identified asbestos or ACM that
are not removed, have been labelled where reasonably practicable and the details
regarding location and condition are recorded in the CCDHB Asbestos Register. The
following is an example of an ACM label
Any labelled asbestos or ACM must not be disturbed by any person without approval
of the Asbestos Management Officer. Only suitably trained and qualified personnel
familiar with current asbestos safety precautions will be permitted to work on the
material.
3.3 Inspection of identified asbestos or ACM
Periodic inspections of all asbestos or ACM are required part of the CCDHB
Asbestos Management Plan. The inspections are intended to document the condition
of these materials annually or after a significant event to determine if they are
deteriorating or have become damaged since the previous inspection. Any
recommendations provided as a result of these inspections will be managed by the
Asbestos Management Officer.
3.4 Management of Asbestos Related Work Activities
Asbestos-related work activities can generate concerns among the public. An
important part of the Asbestos Management Officer role is to provide evidence-based
information and reassurance to CCDHB workers and contractors who may feel
affected by the presence of asbestos.
Asbestos Management Plan
Page 12 of 27
ID 1.103612
Regard printed versions of this document as out of date – The CapitalDoc
document is the most current version
Document facilitator: Facilities Manager
Senior document owner: General Manager Corporate Services
Document number: 1.103612
Issue Date 9 April 2018
Review Date 9 April 2021
Version 1
The Asbestos Management Officer will work with workers, contractors in addressing
their responsibilities. Work Procedures (appended) must be followed by workers and
contractors.
Workers’ responsibilities
Contractors, Maintenance Personnel and Project Managers
Contractors, Maintenance Personnel and Project Managers shall include all
contracted trades and shall:
Undertake the required induction from CCDHB Facilities Management team
Consult the Asbestos Register prior to starting work in any building or in
which asbestos or ACM has been identified or is likely to be present. If there
are any positive results, there is a requirement to carry out an asbestos risk
assessment in relation to the proposed work
If there is any uncertainty as to whether an area may be affected by asbestos
or ACM, do NOT proceed with work until you have consulted with Asbestos
Management Officer or the Facilities Manager
Ensure that all employees under their control have adequate training,
information and instruction to enable them to work safely in areas where
asbestos or ACM may be present
Not be permitted to disturb any asbestos or ACM
Stop work immediately if any suspicious material is discovered that could be
asbestos and notify the Asbestos Management Officer or Facilities
Management as soon as possible.
Ensure that all work activities relating to ACM will only proceed after being
authorized by the Asbestos Management Officer
Record and report any incidents of potential exposure to the appropriate
manager for immediate action
Only appropriately licensed removalists may complete works on ACM.
However, in exceptional cases workers must be prepared to conduct high risk
work under the supervision of a licensed asbestos removalist to ensure that
safe work methods and techniques are used to minimise the risk of potential
exposure
Ensure that any penetrations made to walls, ceilings or floors are
appropriately sealed to maintain building compliance and avoid further
potential contamination
Immediately inform the Asbestos Management Officer if damage or
disturbance of asbestos or ACM occurs during the course of their work
Not damage, remove, paint or otherwise interfere with the asbestos
identification tags
CCDHB Workers All workers shall:
Be made familiar with the type and condition of any asbestos or ACM that
may be present in their workplace and the Asbestos Management Plan,
including the labelling and identification system
Ensure that all maintenance, repair or installation and construction project
work is carried out via Facilities Management, so that all work is properly
assessed for asbestos risk
Asbestos Management Plan
Page 13 of 27
ID 1.103612
Regard printed versions of this document as out of date – The CapitalDoc
document is the most current version
Document facilitator: Facilities Manager
Senior document owner: General Manager Corporate Services
Document number: 1.103612
Issue Date 9 April 2018
Review Date 9 April 2021
Version 1
Not disturb asbestos or ACM (such as textured ceilings). This will prevent any
asbestos fibres from being released
Record any incidents of potential exposure via the appropriate CCDDHB
incident reporting system
Have all renovation, maintenance or service work that may damage or disturb
any asbestos or ACM authorized by the Asbestos Management Officer prior
to any work being carried out
Not damage, remove or paint over any of the asbestos identification labels.
Immediately inform the Asbestos Management Officer if any asbestos or
potential ACM are damaged or disturbed.
3.5 Asbestos Abatement
The following flow chart describes the process undertaken when removing asbestos
at CCDHB sites in line with the current Asbestos Regulations.
Only Class “A” asbestos removal contractors will be engaged to undertake asbestos
removal works at CCDDHB owned and occupied buildings. A contractor in this
category is permitted to remove all types of friable and non-friable asbestos items.
Procedures for licensed asbestos removal work (Appendix 7) must be followed:
Asbestos Management Plan
Page 14 of 27
ID 1.103612
Regard printed versions of this document as out of date – The CapitalDoc
document is the most current version
Document facilitator: Facilities Manager
Senior document owner: General Manager Corporate Services
Document number: 1.103612
Issue Date 9 April 2018
Review Date 9 April 2021
Version 1
Asbestos Management Plan
Page 15 of 27
ID 1.103612
Regard printed versions of this document as out of date – The CapitalDoc
document is the most current version
Document facilitator: Facilities Manager
Senior document owner: General Manager Corporate Services
Document number: 1.103612
Issue Date 9 April 2018
Review Date 9 April 2021
Version 1
References
Health and Safety at Work Act 2015
Health and Safety at Work (General Risk and Workplace Management)
Regulations 2016
Health and Safety at Work (Asbestos) Regulations 2016
Management and Removal of Asbestos - Approved Code of Practice November
2016 (Amended December 2016) WorkSafe New Zealand
Health and Safety Policy
Managing Healthcare Incidents (Reportable Events) Policy
Management of Asbestos Procedure
Appendices
Appendix 1 - Asbestos Materials Risk Assessment
Appendix 2- Asbestos Inventory & Control Method
Appendix 3 Incident Response Plan
Appendix 4: Bulk Sampling Procedures
Appendix 5: Visual Re-Inspection and Re-Evaluation
Appendix 6 Work procedures
Appendix 7 Procedures for Asbestos Removal Work
Disclaimer: This document has been developed by Capital & Coast District Health
Board (CCDHB) specifically for its own use. Use of this document and any reliance
on the information contained therein by any third party is at their own risk and
CCDHB assumes no responsibility whatsoever.
Asbestos Management Plan
Page 16 of 27
ID 1.103612
Regard printed versions of this document as out of date – The CapitalDoc
document is the most current version
Document facilitator: Facilities Manager
Senior document owner: General Manager Corporate Services
Document number: 1.103612
Issue Date 9 April 2018
Review Date 9 April 2021
Version 1
Appendix 1 - Asbestos Materials Risk Assessment
The following matrix is used to determine appropriate actions when asbestos
materials are identified either as a result of management surveys or testing on a
reactive / ad-hoc basis
Asbestos Management Plan
Page 17 of 27
ID 1.103612
Regard printed versions of this document as out of date – The CapitalDoc
document is the most current version
Document facilitator: Facilities Manager
Senior document owner: General Manager Corporate Services
Document number: 1.103612
Issue Date 9 April 2018
Review Date 9 April 2021
Version 1
Appendix 2- Asbestos Inventory & Control Method
The following table lists the ACM identified in the survey reports we have received to
date (at the time of publication of this document) and identifies the control methods
we have in place to manage potential exposure based on the asbestos material risk
assessment score:
Asbestos Management Plan
Page 18 of 27
ID 1.103612
Regard printed versions of this document as out of date – The CapitalDoc
document is the most current version
Document facilitator: Facilities Manager
Senior document owner: General Manager Corporate Services
Document number: 1.103612
Issue Date 9 April 2018
Review Date 9 April 2021
Version 1
Appendix 3 Incident Response Plan –
In the event of an incident such as a ceiling tile collapse in an area where asbestos is
known or suspected, special precautions will be required in order to minimize the
spread of asbestos fibres from damaged asbestos containing building materials.
Other incidents that will be managed using the Incident Response Plan are:
-
Storm Damage
-
Leaks / Flooding
-
Ceiling Tile Collapse
-
Emergency repairs to malfunctioning / damaged equipment (including plant
equipment)
In the above instances, the following procedures are to be observed.
Workers– Responsibilities
-
Nobody is to attempt to clean up potential ACM or remove items from the
area without prior authorization from the Asbestos Management Officer
-
Isolate the area from the adjacent area of the building by closing doors and
windows to restrict airflow and control access to the area.
-
Contact your supervisor or line manager and state the location and
description of the event
Senior Person – Responsibilities
-
Assess the circumstances and determine what actions have been taken
-
Call the Facilities Helpdesk (8:00 to 5:00) or 777 (after hours)
-
Determine the level of risk and appropriateness of actions carried out
-
Initiate additional enquiries and / or actions to safeguard personnel from
further risk
-
Ensure that the CCDHB Duty Manager has been advised
-
Log a Reportable Event in Square or equivalent reporting system
Facilities Management respondents – Responsibilities
-
Ensure that you have and are wearing the correct PPE / PPRE as required to
maintain your safety whilst responding to this incident.
-
Post signs and / or barrier tape at all entrances to the area to prevent
personnel not involved in the clean-up operation from inadvertently entering
the area.
-
Depending on the extent and type of potential exposure, a ceiling tile tower
may be utilised or the cavity isolated by installing a plastic sheet over it until
further correction actions can be taken.
-
Notify the Maintenance Manager or Facilities Manager of the incident and
actions taken immediately.
-
Notify the Health and Safety Manager of the incident and actions taken
immediately.
The Facilities Management team will arrange testing for potential asbestos and if
positive, will organise for the clean-up to be performed in a manner that ensures that
safe work practices in accordance with the Health and Safety at Work (Asbestos)
Regulations 2016 and the Health and Safety at Work Act 2015 are followed and that
the work is carried out by a specialist asbestos removal contractor.
Asbestos Management Plan
Page 19 of 27
ID 1.103612
Regard printed versions of this document as out of date – The CapitalDoc
document is the most current version
Document facilitator: Facilities Manager
Senior document owner: General Manager Corporate Services
Document number: 1.103612
Issue Date 9 April 2018
Review Date 9 April 2021
Version 1
All affected parties will be kept informed of progress and advised as soon as the area
is safe to re-occupy.
Maintenance Contractor – Responsibilities Contractors and maintenance staff should be aware that there is an emergency
response kit available on the Wellington and Kenepuru campuses and any DHB
leased properties in the event that they need to conduct emergency works in an area
with confirmed or suspected ACM. All used PPE is to be securely bagged and
disposed of in the appropriate yellow bin.
Typically, the kit will include the following:
-
Disposable P2 dust masks, coveralls & booties.
-
Disposable plastic drop sheets.
-
Asbestos waste disposal bags.
-
Duct tape.
-
Warning signs and barrier tape.
Locations for emergency kits and waste bins are:
Building
Location
Asbestos Management Plan
Page 20 of 27
ID 1.103612
Regard printed versions of this document as out of date – The CapitalDoc
document is the most current version
Document facilitator: Facilities Manager
Senior document owner: General Manager Corporate Services
Document number: 1.103612
Issue Date 9 April 2018
Review Date 9 April 2021
Version 1
Appendix 4: Bulk Sampling Procedures
Sample Collection
The first step towards implementing this AMP is to conduct an asbestos hazard
assessment (known as asbestos management survey) for every building or in which
asbestos or ACM is identified or CCDHB has assumed ACM likely to be present. The
assessment involves collecting representative samples of materials throughout the
areas in question.
Sampling of potential ACM must only be taken by an experienced and qualified
person. The Facilities Management team have contracted specialist providers to
undertake these tests on our behalf.
Documentation of Results The results (whether positive or negative for asbestos) are documented in a readily
accessible format and available to building maintenance staff, contractors and any
workers likely to come into contact with ACM during the course of their work. The
report includes:
-
A list of all materials confirmed as containing asbestos as well as any that are
presumed to contain asbestos (based on similar positive results)
-
Comprehensive results of bulk sample analysis from an IANZ accredited
laboratory.
-
Description by room number or location of all sample locations.
-
A marked up floor plan of the building clearly showing where each sample
was taken.
-
A list of materials requiring prompt removal due to severe deterioration.
-
A list of materials requiring minor removal, repair or encapsulation due to
slight deterioration.
The Asbestos Management Survey report is held in the custody of the Asbestos
Management Officer and is readily available for review when signing into site via the
CCDHB online Asbestos Register. This allows all contractors & maintenance staff to
use appropriate procedures to prevent fibre release and protect both themselves and
other building occupants if fibre becomes airborne.
Asbestos Management Plan
Page 21 of 27
ID 1.103612
Regard printed versions of this document as out of date – The CapitalDoc
document is the most current version
Document facilitator: Facilities Manager
Senior document owner: General Manager Corporate Services
Document number: 1.103612
Issue Date 9 April 2018
Review Date 9 April 2021
Version 1
Appendix 5: Visual Re-Inspection and Re-Evaluation All ACM identified in the survey shall be re-inspected visually annually. The re-
inspection shall be performed by a certified competent surveyor (or as a second
option licenced asbestos assessor). Further bulk samples may not be needed, but
the re-evaluation must encompass all factors originally noted and should concentrate
on any signs of deterioration, delamination or disturbance by maintenance staff,
renovation or occupant activity. In the event of disturbance of friable material by
water leak, structural failure or other unforeseen occurrence, all asbestos in the area
shall be re-evaluated promptly.
Any recommendations made as a result of these inspections will include details
regarding the priority, nature and extent of any corrective actions.
Common corrective actions are:
-
Encapsulation of damaged or exposed materials.
-
Removal of damaged or exposed materials.
Asbestos Management Plan
Page 22 of 27
ID 1.103612
Regard printed versions of this document as out of date – The CapitalDoc
document is the most current version
Document facilitator: Facilities Manager
Senior document owner: General Manager Corporate Services
Document number: 1.103612
Issue Date 9 April 2018
Review Date 9 April 2021
Version 1
Appendix 6 Work procedures
Facilities Management have initiated the following checks to assist staff and
contractors in making sure their routine work does not inadvertently disturb asbestos:
A “Take 5” checklist which is included on the back of all BEIMS maintenance
requests issued to contractors. This checklist not only prompts contractors to
ensure that their health and safety obligations have been met, but also
provides a prompt for the contractors to check the Asbestos Register prior to
commencing works so that they can eliminate the risk of disturbing any
asbestos during their work activities.
Inclusion within the BEIMS ticket of “known risks” within each building. This
covers asbestos as well as other general health and safety hazards.
Regular monitoring of the BEIMS system to ensure that any stakeholder
requests which may pose an asbestos risk are referred to the Asbestos
Management Officer for review and action as necessary
Work Procedures Contractors may have to work near asbestos or ACM during the normal course of
their work. In order for these workers to proceed in a safe manner, work procedures
covering a variety of tasks are to be developed by all contracted workers to submit
with their Site Specific Safety Plan (SSSP). These procedures are to include all work
involving:
Working with non-friable ACM.
Moderate and High Risk work procedures.
Waste handling.
Contractors and maintenance workers may be required to perform emergency work
in areas where identified or presumed asbestos or ACM are located. In these
instances, the nature of the work will not permit compliance with all normal CCDHB
Regulations insofar as prior authorisation of the work to be done is required.
The contractor may notify the Asbestos Management Officer after the fact in these
situations but must ensure that the work is only conducted by those contractors who
have been provided with the appropriate level of training by our onsite asbestos
consultants and where possible, with the assistance and supervision of said
consultants.
Where there is a risk that the required works may disturb existing or suspected
asbestos, full P3 PPE equipment must be worn and decontamination procedures
followed as per the specialist training provided. Where there is little risk of disturbing
any asbestos but the area is confirmed or suspected to be contaminated, a P2 mask
and booties will provide sufficient personal protection.
Any used disposable PPE must be disposed of in accordance with section 10.10 –
Waste Management.
Disposal of Asbestos Waste and Contaminated PPE
Asbestos waste includes:
Asbestos or asbestos contaminated soil
Debris or ACM removed
Asbestos Management Plan
Page 23 of 27
ID 1.103612
Regard printed versions of this document as out of date – The CapitalDoc
document is the most current version
Document facilitator: Facilities Manager
Senior document owner: General Manager Corporate Services
Document number: 1.103612
Issue Date 9 April 2018
Review Date 9 April 2021
Version 1
Disposable coveralls and boots used during asbestos work.
Sponges and other disposable cleaning materials.
Plastic drop sheets.
HEPA vacuum bags
Any tools used during the clean-up process that can’t be decontaminated.
Any disposable PPE accumulated during maintenance or repair activities in areas
with presumed or confirmed asbestos contamination is to be securely bagged and
appropriately disposed by the a specialist asbestos contractor in accordance with the
Health and Safety at Work (Asbestos) Regulations 2016.
Air Monitoring Air monitoring, if required is conducted in accordance with the requirements of the
Asbestos Regulations. This process is directed and managed by Facilities
Management and the results are logged in the CCDHB Asbestos Register. Should
Facilities Management receive any air monitoring results above the allowable limit(s),
immediate action will be taken to address potential risk in accordance with the Health
and Safety at Work Act 2015, the Health and Safety (Asbestos) Regulations 2016
and Worksafe’s Approved Code of Practice: Management and Removal of Asbestos.
Health Monitoring CCDHB will ensure that any workers contracted to carry out licensed asbestos
removal work or asbestos-related work on our sites are provided with health
monitoring by their employers in accordance with requirements of the Asbestos
Regulations and the Health and Safety at Work (General Risk and Workplace
Management) Regulations 2016. To that end, any contract will be only awarded to
companies that can demonstrate compliance with the regulations.
Contractor Workflow Process for Asbestos Control (BEIMS Requests) The following flowchart describes the process to be undertaken when attending to
BEIMS related maintenance requests within our buildings or in which asbestos or
ACM has been identified or is likely to be present:
Asbestos Management Plan
Page 24 of 27
ID 1.103612
Regard printed versions of this document as out of date – The CapitalDoc
document is the most current version
Document facilitator: Facilities Manager
Senior document owner: General Manager Corporate Services
Document number: 1.103612
Issue Date 9 April 2018
Review Date 9 April 2021
Version 1
Asbestos Management Plan
Page 25 of 27
ID 1.103612
Regard printed versions of this document as out of date – The CapitalDoc
document is the most current version
Document facilitator: Facilities Manager
Senior document owner: General Manager Corporate Services
Document number: 1.103612
Issue Date 9 April 2018
Review Date 9 April 2021
Version 1
Appendix 7 Procedures for Asbestos Removal Work
Contractor Induction Asbestos removal contractors attending to any work at CCDHB sites must complete
the required induction process as per section 11.1.1 of this plan.
Asbestos Removal Control Plan An Asbestos Removal Control Plan is a document that identifies the specific control
measures the licensed asbestos removalist will use to make sure workers and other
people are not put at risk when carrying out the work.
The licensed asbestos removal contractor must provide a copy of the Asbestos
Removal Control Plan along with a SSSP and a copy of the WorkSafe notification to
the Asbestos Management Officer for review and approval prior to the start of any
asbestos removal works.
Notification of Asbestos Removal
Notification to WorkSafe Before undertaking asbestos removal works at CCDHB sites, the asbestos removal
contractor must notify WorkSafe NZ in writing at least 5 days before the removalist
commences licensed asbestos removal work using the
Notification of Licensed
Asbestos Removal form which is available from WorkSafe’s website and in
accordance with regulation 34. If the asbestos must be removed immediately, the
licensed asbestos removalist must give notice to WorkSafe immediately by telephone
and in writing within 24 hours after notice is given by telephone.
Notification to workers and other occupants CCDHB will ensure that the following persons are informed that asbestos removal
work is to be carried out at the workplace and when the work is to commence, before
the work commences:
The Health and Safety Service at CCDHB
workers and any other persons at the workplace; and
the person who commissioned the asbestos removal work.
any PCBU at, or in the vicinity of the workplace; and
anyone occupying premises in the immediate vicinity of the workplace.
Limited Access to Asbestos Removal Area CCDHB will ensure, so far as is reasonably practicable, that no one other than the
following has the access to an asbestos removal area:
-
workers engaged in the asbestos removal work;
-
other persons associated with the asbestos removal work; and
-
anyone allowed under the Asbestos Regulations or another enactment to be
in the asbestos removal area.
CCDHB may refuse to allow access to an asbestos removal area at the workplace to
anyone it wishes. CCDHB will refuse entry to anyone who does not comply with a
control measure implemented for the workplace in relation to asbestos, or a direction
of the licensed asbestos removalist.
Asbestos Management Plan
Page 26 of 27
ID 1.103612
Regard printed versions of this document as out of date – The CapitalDoc
document is the most current version
Document facilitator: Facilities Manager
Senior document owner: General Manager Corporate Services
Document number: 1.103612
Issue Date 9 April 2018
Review Date 9 April 2021
Version 1
Clearance Inspection and Certificates CCDHB will engage an independent licensed asbestos assessor to undertake
clearance inspections upon the completion of asbestos removal works. The
clearance inspection is a four stage process as follows:
-
Stage 1: Preliminary check of site condition and job completion
-
Stage 2: Thorough visual inspection inside the enclosure / work area
-
Stage 3: Air monitoring and swab samples
-
Stage 4: Final assessment post enclosure / work area dismantling
Upon successful completion of the clearance inspection, the independent assessor
will issue a clearance certificate verifying that the area is safe to re-occupy and all
asbestos has been safely removed from the area according to the scope of works
and the Asbestos Removal Control Plan. A copy of this document is provided to any
staff member in the vicinity of works as an assurance that the area is safe to re-
occupy.
Integrity Testing and Background Air Monitoring CCDHB will engage an independent, licensed assessor to undertake integrity testing
of the asbestos removal containment area prior to works beginning. The independent
assessor will also undertake background air monitoring during asbestos removal and
provide a report on results daily. These results will be made available to any staff
member in the vicinity as an assurance that works do not affect their health and
safety.
Updating the Asbestos Register Upon completion of asbestos removal works, the Asbestos Management Officer will
update the Asbestos Register with the relevant documentation and actions taken,
including labelling of any remaining asbestos not able to be removed.
Asbestos Management Plan
Page 27 of 27
ID 1.103612
Regard printed versions of this document as out of date – The CapitalDoc
document is the most current version
