03 March 2020
Mark Montgomery
Via FYI.org
Email:
[FYI request #12128 email]
Dear Mark,
Official Information Act (1982) Request
I write in response to your Official Information Act request, received by us on 31 January 2020. You
requested the following information:
Pursuant to the Official Information Act 1982 please provide copies of:
•
All Asbestos Management Plans, prepared under Regulation 13(2) of the Health and Safety
at Work (Asbestos) Regulations 2016 for all workplaces occupied, or from time to time
occupied by the District Health Board, where asbestos or ACM (Asbestos Containing
Material) is suspected to be or has been identified at the workplace.
As context for this response, Counties Manukau Health (CM Health) provides health and support
services to people living in the Counties Manukau region (approx. 569,400 people), as well as regional
and supra-regional specialist services (Burns, Plastics and Orthopaedics). Our services are delivered via
hospital, outpatient/ ambulatory and community-based models of care provided across seven main
sites, and at a range of community clinics and bases.
A copy of the current CM Health Asbestos Management Plan, along with copies of all completed CM
Health site asbestos management surveys are accessible in the following link:
https://hanz.sharefile.com/share/getinfo/s149bcb09ce443beb
The current CM Health Asbestos Management Plan is
attached to this response for reference.
The site survey reports are held in electronic and hard copy by CM Health Engineering Department,
and are available for further inspection via the department, located at Building 27, Middlemore
Hospital. We are currently working with our contracted asbestos consultants and removal companies
to address/ remediate any areas to eliminate or significantly reduce those areas within our facilities.
We note that staff employed by CM Health can work at sites across the metro Auckland region,
including those managed by other DHBs, and other DHB staff work at some of our facilities. Documents
related to facilities managed by other DHBs will be available from that DHB.
Counties Manukau District Health Board
Private Bag 93311, Otahuhu, Auckland
T: 09 276 0000 | cmdhb.org.nz
I trust this information satisfactorily answers your query. If you are not satisfied with this response you
are entitled to seek a review of the response by the Ombudsman under section 28(3) of the Official
Information Act.
Please note that this response or an edited version of this may be published on the Counties Manukau
DHB website.
Yours sincerely,
Fepulea’i Margie Apa
Chief Executive Officer
Counties Manukau Health
Appendix 1 - CM Health Overarching Asbestos Management Plan
03 March 2020
Overarching Asbestos Management Plan July 2018
under Official Information Act - 03032020
Released
Document ID:
A916020
CMH Revision No:
1.0
Service:
Engineering and Property
Last Review Date :
31/07/2018
Document Owner: Hazardous Substance, Facility Safety and Compliance
Next Review Date:
31/072020
Approved by:
Executive Leadership
Date First Issued:
31/07/2018
Counties Manukau Health
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Prepared: Hazardous Substance and Compliance Advisor
Counties Manukau Health
under Official Information Act - 03032020
Released
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Act
Information
Official
under
Released
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1. Forward
Exposure to asbestos containing material (ACM) is recognised worldwide to pose health
risks. The greatest risk to health occurs from inhalation of asbestos fibres. Counties
Manukau Health (CM Health) acknowledges these risks and its duties in relation to these
risks under New Zealand law, to keep all persons safe.
As a responsible employer, CM Health manages asbestos in accordance with the
requirements outlined in New Zealand Law. These requirements are observed in CM Health
policy, procedure and the CM Health Asbestos Management Plan (AMP).
The AMP provides an overview of asbestos management undertaken by CM Health. The
plan outlines information needed to manage asbestos including the following aspects:
Responsibilities for managing Asbestos
Processes and methods necessary to ensure asbestos is identified, appropriately risk
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assessed, and asbestos risks are controlled and safely managed
Processes and methods necessary for managing incidents and emergen
Act cies involving
asbestos.
More specific detail is located in additional CM Health documentation associated with the
management of asbestos and facility operations.
In accordance with this plan, CM Health continues to assess its facilities to ensure any
asbestos containing materials present are identified and effectively controlled. Assessment,
Information
which includes appropriate survey, is currently prioritised and underway to those areas or
facilities constructed before 2003;
Known or likely to contain ACM; or ndergoing refurbishment or demolition.
Official
Facilities constructed post 2003, are deemed a lesser risk and will be progressively surveyed
unless; planned work is scheduled before a planned survey or, a risk of ACM being present
has been identified.
under
Where practical to do so, CM Health will remove ACM identified. Where this is not practical,
alternate measures are taken to minimise environment risk and maximise safety, including:
Encapsulation of the ACM
Segregation/Isolation of the ACM source and restricting access
Other controls to manage ACM sources in situ.
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CM Health ensures appropriate asbestos information and training is readily available to all
persons who require knowledge of, occupy areas containing and or work on ACM, to work
safely.
The safe management of asbestos is supported by the AMP, all managers and workers
throughout the organisation.
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2. Asbestos Overview
Asbestos has been used for centuries by many nations for its water, fire and electrical
resistant properties. Products manufactured from asbestos included a variety of
construction and insulation materials, clothing, cloth and brakes.
Asbestos in New Zealand
New Zealand began importing raw asbestos around the early 1940’s with quantities of
imported asbestos greatly increased during the mid to late 1960’s.
Imported asbestos was predominantly used to make bonded products for use in
construction such as cement roofing (e.g. Super 6) and fibre boards (e.g. cement sheeting).
Other common manufactured products included fireproofing material and textured
coatings.
Use of raw asbestos fell when New Zealand imposed restrictions on the importation and its
use during 1984 and 1999. These restrictions did not completely stop the importation or use
of ACM across New Zealand.
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In November 2016 New Zealand imposed further restrictions banning the importation of
ACM. However these increased restrictions do not completely ban ACM importation, some
Act
products may still be imported under special license.
Many buildings constructed, and equipment imported, prior to 2016 may potentially contain
ACM. The greatest likelihood of a building or equipment containing ACM exists prior to
2003.
What is Asbestos?
Information
Asbestos is the name given to a group of naturally occurring fibrous minerals. There are
more than six types of asbestos minerals split into 2 mineral subclasses, Serpentine and
Amphibole.
Official
Serpentine minerals have a curly fibrous structure. Chrystotile, commonly referred to as
white asbestos, is the only asbestos in this subclass. It was extensively used in the
manufacture of:
under
Building materials including vinyl flooring, adhesives and cements, drywall, and brake pads,
fire proofing materials e.g. fire blankets, textured ceilings (Stucco)
Amphibole minerals have fine fibrous needle-like structures. The most common of the 5
known asbestos types used are Amosite and Crocidolite, commonly referred to as blue and
brown asbestos respectively. They were extensively used in the manufacture of:
Released
Reinforced material including cement sheeting and roofing (Super 6), insulation board,
cement piping, and pipe lagging, gaskets, insulation, sound proofing and fire retardants
Types of Asbestos Containing Materials
There are 2 forms of manufactured asbestos containing materials:
Those that contain tightly bound asbestos fibres (bonded asbestos) are deemed Non-Friable.
Bonded products are generally strong, rigid and cannot easily release asbestos fibres by
hand pressure. Bonded products include vinyl flooring, cement sheet and roofing.
Asbestos products that can be easily crushed or release fibres through hand or light pressure
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are deemed Friable. These products pose the greatest risk to health due to their ability to
release airborne fibres. Examples include pipe lagging, fibrous and sprayed on insulation.
Note: Bonded ACM can break down over time, through weathering and or mechanical
abrasion, enabling the release of asbestos fibres deeming products to be friable.
3. Asbestos Management Plan
ACM, left undisturbed, are considered to present minimal health and organisational risks.
ACM, in particular sources considered in poor and or friable condition, having a potential to
or undergo damage or disturbance and result in the generation of airborne asbestos fibres,
present the greatest risks to health and organisational operation. CM Health acknowledges
these significant risks.
In an attempt to effectively and safely reduce these risks, CM Health has developed and
implemented an Asbestos Management Plan (AMP).
The AMP provides a level of overarching strategy on how CM Health iden
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tifies, assesses and
controls potential asbestos health risks and hazards present in its buildings; and, during all
Act
activities conducted by or on behalf of CM Health that may or are known to involve
asbestos.
The AMP provides a level of detail indicating the systems that are in place to check review
and verify asbestos management for each CM Health worksite.
The AMP will be available to all CM Health workers, officers, associated contractors and, to
other interested parties upon request. The plan is accessible via CM Health’s intranet and,
Information
the electronic document management system, OBJECTIVE.
A review and update of asbestos controls and remediation plans for each asbestos source
recorded in the CM Health asbestos register (identified and managed through this Plan) shall
Official
occur if;
An asbestos management control changes
Additional asbestos containing material is identified
under
The asbestos source identified is removed, modified (including sealed or enclosed, or
disturbed (not minor disturbance), as part of asbestos related works.
The AMP must be read in conjunction with the CM Health Asbestos register, asbestos site
survey reports and associated CM Health policy and safe work procedures.
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The AMP will be reviewed as a minimum every 5 years or;
When it is deemed inadequate
It is recommended following asbestos incident
Following reasonable request made by a worker or, health and safety representative.
4. Purpose and Commitment
CM Health is committed to ensuring no person is harmed from an exposure to asbestos; and
all services, organisational operation and reputation are maintained.
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Purpose
The purpose of the AMP is to provide a level of guidance and instruction to ensure asbestos
is effectively and safely managed, and to ensure;
ACM is identified, risk assessed and all reasonably practicable steps are taken to
eliminate or manage exposure to airborne asbestos
The location, condition and management of ACM, is effectively communicated, and
personnel are trained to manage asbestos safely
Development and implementation of safe systems of work including an effective
strategy for maintenance and management of assets
Active audit and reporting occurs, including contractor management
An effective exposure prevention programme is developed and implemented which
includes health monitoring and advice.
Scope
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The AMP forms an integral part of CM Health’s strategy for keeping people healthy and safe.
The AMP is to be read in conjunction with associated policy, safe procedures, asbestos
Act
register and reports prepared for CM Health sites.
The plan applies across our entire business and includes;
Every CM Health workplace, including those not owned or managed by CM Health
where workers attend whilst deemed ‘at work’ e.g. schools
All work having a known or potential to involve ACM including facility and plant
maintenance, repair or removal of ACM
Information
All workers including contractors and associated persons who have a known or
possible risk of exposure to ACM
Other persons who may utilise CM Health facilities for business or welfare; and may
Official
be at risk of being exposed to or affected by ACM as a result of asbestos work
undertaken by CM Health.
Where guidance indicates a requirement, including ‘must’ or ‘shall’, these are to be adhered
under
to. Where an item indicates ‘may’ or ‘should’, it is highly recommended.
Commitment
CM Health is committed to ensuring a safe working environment is maintained for all and
any asbestos present does no harm.
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Managing Asbestos - Policy Statement
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Act
Information
Official
under
Released
5. Management Strategy
Safe and effective management of asbestos is reliant on accurate identification
of asbestos containing materials (ACM) and, effective risk assessment and
management controls.
A review of asbestos and associated records, including those provided
following previous asbestos remediation work indicated inconsistencies and
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gaps in information available. As a result, a staged asbestos management
strategy has been developed and initiated across all CM Health sites to ensure:
Accurate asbestos records are established and maintained
Effective and consistent safe management of asbestos is achieved
All ACM identified will be appropriately monitored and managed until such
time it can be removed safely.
An overview of each stage is described below.
1.1 Interim Stage
The interim stage consists of initial system improvement, ongoing
asbestos identification and management of known asbestos risks.
Initial improvements include the development and implementation of
improved safe systems of work including the implementation of interim
safe work procedures; and improvements in the identification and
management of ACM, training and, the selection and implementation of
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an electronic asbestos management system.
Work in areas previously cleared of asbestos or where acc
Act uracy and
validity of asbestos records are questionable will not be permitted
unless:
Recent asbestos survey (post 2014) of the proposed work area
confirms no asbestos identified, or
The worksite is re-surveyed and provides confirmation no
Information
asbestos identified for the work being carried out, or
Where the presence of asbestos is known or there is
uncertainty that it may be present, agreement from the
Official
facilities management team is obtained before work may
commence; and
Safe Asbestos Work Procedures including Permit to Work are
under
followed and strictly adhered to.
Areas undergoing major refit or, demolition and rebuild will continue
to have a destructive survey carried out before any work commences.
If ACM is identified, clearance or remediation of ACM will occur before
proposed demolition or refurbishment is commenced.
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Progressive Stage
The progressive stage will focus on further improvements in
organisational asbestos management including attaining a global
overview of ACM locations. Aspects that will be covered in this stage
include;
Ensuring all CM Health sites undergo suitable asbestos survey
and all ACM identified is risk assessed, provided with a
management and remediation action plan outlining action to
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be undertaken including removal, encapsulation, monitoring or
other.
Implementation of an effective communication programme
providing appropriate information on asbestos and its
management.
Further development of asbestos training elements including
induction and asbestos awareness.
Further development and implementation of Safe Systems of
Work including development of prescribed safe work
procedures and risk assessment.
Improved contractor management ensuring all contractors
work safely, are adequately trained, appropriately supervised
and managed.
Note: CM Health is currently progressing through the ‘Progressive Stage’ of the asbestos
management strategy.
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Maintenance Stage
Act
Following completion of the ‘Progressive Stage’ CM health shall enter a
program of maintenance, ‘Maintenance Stage’.
The maintenance stage will focus on ensuring ongoing review and
management of identified ACM occurs in accordance to the AMP, audit
and inspection; and opportunities for further improvement are
Information
identified and progressed.
6. Roles and Responsibilities
Official
Under current New Zealand law every person has a duty to work safely. The level and extent
of this obligation differs according to a person’s role, their accountabilities within an
under
organisation and work undertaken. Roles and key responsibilities for managing asbestos at
CM Health are summarised below;
Overview of the Governance and Responsibilities for Managing Asbestos
Released
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CM Health Board
Has overall accountability for the resourcing and safe management of asbestos
Chief Executive
Ensure asbestos is being managed in compliance with NZ Law and, appropriate
Supportive Roles
arrangements for the safe management of asbestos are in pace
Director of Strategy/GM Facilities
Internal Specialist
Accountable for asbestos planning, ensuring all works involving
Provides guidance on managing asbestos
asbestos are adequately resourced and all asbestos work is
safely, supports CMH personnel to manage
completed in a timely manner, safely
ACM safely; develops, implements and
administers safe systems and the AMP,
and ensures asbestos records are accurate
and up to date
Manager
Manager
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Capital Works
Facilities and Engineering
Ensures asbestos is considered throughout the
Ensures all work to be undertaken considers
Asbestos Register
Act
whole capital project process; sufficient funds
asbestos, work is carried out in accordance with
are available to mitigate asbestos risk; contracts
the AMP and CMH PPG; and all staff including
Administrator
protect CMH assets; and contractors work
contractors are suitably trained, supervised, and Administers and maintains the
safely
safe to work with asbestos.
CMH Asbestos Register
External Specialists
Information Provide CMH specialist services and or
Project Managers and Senior Engineers
support to manage and mitigate asbestos
Ensure any work undertaken involving or having the potential to involve asbestos is
risks including asbestos survey and removal
undertaken safety an, work carried out is in accordance with approved safe methods
work
and completed to an acceptable level.
Official
Maintenance Team and Approved Contractors
Workers
under
Ensure work undertaken with or in the vicinity of ACM is carried out safely in
Communicate asbestos risks and, follow
accordance with safe practice and the AMP
reasonable instruction to work safely
Released
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1.2 CM Health Board, Executive and Senior Management
CM Health’s Board, Chief Executive, Executive and Senior Management
are responsible for ensuring asbestos is managed safely throughout the
organisation.
1.2.1 CM Health Board
Overall governance and accountability for managing asbestos,
and ensuring sufficient resource is available sits with CM
Health’s Board.
1.2.2 Chief Executive and Executive Leadership Team
The Chief Executive and Executive Leadership Team set the
strategic direction for asbestos management, approve the AMP
and ensure;
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Asbestos management is undertaken in compliance
with NZ law
Act
Arrangements for managing and controlling asbestos
safely are developed, delivered, implemented,
monitored and effectively resourced
1.2.3 General Manager (GM) Facilities
Information
The GM Facilities ensures the management of asbestos is
undertaken in alignment with strategic direction and according
to NZ law; and
Official
Sufficient resources are made available to enable all
asbestos work to be completed safely and in a timely
manner
under
Informing the Chief Executive of any compliance risk,
safety concerns or incidents involving asbestos
The AMP is implemented across all works involving any
aspect of CM Health estates or infrastructure, utilities
and services.
Released
Engineering, Property and Facility Service
The day to day management of asbestos throughout CM Health sits
with the Engineering, Property and Facility Service. Estates and assets
containing or suspected of containing ACM are managed in accordance
with the AMP.
Manager Facilities and Engineering:
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The manager of Facilities and Engineering ensures the day to
day operational safe management of asbestos across all estate
and plant, including;
All maintenance, repair and asbestos associated work is
carried out in accordance with the AMP, safe work
procedures and policy
Safe work procedures are developed, regularly
reviewed and updated
Facilities staff, and contractors, are suitably trained,
competent, and where required licenced, to work safely
with asbestos material and when undertaking related
activities
PPE is made available to all CM Health facility workers
for the safe management of asbestos and, it is used and
maintained
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All facilities personnel and contractors are informed of
Act
CM Health’s asbestos management requirements, and
where required supervised.
1.2.4 Manager Capital Works:
The manager of Capital Works ensures asbestos is considered
throughout the entire ‘Project’, including design, procurement
Information
and construction phase; and
All project personnel where such information is
required are fully informed of potential or known
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asbestos risk(s)
Projects include sufficient provisions for asbestos
survey, removal and or remediation
under
No construction material or procured commercial
product contains asbestos
No site work commences without appropriate safe
systems in operation, CM Health approval and,
Released employment of appropriately trained and licenced
personnel.
1.2.5 Hazardous Substances, Safety and Compliance
The manager of Hazardous Substances, Safety and Compliance
overseas asbestos compliance with safe systems and regulation,
including ensuring;
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CM Health worksites are surveyed for asbestos and
where it is identified, risk assessed, managed and/or
monitored
Asbestos records are managed, reviewed and
maintained
Safe work systems including management controls,
AMP, training and assessments are developed,
implemented and maintained
Asbestos reports and information is accessible to all
workers for the purposes of being able to perform their
duties safely
Appropriate programmes for monitoring facilities and
CM Health personnel are developed and maintained
Remediation and control of asbestos is prioritised and
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undertaken in accordance with NZ law.
Act
Project and Senior Engineers
Project and senior engineers ensure all allocated work is carried
out in accordance with the AMP, and;
Monitor and supervise all work carried out for or on
behalf of CM Health, ensuring all work is completed
Information
safely, on time and to an acceptable level
Allocating and approving work, including work permits
and other permissions are obtained before any work
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commences
Workers including contractors receive required
information including training, before commencement
under
of any work.
CM Health Maintenance and Contractor Personnel
CM Health maintenance and contractor personnel are
Released responsible for ensuring;
All work is carried out in accordance with NZ law, NZ
Codes of Practice, documented safe work practice and
correct approvals
Where PPE including RPE has been assigned for use with
asbestos, is used and maintained
Any incident involving asbestos is promptly notified.
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Others
Limited responsibilities sit with all remaining personnel regarding the
management of asbestos.
Managers (including Service and Line Managers)
Managers of work locations where ACM has been identified
ensure;
Information on identified ACM is communicated to
work personnel informing them of risks, controls and
safe processes;
Damage to asbestos containing material is promptly
reported to the F&E service for repair, remediation and
or control
All workplace personnel perform their asbes
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tos duties
in accordance with the AMP.
Act
Workers (General – including CMH employees, contractors,
students etc.)
Workers are responsible for ensuring;
No action or inaction harms themselves or other
Information
persons whilst at work
Asbestos risks are communicated immediately to their
manager, or if delegated, directly to the facilities service
Official
All reasonable instruction for the safe management of
asbestos is followed including the use of any PPE
supplied or recommended.
under
Others
Others personnel including patients, visitors and other workers
not undertaking work for or on behalf of CM Health are
Released responsible for ensuring they follow the direction of delegated
CM Health personnel when instructed, including where required
the use of PPE.
7. Identifying and Assessing Asbestos
To effectively manage asbestos, an understanding of where ACM is located, its
condition and the risks it poses must first be determined.
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Identification and robust risk assessment of ACM assists appropriate corrective
actions and controls to be determined, prioritised and implemented, ensuring
the safe management of ACM identified.
1.3 Identifying Asbestos
Identifying asbestos cannot be achieved by a simple visual inspection.
Specialist knowledge and, testing of materials and substances thought
to contain asbestos are required to ensure ACM is correctly identified.
1.3.1 Asbestos Survey
The formal assessment of materials suspected to contain
asbestos is achieved by way of asbestos survey. Surveys are
performed by and in accordance with a survey plan developed
by a licensed asbestos assessor to provide, with reasonable
assurance, confirmation of the presence or not of ACM.
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Asbestos survey may only be undertaken following approval by
the manager Hazardous Substances, Safety and
Act Compliance; and
must be carried out a competent and suitably qualified assessor
in a manner that poses no harm to any person, creates
operational disturbance or distress. Where necessary, surveys
may be performed after hours including weekends.
There are 2 types of survey;
Information
Asbestos Management (Partially Intrusive) Survey:
A management survey assessment is the minimum requirement
Official
for all facilities, consisting of a visual and partially intrusive
inspection (taking samples for laboratory assessment) to, so far
as reasonably practicable, identify the presence of ACM.
under
Management surveys have been completed for all CM Health
owned facilities. Surveys were performed on a priority basis,
prioritised to those buildings constructed prior to 2003 or,
where planned works were to be carried out. (
CM Health
Asbestos Site Summary – Feb 2018 , pg. 48)
Released Areas that were unable to be assessed shall, until such time a
management or other survey can be performed, be considered
to ‘contain’ ACM.
Persons in control of property leased to CM Health shall provide
evidence of appropriate management survey and AMP.
Refurbishment / Pre-Demolition (Fully Intrusive) Survey:
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A more extensive invasive survey is required to be performed on
any CM Health property prior to any facility refurbishment or
demolition involving the removal of plant, structures and or
building material.
Fully intrusive surveys shall be undertaken in consideration of a
proposed scope of work to ensure all potential material and
equipment that may contain asbestos, is reviewed and
identified.
Where ACM is identified it shall be appropriately remediated
prior to any proposed work commencing or, require the scope
of work to be modified.
Repeat or additional intrusive survey shall be performed where
a change in work scope occurs or, a period of 6 months has
elapsed from the original survey without commencement of
proposed work.
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Survey Reports
Act
Survey reports shall be provided to CM Health in a format
providing consistent detail and terminology, and the
information provided is accurate. Copies of all survey reports
are freely available to all workers, including contractors, in hard
copy (paper) and electronic format.
Specific detail from all surveys is transcrib
Information ed into the CM Health
electronic asbestos register.
1.3.2 Asbestos Samples
Official
Samples of materials suspected to contain asbestos, including
air and dust samples, may be collected during an asbestos
survey, asbestos remediation, part of health monitoring or other
under
work activities.
The number and frequency of samples required, as part of
asbestos survey or removal works, is the responsibility of a
licensed asbestos assessor.
Released Samples from other activities may be collected by suitably
trained personnel and tested following approval from the
manager Hazardous Substances, Asbestos and Compliance.
All asbestos material and air samples are submitted to, and
analysed by, an accredited laboratory approved by CM Health;
and, must be accompanied by documentation providing the
assessing laboratory a required level of detail. Information must
be clear, accurate and include but not limited to;
Description of material and location obtained
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Date and time sample collected, and by who.
A record of sample collection must be recorded in CM Health’s
asbestos register and or survey report; and include a
photographic image of material and its physical sample location.
Material Samples
All material and dust samples are collected following defined
safe sampling methodology and in accordance with any
laboratory requests.
Air Samples
Air monitoring provides a level of assurance asbestos
management and controls are effective and, environmental
airborne asbestos fibre levels are below the minimum
prescribed level of
0.01 f/ml, trace. Air monitoring also provides
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opportunity to review and modify controls where this level is
exceeded.
Act
Air monitoring may be performed during asbestos work and
other associated activities including asbestos related work, post
asbestos incident, specialist recommendation; and, to provide
reassurance to workers occupying spaces identified to contain
ACM.
Air sampling carried out during licensed asbestos work and as
Information
part of the 4 stage asbestos clearance process, is undertaken by
a CM Health approved independent licensed asbestos assessor.
Background, assurance and personal air monitoring may be
performed by a licensed
Official asbestos assessor or, the manager
Hazardous Substances, Asbestos and Compliance.
Laboratory
under
Assessment
All asbestos samples must be tested by an Australian or New
Zealand accredited laboratory (IANZ).
Laboratory results are to be received within agreed timeframes
from receipt of samples. Laboratory test reports supplied must
Released provide detail consistent with information required to
effectively complete the CM Health asbestos register.
Where an air sample is identified to exceed trace, the Manager
Hazardous Substances Safety and Compliance shall liaise with
the testing laboratory to approve further assessment at a
specialist laboratory. A process of escalation and notification
shall also be undertaken (refer to section 10).
1.3.3 Survey Reports
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Asbestos survey reports must ensure consistency in format and
information provided. Reports must enable easy interpretation
and review of information, and entry into the CM Health
electronic asbestos register, and include;
Asbestos content including type, condition, extent
etc.
An initial risk assessment for each ACM identified
Images of sample and location, floor plan outlining
sample locations
Locations of areas not assessed and presumed to
contain asbestos containing materials.
Survey responses must be recorded in the CM Health asbestos
register within 1-2 weeks of a reports receipt.
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1.4 Asbestos Risk Assessment
Act
Asbestos risk assessment is performed throughout various stages of
asbestos management including survey and sampling, asbestos
remediation and associated work.
To be effective, various elements need to be considered in order to
assure a robust assessment occurs. Elements for consideration include;
Type and condition of suspected or confirmed ACM sources
Information
Current and/or proposed management controls
Exposure and disturbance risk
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Service and site operational risks.
Active assessment enables CM Health and its workers ensure each
under
source of asbestos management is prioritised, effective controls are in
place and working, including authorisations; and workers work safely
for planned and unplanned asbestos work activities.
1.4.1 As
Released
sessing Asbestos Risk
Assessing asbestos risk follows defined methodology and
considers multiple risk factors to determine overall risk, priority
and corrective action required.
Initial risk assessment occurs following identification of ACM
through asbestos survey, providing an asbestos material and
condition assessment and risk score. The initial assessment
provides an indicative overview on the extent of material
observed and risks the perceived risks the AMC poses.
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Following material assessment each ACM source undergoes a
broader risk mitigation and prioritisation assessment. Risk
mitigation and prioritisation assessment considers several
factors including the initial material and condition assessment
score, impact assessment (clinical/service and facility
operation), and exposure/frequency.
The following table simplifies the approach undertaken to
determine a level of risk mitigation and prioritisation.
Asbestos Risk and Prioritisation Assessment Matrix
CONSEQUENCE (Health and/or Service)
Extreme
Major
Moderate
Minor
Low
Priority
Corrective Action
Immediate Action:
Access to or activity on the ACM source
OD)
Exposure/risk to
Certain
must cease and immediate corrective
health and/or CM
actions must be identified and implemented.
Health service
Notification to senior management.
ELIHO
deemed extreme
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IK
ntrols
Almost
Urgent Action:
Access to or activity on the ACM source
(L
Certain
Exposure/risk to
requires approval and suitable controls to be
ve Co
health and/or CM
in place. Prioritised corrective actions must
Act
IBRES
cti
Health service
be identified and implemented urgently.
F
ffe
deemed high
Notification to senior management.
Likely
t E
Planned Action:
Access to or activity on the ACM source
STOS
u
Exposure/risk to
requires approval and suitable controls to be
SBE
tho
health and/or CM
in place. Planned corrective actions must be
Health service
identified and implemented within
O A
r Wi
Unlikely
T
o
deemed moderate
reasonable timeframes.
RISK MANAGEMENT
RE
ith
Low Priority Action:
U
Activity on ACM source requires approval
W
Exposure/risk to
and suitable controls to be in place. No
OS
Highly
health and/or CM
Information
P
Unlikely
further controls deemed necessary at this
Health service low or
EX
time.
negligible
Airborne
Bonded
Friable
Bonded Major
Bonded Minor
Fibres
Damage
Damage
Intact
ASBESTOS TYPE & CONDITION
Official
the manager Hazardous Substances, Asbestos and Compliance; and in consultation with
identified stakeholders including F&E workers, workplace managers, contractors and
under
asbestos specialists as required.
Following assessment, a record of the priority and corrective actions are recorded in the
ACM entry within the CM Health asbestos register.
Assessed ACM sources undergo regular re-assessment at scheduled intervals or, where the
Released
source of ACM has been modified through damage, deterioration or work undertaken. Each
ACM asbestos entry is actively updated following re-assessment. Where an asbestos source
is removed, the associated asbestos register entry is updated and communicated.
Risk mitigation and prioritisation assessments are performed by
1.4.2 Managing Asbestos Risks
Risk assessment also provides a level of detail outlining
recommended corrective actions required to manage ACM
sources that are not required to be removed, safely. Mitigation
20 | P a g e
and management plans developed in consultation with workers
and where necessary key stakeholders and or asbestos
specialists are recorded in the respective ACM register entry.
Each plan documents;
A description of the risks identified
Current and proposed corrective actions required
including a priority timeframe for implementing
corrective actions and delegation of responsibility for
ensuring actions are completed
A timeframe for re-assessment and monitoring
activities.
Plans are communicated and implemented for each ACM source
identified. Plans requiring immediate or urgent corrective action
are escalated to the appropriately delegated manager, and
implemented within defined timeframes, including any
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additional escalation and notification.
Act
1.5 Communicating The Presence of Asbestos
ACM which has been identified and assessed must be communicated to
every person having a potential to come into contact with it.
Asbestos and associated information shall be provided in various
printed and electronic formats. Information provi
Information ded will provide
workers and associated personnel the necessary detail to keep
themselves and other people safe; and shall be easily accessible.
All documents developed and released shall follow CM Health’s
Official
document control and approvals process.
1.5.1 Asbestos Register and Reports
under
CM Health’s asbestos register provides accessible detailed
records of all surveyed locations and identified ACM. The
register and survey reports are available to those responsible for
directing or undertaking work on or in the vicinity of ACM, and
workers occupying areas identified to contain ACM.
Released Any person planning or directed to undertake work on or in the
vicinity of asbestos containing material must ensure the relevant
survey report and register entries are reviewed before such
work is planned, approved or undertaken.
Asbestos survey reports are accessible at all CM Health sites and
the facilities and engineering offices at MMH and MSC in hard
copy, and electronically in Objective or via CM Health’s Intranet.
Access to CM Health’s asbestos register may be achieved by
email, CM Health’s Intranet or mobile device. Entries and
21 | P a g e
updating of the asbestos register may only be carried out by the
register administrator or approved delegated person. Register
entries are updated at defined intervals (periodic ACM review)
at a minimum annually or, following change in an ACM source or
mitigation and management plan changes e.g. ACM is removed
or becomes damaged. Register records include;
A description of the facility or worksite, ACM
source(s) identified, their location and condition
status
Mitigation and Management plan, risk assessment
and monitoring requirements including
reassessment requirements etc.
Labelling and Signage
CM Health acknowledges the requirement to ensu
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re all sources
of ACM are appropriately labelled.
Act
Members of the public have relatively unrestricted access to
many work areas. Asbestos signage or labelling in public areas
may give rise to undue concern or increased incidence of
vandalism. With the exception of licensed asbestos work,
asbestos labelling or signage is not considered appropriate in
public areas.
Information
As a minimum, all ACM locations will be identified in the CM
Health Asbestos Register and survey report plans. ACM located
in staff only areas shall be appropriately labelled according to
the level of risk posed by the source of ACM.
Official
Labelling and signage shall be of an agreed standard, easily
recognisable, understood and prominently placed. Approved
asbestos sig
under nage and labelling will be installed, where
necessary, in consultation with the workplace.
Examples of Asbestos Labelling
Released
Asbestos Information
22 | P a g e
All CM Health personnel, contractors and associated personnel
will be provided an appropriate level of general and specialist
asbestos information.
The level and content of information shall be consistent with the
type and risks associated with the ACM identified, and work
undertaken or proposed.
Where it is deemed necessary, visitors including patients and
other persons will be informed of the presence of asbestos and,
the precautions needed to ensure their safety.
8. Managing and Control of Asbestos
Following identification and assessment of ACM, suitable action can be taken
to ensure effective asbestos controls are determined and implemented. A
variety of controls are used to effectively and safely manage asbestos including
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asbestos remediation, safe work methods and training.
CM Health continues to develop and implement safe systems and methods to
Act
assist workers to safely manage asbestos. The following section outlines
aspects of safe management developed and implemented across CM Health for
the safe and effective management of ACM.
Further guidance including specific safe work procedures, may be accessed in
local workplaces, CM Health Facilities and Engineering department, services
and contractor specific documentation.
Information
Primary Management
Official
The primary aim of CM Health is to achieve an asbestos free organisation. Where it is both
practical and non-prohibitive, CM Health will endeavour to achieve this goal by actively
removing ACM identified.
under
Where this is not possible the following management principles will be undertaken in order
of priority, to minimise potential asbestos exposure and disturbance risk;
Released
23 | P a g e
Encapsulate/seal ACM source to prevent release of fibres
Enclose or segregate ACM source restricting access by
unauthorised personnel, or preventing environmental
release of asbestos fibres
Manage ACM source in situ where risk of damage of
material is low and disturbance of potential fibres unlikely,
until such time periodic assessment or notification
determines an increase in asbestos risk.
Training and Competency
Workers required or having the potential to work with or in the vicinity
of ACM must be suitably trained, competent and experienced. Where
necessary they will also be appropriately licenced and or registered.
Training shall be, sourced, and where necessary developed, and
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delivered providing all workers a level of knowledge and competency to
work safely with known or suspected ACM. Training shall be delivered
Act
and assessed by suitably qualified and experienced personnel and or by
agreed methods e.g. web based e-learning, class room etc.
Appropriate training records shall be maintained in accordance with CM
Health’s training policy and, contractor management policy.
Note: No person may work on any or in the vicinity of ACM without
Information
the minimum agreed level of training and competency.
CM Health Employees
Official
All CM Health employees receive an initial workplace induction. The level of asbestos
information provided during induction shall be consistent with a person’s exposure risk to,
and work requirements with ACM.
under
Specific asbestos and associated training is provided to all employees including managers,
having a potential to be exposed to ACM as part of their normal work.
The minimum training requirements shall comprise asbestos awareness and, training on;
Released
24 | P a g e
Specialist equipment including PPE and RPE
Safe work procedures/methods involving ACM.
Contractors
All contracted and 3rd party trades/services personnel are required to
complete an annual CM Health Contractor Induction. The level of
asbestos information provided shall be consistent with the
contractor’s exposure risk to, and work requirements with ACM.
In addition to induction, contracted and 3rd party trades/services
personnel are required to have completed the minimum CM Health
asbestos training requirements, asbestos awareness and RPE/PPE
training.
Evidence of training must be provided prior to engagement of the
contractor and any work being undertaken.
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Non-completion of a CM Health Contractor Induction or evidence of
the minimum asbestos training requirements shall result in the
Act
contractor being prevented from undertaking any work for or on
behalf of CM Health.
Licenced Asbestos Specialists
Information
Any person engaged by CM Health to provide asbestos consultancy,
supervision, survey, remediation or removal shall be appropriately
qualified, competent and where required licensed. Work requiring
asbestos licensing;
Official
Removal of friable asbestos and asbestos containing dust
(ACD) -
Class A Asbestos Removal Licence
Removal
under of over 10m2 of non-friable asbestos and
associated ACD -
Class B Asbestos Removal Licence
Asbestos clearance certification and air monitoring for
Class A removal work -
Asbestos Assessor License
Before any licensed asbestos work is undertaken, each worker license
Released is checked for validity and appropriate scope. CM Health’s facilities
and engineering manager, delegated engineer or representative sight
and confirms license detail ensuring validity for the work and work
duration.
Asbestos and Personnel Protective Equipment
Where ACM is not removed and asbestos risk remains, specialist
equipment may be required to effectively manage remaining asbestos
and safety risks.
25 | P a g e
A range of specialist equipment has and shall continue to be reviewed,
procured and used to assist in the safe management of all remaining
ACM sources.
All equipment purchases shall occur in accordance with CM Health
procurement process and; following appropriate consultation and be fit
for its intended purpose, where required specifically for the use and
management of asbestos; and, comply with all relevant legislative
compliance, local rules and best practice.
General Equipment:
General asbestos equipment is selected according to job task; ease of use, cleaning, storage
and handling, and for minimising or controlling potential release of asbestos fibres.
No new risks shall be introduced unless they can be easily and safely controlled.
Suitable instruction is to be provided to all workers responsible for managing and
maintaining the equipment.
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Relevant information and records shall be kept and maintained in accordance with CM
Act
Health policy.
Personal Protective Equipment (PPE):
CM Health acknowledges the requirement to provide employees access to a range of
personal protective equipment (PPE), when undertaking any asbestos related activities.
Information
All PPE, including respiratory protective equipment (RPE), is selected in accordance with
current codes of practice and required standards. PPE procured shall be fit for intended
purpose and selected in consideration of job task, ease of use and maintenance, and where
identified ease of cleaning. Where required, PP
Official E shall be fitted.
There are specific requirements which must be achieved for the selection and use of RPE for
asbestos related activities. CM Health personnel required to wear RPE shall be fit tested and
under
assigned a suitable respirator. The minimum respirator standard for CM Health employees is
a P2/N95 half face reusable respirator for all asbestos related work activities.
Where PPE has been identified as a requirement for a safe work method/procedure it must
be worn.
With the exception of licensed asbestos removalists, general contractors who perform
Released
asbestos related work must select and use equipment including PPE in accordance with the
minimum CM Health requirements. Contractors must provide evidence of RPE fit test,
allocation of equipment and evidence it is fit for purpose. Contractors who are unable to or
do not comply with these rules are not allowed access to a CM Health site.
Relevant information and records shall be kept and maintained in accordance with CM
Health policy.
Note: Any worker unable to achieve a suitable seal when using an assigned respirator is not
be permitted to work with or in the vicinity of ACM; and, must ensure they are clean shaven
before use.
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Safe Work Method/Procedures and, Permit to Work
CM Health operates a system of Safe Work Procedure and Permit to Work (
13.4,
Overarching Safe Work Processes, p.g.50). The system has been developed to assist facilities
personnel and approved contractors work safely across all CM Health sites.
CM Health’s Facilities and Engineering Service continually develop in consultation, and
manage all estate and plant safe work procedure and permits, including those involving
asbestos. Procedures are available electronically via the F&E intranet.
Procedural and permit review occurs at defined intervals or where there has been changes
in process/method, incident or worker request. Processes are tested to ensure they are
operationally practical and safe.
Contractors wishing to work outside of approved CM Health procedures must develop in
consultation with CM Health’s facilities and engineering manager, delegated engineer or
representative; and have authorised, their procedures before work is assigned or
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commences.
Act
Deviation from approved procedure may only occur in an emergency where no suitable
process is available and, following an appropriate risk assessment. In these circumstances
approval should be obtained from CM Health’s facilities and engineering manager,
delegated engineer or representative prior to work being undertaken.
The following provides an overview of general safe work processes adopted to safely work
with ACM.
Information
Official
under
Released
27 | P a g e
Asbestos and Asbestos Related Work Flow
Building Age
Post 2016
Pre 2017
Review
No ACM Identified
Asbestos Register/Survey
Report
No Report
Work Task
Risk Assessment
Request Survey
Emergency or
Maintenance
Maintenance
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ACM
Confirmed
Considered ACM
Free Task
Emergency
Act
No Disturbance of
Presume
or Exposure to
Negligible
Asbestos Present
ACM
Risk
General Safe
ACM Work Task
Practice
Risk Assessment
High Risk,
Low
Information
Removal
Risk
Moderate
or
Risk
Emergency
Elevated
Minor ACM
Increased likelihood
Minor ACD
exposure and or
of disturbing or
Risk
generation or
minimal ACM
generating ACD/
disturbance
Official
disturbance
removal of < 2m2
Consult Licensed
expected
expected
Bonded ACM
Asbestos removalist
Low Risk ACM
Moderate Risk ACM
Elevated Risk ACM
ER ACM Work
Licensed
Work Procedure
Work Procedure
Work Procedure
Procedure
Removal Work
under
1.5.2 Permit to Work
CM Health operates a permissions based system, ‘Permit to Work’, as an additional formal
‘administrative’ control
Released for improved safety. Work having a known or potential to involve
ACM (not licensed asbestos removal work) requires as a minimum an
Asbestos Permit to
Work. Additional permits may also be required for associated works e.g. hot work.
Permits must be authorised by the CM Health’s facilities and engineering manager,
delegated engineer or representative before any work can proceed. Approved permits are
to be registered into BIEMS and filed. An example of the CM Health Interim Asbestos Work
Permit can be found in
Refer to (13.4.5, Permit to Work – Asbestos Related Work, p.g. 56)
28 | P a g e
General Maintenance including Minor Asbestos Related Works
General maintenance and scheduled repair work are planned activities, and may involve
work on or in the vicinity of known or suspected ACM.
Where ACM is known or suspected and, activity does not involve > 1-2m2 of bonded ACM
removal and or excessive fibre production or dispersal, e.g.:
Cabling and ceiling work, drilling into bonded asbestos board
Removal of minor quantities of intact bonded ACM e.g. vinyl flooring, cement
sheeting
Where there is no defined work safe work procedure for the task, the overarching Asbestos
Related Work procedures are to be followed must be used, Refer to (
13.4, Overarching Safe
Work Processes, p.g.50)
Project and Capital Works (including refurbishment)
Capital and project works undertaken by or on behalf of CM Health including demolition,
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construction and refurbishment follow similar principals.
The Capital and Project Works procedure outlines the steps required t
Act o ensure asbestos is
considered and effectively mitigated for all such works.
Emergency Asbestos Procedure
Unplanned work which may require access to known ACM containing locations, planned
work or other action resulting in unexpected release of asbestos
Information containing material and or
dust are considered an asbestos emergency.
As a result the Emergency Asbestos procedure must be used to;
prevent and or limit the extent of asbestos release and contamination during work and or
Official
clean up;
mitigate a situation which poses significant operational impact and a risk to the safety of
patients, staff or others
under
Emergency work considered, to present minimal asbestos risk i.e. involving < 2m2 of bonded
ACM removal and or minimal fibre production or dispersal, may follow the principles of the
Minor Asbestos Related Works procedure.
Where there is a greater known, suspected or uncertain asbestos risk the Emergency
Released
Asbestos procedure must be followed, and where possible in consultation with and
assistance from . All emergency work should be undertaken with assistance from a licensed
asbestos specialist unless there is an immediate threat to life. Refer to (
13.4.4 Emergency
Asbestos Procedure, p.g. 53)
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Asbestos Removal Work
Not all ACM removal requires a licensed removalist. There are 3
categories of asbestos removal work:
Unlicensed – quantities < 10m2 of non-friable ACM
Licenced
Class A – Any amount of friable and non-friable ACM, and
ACD
Class B – Any amount of non-friable ACM
Appropriately trained, and where necessary licensed personnel are
permitted to remove defined quantities of asbestos in accordance with
current asbestos regulation.
Unlicensed Asbestos Removal
Though regulation allows for unlicensed removal of a limited
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amount of non-friable ACM, CM Health requires any amount of
non-friable asbestos greater than > 2m2 to be removed by a
Act
licensed removalist. Quantities of non-friable ACM < 2m2 may be
removed by appropriately trained and equipped CM Health
facilities personnel or approved contactors; and in accordance
with approved safe work and disposal procedures.
Quantities of non-friable ACM < 10m2 may, on occasion, be
removed by non-licensed suitably trained and equipped
Information
personnel following prior approval by the CM Health’s facilities
and engineering manager, delegated engineer or representative.
Reassurance/background air monitoring may be performed
Official
where risk assessment determines or service request for
assurance.
Class A and B Asbestos Removal
under
CM Health shall employ Class A removalists to undertake all Class A
and B removal work. Where it is not possible Class B licensed
removalists may be employed to remove limited quantities of non-
friable ACM.
Released Prior to any class A or B removal work:
All licensed contractors shall undergo appropriate CM Health
induction
WORKSAFE shall be notified by the licensed removalist of
proposed removal work within a minimum of 5 working days
by application for all planned work and 24hrs by phone for
urgent removal work
CM Health shall notify workers and associated persons
occupying CM Health owned and leased property; and any
30 | P a g e
PCBU or person occupying premises in the vicinity of the
workplace likely to be impacted by the work
All reasonably practicable steps shall be taken by the
removalist, in consultation with CM Health, to ensure access to
the asbestos removal work area is controlled and limited to
approved persons only
The removalist shall provide and gain approval of, from CM
Health and where required independent asbestos assessor, a
compliant asbestos removal and control plan (ARCP) and SSSP
Asbestos enclosures shall undergo integrity assessment and
worksite set up approved by CM Health’s independent
asbestos assessor
During removal work, appropriate monitoring of the worksite and any
agreed associated areas shall be carried out by CM Health and CM
Health’s independent asbestos assessor.
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Prior to, during and upon completion of removal work the contractor
Act
shall, in consultation and collaboration with CM Health, ensure site
access is controlled until all work is complete, and any clearances
obtained. CM Health may also refuse access to any person who does
not comply with required control measures or direction of the
asbestos removalist.
Upon completion of licensed asbestos removal work and before site
Information
can be released CM Health’s independent asbestos assessor will
undertake a 4 stage clearance assessment. Only when the assessor is
satisfied, may the contractor remove all asbestos removal equipment
etc. from the site. A certificate of clearance must be provided before
Official
general access is allowed following works.
CM Health’s asbestos register shall be updated accordingly upon
completion of work.
under
Site and Work Area Access
Access to any CM Health site or work area shall be in accordance with
current security policy and organisational permissions.
Areas con
Released taining ACM presenting no immediate airborne health risks
i.e. bonded and intact ACM shall not be restricted. Access may occur
under general permissions and security protocol.
Work on or in the vicinity of identified ACM requires authorisation and
permit before activity may proceed. Access to clinical areas to carry out
such work also requires clinical manager approval.
Access to work areas with known or perceived airborne asbestos risk
will be restricted to those personnel who;
Are suitably trained (where necessary licensed), and approved
31 | P a g e
Have obtained authorisation to enter the restricted area from
the facilities manager or delegated senior; and have completed
the correct permits etc.
Have signed for and obtained access keys, codes or electronic
security pass etc.
Have and are to use appropriate equipment suitable for the
work including RPE, PPE etc.
Where necessary are suitably supervised
Any breach of access shall be brought to the attention of the facilities
manager for investigation and remediation.
1.6 Disposal of Asbestos Waste
Asbestos waste is any item containing or may contain ACM or asbestos
fibres including PPE, debris and dust, cleaning cloths and d
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rop sheets for
disposal. All asbestos waste shall be disposed in accordance with
current regulation and asbestos codes of practice.
Act
General Works
ACM or material generated for asbestos disposal as part of general works shall be
undertaken in a safe manner and in a way that does not cause distress to other workers or
members of the public.
Asbestos waste generated as part of general works is double bag
Information ged and appropriately
labelled. Waste is then transferred to dedicated asbestos waste bins located on MMH and
MSC sites. The waste is transferred in to these bins and secured for collection by an
approved licensed carrier.
Official
A licensed carrier will transfer the asbestos waste to a licensed waste disposal site or holding
facility. The licensed carrier will provide CM Health copies of all documentation notifying
storage and or final disposal. All records shall be kept for a minimum period of time.
under
Asbestos Removal Works
Waste generated as part of licensed removal work is the responsibility of the licensed
removalist, and managed in accordance with their approved ARCP.
The licensed removalist shall ensure all asbestos waste generated is appropriately
Released
contained/sealed prior to removing from the removal work area. Minimal quantities of
asbestos waste shall be retained in the removal work area during removal works. Asbestos
waste shall be removed at regular intervals along defined routes with minimal access, which
may include removal after hours.
Asbestos waste may be stored in a secure holding/containment location prior to its removal
from the worksite by the removalist. The removalist will ensure all asbestos waste
generated is disposed at an approved disposal site and will provide CM Health required
documentation confirming final disposal.
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9. Contract Management
Contract management refers to the lifecycle management of any contractual
arrangement for product, services or construction.
Contracts and contractors shall be monitored during the course of the contract
and or beyond, to ensure compliance with agreed legal and safety
arrangements. Monitoring and management may be assigned to CM Health
delegated member of staff or 3rd party provider.
Asbestos considerations for sale or lease of property (land and buildings) are
considered in section 7, Property Management.
Procurement Contracts
All procurement and contract documents must ensure sufficient clauses and technical
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requirements are present, ensuring no product purchased contains asbestos.
Tender processes must ensure suitable review of respondent information is undertaken to
Act
assure products under consideration do not contain asbestos. Certificates from unknown
and uncertified testing facilities shall not be accepted.
Design and Construction Contracts
Information
Construction contracts shall ensure asbestos is considered throughout the whole design,
development and construction phases of a project.
All construction materials used must be certified as asbestos free and be supported by
relevant product certification from valid testing facilities.
Official
Contract clauses must include the ability to seek compensation and or remediation, if any
asbestos material is disturbed during construction (including any demolition) and or, any
material used is found to contain as
under bestos during construction or past handover.
Maintenance and Service Contracts
All maintenance and service contracts are required to ensure all contractors and companies
Released
providing such services are aware of and attain the minimum requirements necessary for
working on or around known or potential ACM.
Contracts will be required to have a minimum of liability and environmental insurances to
ensure any damage caused by work undertaken or disturbance of asbestos material by the
contractor, affords appropriate and timely remediation at the contractors expense.
Contracts must ensure contracted personnel are suitably qualified for the duration of the
contract and that any material used in the process of maintenance/servicing supplied by the
vendor does not contain asbestos.
33 | P a g e
Contractor Management
Contractors having a potential or requirement to work with or in the vicinity of ACM must
have a minimum level of training, have had a respirator fit test and access to health
monitoring before work is granted; and follow CM Health safe procedure.
CM Health may supervise and or monitor any contractor at any time while work is being
undertaken, at any CM Health site. Where a contractor is observed to be in breach of safe
work process CM Health may remove from the site the contractor, temporarily or
permanently.
10.
Property Management
Property management refers to the acquisition (purchase, rental or bestowal) and disposal
(sale, transfer or lease) of land and buildings.
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Asbestos must be considered throughout all aspects of property acquisition or disposal. CM
Health will endeavour to acquire property that contains no asbestos an
Act d, dispose of CM
Health property ensuring buyers/recipients are informed of any asbestos risks.
Legal arrangements including insurances, for acquisition or disposal of property, must be
available and, ensure adequate protection for CM Health to remediate any risk that may
occur or is identified.
Information
Property Acquisition
Before property can be acquired, sufficient assessment must be undertaken to ensure a
Official
property does not pose asbestos and or other risks. The acquisition lead or delegate shall
ensure a robust assessment is carried out, of all proposed property, by Facilities and
Engineering before any acquisition is progressed.
under
Property Review (Pre-Acquisition)
CM Health must be provided accurate asbestos records for all property under consideration
of acquisition. Where records are unavailable, deemed limiting or inaccurate the vendor
Released
shall be approached to rectify these omissions.
34 | P a g e
Note:
Asbestos records cannot be wholly relied upon due to historic
industry practices, therefore records must:
Be consistent with the use and development of the
property, in date and valid for the duration of any
proposed activity
Provide a factual description of ACM determined
including extent and status of asbestos material
identified and its management to date
Have been completed by reputable licensed asbestos
assessors
If the vendor is unwilling to provide required asbestos detail CM
Health may, in agreement with the vendor, undertake an
independent asbestos review/survey. Every effort shall be made
to recoup expenses incurred.
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Where agreement cannot be reached to ensure asbestos and
Act
other assessments are completed, the acquisition process shall
no longer be progressed.
Negotiation
The CM Health acquisition lead or delegate may progress property negotiations when all
Information
building assessments have been completed including review of asbestos survey; and,
required approvals from the Facilities and Engineering service have been obtained on
building fitness.
Property negotiations must not proceed where asbestos has been identified until Facilities
Official
and Engineering provide further assessment and approval and or recommendations.
Assessment shall include cost of removal/remediation and on-going management.
Where additional assessment deter
under mines;
Commercially realistic expectations are identified
enabling costs to be recouped (e.g. price reduction), or
vendor agrees to remediate before transfer –
procurement negotiations shall proceed.
Released Commercially unrealistic expectations are identified –
procurement negotiations shall not be progressed.
Negotiation must include legal arrangements which accommodate for any possible future
identification of asbestos not identified by initial review.
Property Transfer
Prior to the transfer of property title, and exchange of funds if applicable, CM Health must
be provided all original asbestos records and associated documents. Final transfer of
35 | P a g e
property shall not take place until all regulatory and required documents are provided.
Contracts must include a clause which places a duty on the vendor to ensure any asbestos
identified post transfer, is to be remediated by the vendor. This may be limited to ensuring
appropriate insurances are in place to cover any future asbestos issues identified.
Property Disposal
The disposal of any CM Health property shall be coordinated by the CM Health delegated
property disposal lead.
Prior to the commencement of any property disposal process the CM Health property
disposal lead shall be provided a necessary level of detail to assist disposal. Initial detail is
provided by CM Health’s Facilities and Engineering service and includes required
engineering and asbestos information.
Asbestos survey reports supplied to prospective owners or lessees shall be up to date and
include all necessary detail to assist property disposal. Where an asbestos survey report is
unavailable or out of date CM Health shall undertake prior to the comme
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ncement of any
property disposal process.
Act
Where prospective owners or lessees require additional reasonable facility or site
information, the CM Health property disposal lead shall provide following liaison with CM
Health’s Facilities and Engineering service.
Upon transfer of title or acceptance of lease the new owner or lessee shall be provided
copies of all relevant detail held on the property.
Information
11.
Asbestos Health Risks
Exposure to asbestos containing material does not necessarily lead to a health risk. The
Official
greatest concern to health is exposure to airborne asbestos fibres.
Inhaled asbestos fibres can become embedded in the lungs, if in sufficient concentration,
lead to an asbestos related disease.
under
The following provides an overview of potential health issues associated with various
asbestos exposures and management if exposure were to occur.
Airborne Asbestos Fibres
Asbestos fibres are pres
Released ent in the atmosphere due to natural erosion of asbestos ores or
manmade asbestos containing materials. The concentration of asbestos fibres in the
atmosphere and the risk they pose to health is considered very low.
High asbestos fibre concentrations in air present the greatest risk and concern to health. The
greatest risk to workers occurs during frequent and unprotected exposure to high
concentrations of airborne asbestos fibres.
The permissible concentration of asbestos fibres in air, within the workplace and during
Class A removal work, must remain below 0.01 Fibres/ml air, trace level. Anything above
trace level requires investigation and review of controls. Levels exceeding 0.02 Fibres/ml are
36 | P a g e
considered notifiable and must be reported.
CM Health endeavours to ensure no workplace or activity involving asbestos, exceeds trace
levels; and, no worker exceeds a work exposure above 0.1 Fibres/ml air averaged over an 8
hour period. .
Low Fibre Concentration
Working safely with or in the vicinity of bonded asbestos products in good condition is
considered unlikely to pose a health risk.
Working with moderate risk asbestos materials using appropriate controls including PPE, or
exposure to isolated acute low fibre concentrations, are not considered to result in short or
long term asbestos related health issues. Minor respiratory, skin or eye irritation may
however occur.
Though health risks are deemed unlikely, any low fibre exposure cannot be completely
ignored.
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High Fibre Concentration
Working with friable asbestos, or exposure to airborne asbestos concen
Act trations above trace
levels without using appropriate controls, poses the greatest risk to health. Uncontrolled
exposure to high asbestos fibre concentrations, over a long period of time, presents the
greatest risk to a person’s health.
Chronic asbestos exposure is considered to be the main cause of asbestos related diseases.
Acute very high fibre exposure may also result in respiratory, skin or eye irritation.
Information
Workers engaged in construction and demolition trades are deemed at greatest risk of being
exposed to high asbestos fibre concentrations and considered more likely to develop an
asbestos related disease. Particularly builders, plumbers, electricians, installers of IT
Official
systems, fire alarms, and some machine operators.
Asbestos Related Diseases
under
Asbestos related diseases1 include asbestosis, lung cancer, mesothelioma and pleural effects
(e.g. fluid on the lungs, thickening of lung tissue). Symptoms are likely to include shortness
of breath, persistent and productive cough, and loss of appetite.
Early diagnosis is difficult due to the nature of asbestos related diseases. There is a long
latency period upwards of 20 years before symptoms might become detectible, even after
Released
exposure to asbestos has ceased.
Workers, who smoke and are exposed to airborne asbestos, are considered more at risk of
developing an asbestos related disease especially lung cancer. There are currently no known
effective cures for asbestos related diseases.
Health Monitoring
CM Health has developed and implemented an Asbestos Health Monitoring program. The
program is overseen by CM Health’s Occupational Health Medical Practitioner (OHMP) and,
37 | P a g e
managed by CM Health’s internal Occupational Health Service (OHS).
Health monitoring is available to all CM Health personnel identified to have undertaken,
continue to undertake, or commence working for CM Health and required to undertake
asbestos related work.
The worker shall be provided copies of any clinical test and, environmental exposure
reports. The workers GP shall be notified of medical assessment, management, tests
undertaken and results and ongoing monitoring.
1.6.1 Asbestos Related Work
The manager of the worker, worker or manager hazardous substance, asbestos and
compliance notify CM health’s OHS of a workers exposure risk.
OHS facilitates initial health assessment and any clinical investigations required. Following
initial assessment the OHMP determines on-going health monitoring and any surveillance
requirements.
1.6.2 Acute/Emergency Asbestos Exposure - 03032020
CM Health’s OHS will be notified of any worker exposed or suspected to have been exposed
Act
to, airborne asbestos concentrations in excess of 0.02 Fibres/ml or WES 0.1 Fibres/ml.
Notification shall include exposure/air monitoring report.
OHS shall facilitate medical assessment of the exposed worker and any additional and or on-
going clinical assessments required.
1.6.3 National Asbestos Exposure Register
Information
The New Zealand National Asbestos Exposure Register is a voluntary registration system for
any person who may have been exposed to asbestos. Workers shall be provided information
on the register and provided the necessary details to complete registration.
Official
1 Pleural plaques on Chest X-ray are considered a marker of exposure but do not
(in themselves) progress to disease
under
12.
Incident Management
All incidents involving suspected or confirmed sources of ACM and airborne asbestos are
initially managed to ensure any risks to person or the environment (internal and external),
are minimised.
Released
Asbestos incident management is overseen by the Hazardous Substance, Asbestos and
Compliance manager, including notification and communication with or to WORKSAFE.
Asbestos incident investigation is performed in accordance with CM Health’s Incident
Investigation policy. Where an asbestos incident involves a contractor, the principal
contractor is required to undertake an investigation in parallel and consultation with, CM
Health.
All findings, recommendation and corrective actions are communicated and escalated in
accordance with CM Health policy and legislative requirements, and where identified
38 | P a g e
implemented.
General Asbestos Incident
General asbestos incidents are considered any incident involving or
suspected to involve ACM and or, airborne asbestos concentrations less
than 0.02 Fibres/ml.
Following general asbestos incident appropriate emergency procedure
is implemented to minimise any potential risk of increased
contamination of and or exposure to ACM and or airborne asbestos.
This may include the cessation of all asbestos and asbestos associated
works to stop, and air monitoring.
General asbestos incidents are investigated by the Facilities and
Engineering or Capital Works manager overseen by Hazardous
Substance, Asbestos and Compliance manager.
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Notifiable Asbestos Incident
Notifiable asbestos incidents are considered any situation, requiring
Act
notification to WORKSAFE, resulting in:
Emergency demolition of a structure or plant containing
asbestos that triggers the application of HSW Asbestos
Regulation 23 or 24; and or
Concentrations of airborne asbestos fibres are reported to have
Information
exceeded 0.02 Fibres/ml or the workplace exposure standard
limit of 0.1 Fibres/ml;
Emergency Demolition and Removal
Official
Emergency demolition and removal of ACM follows CM Health’s Asbestos Emergency
procedure.
CM Health shall consult with approved licensed asbestos specialists prior to any emergency
under
asbestos demolition and removal; and to ensure appropriate interim controls are in in place
to minimise release of and exposure to asbestos fibres.
Locations requiring emergency work shall be secured preventing unauthorised access until
demolition and removal work has been completed, and required clearances obtained.
Occupants within or clos
Released e to the location of proposed emergency works shall be adequately
informed, and where necessary relocated.
Notification to WORKSAFE of emergency asbestos removal works, and removal work, shall
be performed by CM Health’s approved licensed asbestos removalist.
Emergency asbestos work may only proceed following required notification, and is
undertaken in accordance with the licensed specialist’s emergency ARCP.
Airborne Asbestos Concentrations Exceeding 0.02 Fibres/ml
Incidents involving airborne asbestos levels exceeding concentrations of 0.02 Fibres/ml shall
result, if safe to do so, in the immediate cessation of all work activities, site being secured
39 | P a g e
and notification to the hazardous substance, asbestos and compliance and F&E manager, or
duty manager if after hours.
Emergency asbestos procedures are initiated to contain ACM and airborne asbestos fibre
sources, preventing further contamination and exposure risk.
Note: Where cessation risk is too great, e.g. inability to stop work is considered to result in
increased release of asbestos fibres or risk to life, suitable measures shall be taken to limit
asbestos exposure and contamination risk until cessation of work activity can be achieved.
Initial investigation of the worksite is undertaken, avoiding site disturbance, to determine
detail required to notify WORKSAFE and immediate corrective actions required.
Notification of an asbestos notifiable event to and on-going communication with WORKSAFE
is undertaken by the manager Hazardous Substance, Asbestos and Compliance or their
delegate. Notification shall occur at the earliest opportunity and, to facilitate urgent
corrective action required.
Emergency demolition or removal work required shall be undertaken following WORKSAFE
approvals and, appropriate consultation and communication.
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Notifiable asbestos incident investigation is overseen or may be conducted by, the manager
Act
Hazardous Substance, Asbestos and Compliance.
Senior management are notified of a notifiable asbestos incident, WORKSAFE notification,
action taken and to be taken in accordance with CM Health’s escalation procedure.
Following investigation, a report outlining findings, action taken and corrective actions
required is provided to senior management, involved managers and workers.
Information
13.
Audit, Inspection and Record Management
CM Health performs a range of audit, inspection and review of work site, workers and
Official
contractors, policy and procedure.
Information collected from audit and inspection, including asbestos survey and monitoring is
managed in accordance with CM Health’s Information Management policy.
under
Information collected is openly available to those workers and contractors required to
undertake asbestos related work or occupy sites identified to contain asbestos, and other
delegated persons having responsibilities under the AMP.
Released
40 | P a g e
Worker and Contractors
Audit and inspection of contractors, CM Health workers and work
performed is undertaken in accordance with CM Health’s contractor
management policy. Assessment may be undertaken by CM Health
delegated personnel or a third party consultant.
Assessment findings and reports are reviewed by the relevant CM
Health contract manager or delegate, CM Heaths F&E safety
committee. Where necessary, reports and or additional
recommendations are escalated to senior management and the
Executive Leadership Team.
Policy and Procedure
Review of CM Health policy and procedures occur in accordance with CM Health document
control policy. As a minimum, documents may be reviewed annually or every 2-3 years.
Policy and procedure may also be reviewed if process changes or incident investigation
- 03032020
recommends.
Policy and procedures are reviewed by key stakeholders in collaboration and consultation
Act
with CM Health and other workers.
Modification to any policy or procedure following appropriate review is documented and
approved by the delegated authoriser(s) and or committee(s). Updated documents are
published and communicated in accordance with CM Health’s document control and,
communications policies.
Information
Official
under
Released
41 | P a g e
Asbestos Containing Material and Asbestos Register
CM Health’s asbestos register is reviewed as a minimum, every 2 years.
Where necessary the register will also be revised in the following
circumstances:
an asbestos management control changes;
additional asbestos containing material is identified;
the asbestos source identified is removed, modified (including
sealed or enclosed, or disturbed (not minor disturbance, as part
of asbestos related works);
changes occur to the physical environment or work practices in
the area surrounding the ACM
Amendments to the asbestos register, resulting from any review, are
communicated to workers and management in accordance with the
AMP and, CM health escalation process.
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Formal visual and periodic inspections of all known ACMs are carried
out in accordance with the risk and remediation priority
Act assessment.
Where assessment has not yet been completed, and the ACM recorded
is considered low risk, inspection of these sources shall occur annually.
Periodical inspections may be undertaken by delegated personnel who
have received appropriate training. Visual inspection may be conducted
by a competent and or licensed assessor having completed a minimum
Information
agreed level of training.
Damaged or deteriorated materials found during inspection undergo
further risk and remediation priority assessment; findings are reported
and escalated according to modified risk determined.
Official
Details of inspection and or risk assessment are communicated to the
asbestos register administrator or their delegate, and recorded into the
appropriate register
under entry. Notification and access to updated entries
are communicated to delegated workers and associated persons.
1.7 Record Management
Committee
Released and delegated decisions and asbestos and associated
records, are to be retained, archived and disposed of, in accordance
with CM Health Document Control policy and NZ regulatory compliance.
The following asbestos specific records are stored in Objective and
accessible via CM Health’s Intranet:
all asbestos survey reports, including updates and amendments
records of any asbestos management, removal or disposal works
performed on site, including clearance certificates indicating
42 | P a g e
areas are safe to re-occupy after asbestos management works
and any applicable disposal certificates
asbestos air monitoring results
Health records associated with CM Health workers are kept and
managed in accordance with asbestos and, medical record regulation.
14.
References
New Zealand
Health & Safety At Work Act, 2015
Health & Safety At Work (General Risk And Workplace Management) Regulations, 2016
Health & Safety At Work (Worker Engagement, Participation, And
Representation) Regulations, 2016
Health & Safety At Work (Asbestos) Regulations, 2016
Approved Code Of Practice (ACOP) – Management And Removal Of Asbestos,
November 2016
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NZ Code Of Practice - How To Manage And Control Asbestos In The Workplace,
2017
Act
Working With Asbestos? – Rules Changing On 4 April 2016, March 2016
Quick Guide;
Working With Or Near Asbestos – For Plumbers, April 2018
Working With Or Near Asbestos – For Painters, April 2018
Working With Or Near Asbestos – For Builders, April 2018
Good Practice Guidelines – Conducting Asbestos Surveys, October 2016
WORKSAFE NZ, Information Sheet 5,
Personal Protective Equipment to Use When
Information
Working With Asbestos, April 2016
Overseas
Australia;
Work Health and Safety Regulation, 2017
Model Code of Practice:
How to manage and control asbestos in the workplace
Official
Model Code of Practice:
How to safely remove asbestos United Kingdom;
Control of Asbestos Regulations, 2012
Approved Code of Practice –
Managing and working with asbestos, 2013
under
Task Manual –
Asbestos Essentials, 2012
Asbestos:
The licensed contractors' guide, 2006
CM Health
Policy:
Managing Substances Hazardous to Health, Safety and the Environment
Policy:
Health and Safety Policy Policy:
Policy for Managing Asbestos
Released
Policy:
CM Health Incident Reporting and Investigation Guide:
How to Conduct a Workplace OSH Incident Investigation
15.
Glossary of Terms and Abbreviations:
CM Health
Counties Manukau Health
AMP
Asbestos Management Plan
Asbestos Containing Material -
Is any material or thing that, as part of its design, contains
ACM
asbestos fibres including products, objects, materials or debris
Respirable Fibres
Extremely fine particles (fibres) with defined size, which can be
43 | P a g e
inhaled (breathed) into the deepest parts of the lungs
PPE – Personal Protective
Any item of equipment used to protect a person from hazards,
Equipment
for example, safety helmet, safety goggles, safety belt and line
RPE – Respiratory Protective
Is a specific type of PPE used to protect an individual against the
Equipment
risk of (minimise their exposure to) inhaling hazardous
substances
Asbestos Related Disease
Group name given to diseases known to be caused as a result of
inhaling asbestos fibres including lung cancer, mesothelioma
and non-malignant lung conditions such as asbestosis.
Asbestosis
Diffuse interstitial fibrosis of the lung
Worker
Any person employed or contracted by CM Health, including
contractors and subcontractors, volunteers, visiting health
professionals, students and trainees etc.
At Work
Legally doing ones job at an agreed time (work time) and place
of work (workplace)
Associated Person
Any person not employed by CM Health or contracted company
- 03032020
undertaking work like activities on a CM Health site e.g. student,
visiting health professional etc. Act
Workplace
Any location where a worker is required to carry out work
activities which may or may not be owned by their employer,
including the employer’s worksite, visiting a patient’s home,
other healthcare facilities (e.g.) GP clinic, schools or conference.
Asbestos
Is the generic name given to a group of naturally occurring
fibrous mineral silicates consisting of 2 classes, serpentine or
Information
amphibole
Friable Asbestos
Asbestos Containing Material that is in a powder form or a form
that can be crumbled, pulverised or reduced to a powder by
hand pressure when dry
Official
Asbestos-contaminated dust or
Dust or debris which is or assumed to be contaminated with
debris (ACD)
asbestos fibres
Asbestos Containing Material
Any material, usually considered a manufactured object or
under
(ACM)
product which or is considered to contains asbestos fibres
Risk
The likelihood a hazard may cause harm to a person, place or
environment. For the purposes of the AMP, risk refers to the
likelihood of an illness or disease arising from exposure to
Asbestos Fibres.
Licensed Asbestos Removal
Released
ist A person who has received specific training, is considered
competent and licenced to remove an agreed type of asbestos
material
Licensed Asbestos Assessor
A person who has who has received specific training, is
considered competent and licensed to undertake class A
asbestos assessment work
Competent Person
A person who has acquired, through training and experience,
the knowledge and skills of relevant industry practice and who
holds a specific certificate from WorkSafe or an appropriate
tertiary qualification for the work to be undertaken
44 | P a g e
IANZ Accredited Laboratory:
A testing laboratory accredited by International Accreditation
New Zealand (IANZ)
SWOW, JSA, SWP, SWMS
Are all forms of documenting work risk assessment,
hazards and safe work method/process
Permit to Work
Is a written process which specifies the work to be done and the
controls/precautions to be taken when doing the work
Asbestos Removal Control Plan
A site specific document, prepared by a licensed removalist in
(ARCP)
accordance with Code of Practice for the Safe Removal of
Asbestos which outlines PPE requirements, barriers, signage,
removal methodology, project timing and staging etc.
Asbestos Removal Work Area
The area in which ACM removal and management is being
undertake as part of an ARCP
Clearance Inspection (4 stage
An inspection, carried out by a licensed Asbestos Assessor to
Clearance Inspection)
verify asbestos removal work has been undertaken and area is
safe to re-occupy.
Bonded Asbestos
Asbestos containing material in which th
- 03032020
e asbestos is firmly
bound into a firm matrix
Act
Asbestos Trace Level
Refers to minimum detectable airborne asbestos fibre
concentration, for NZ this is below asbestos
0.01 fibres/mL
Health Monitoring
Monitoring of a worker to identify any changes in a person’s
health status because of work activity including exposure to a
substances
Workplace Exposure Standard
Refers to a prescribed level of exposure a worker should not
(WES)
exceed at work to particular sus
Information btances. For asbestos a value of
0.1 fibres/mL averaged over an 8hr work period is prescribed
16.
Appendix
Official
Asbestos Material Risk Assessment
The Material Assessment Tool a
under ssists in the overall assessment of asbestos risk and
remediation prioritisation.
Material Assessment Table:
Released
Category
ACM
Score
Examples of scores Asbestos-reinforced composites (plastics, resins,
1
mastics, roofing felts, vinyl floor tiles, semi-rigid
paints or decorative finishes, asbestos cement etc.).
AIB, millboards, other low-density insulation boards,
Material
A
2
asbestos textiles, gaskets, ropes and woven textiles,
Description
asbestos paper and felt.
Thermal insulation (e.g. pipe and boiler lagging),
3
sprayed asbestos, loose asbestos, asbestos
mattresses and packing.
45 | P a g e
0
Good condition: no visible damage
Low damage: a few scratches or surface marks,
1
broken edges on boards, tiles etc.
Material
Medium damage: significant breakage of materials
B
Condition
2
or several small areas where material has been
damaged revealing loose asbestos fibres.
High damage or delamination of materials, sprays
3
and thermal insulation. Visible asbestos debris.
Composite materials containing asbestos: reinforced
0
plastics, resins, vinyl tiles.
Enclosed sprays and lagging, AIB (with exposed face
Material
C
1
painted or encapsulated) asbestos cement sheets
Format
etc.
2
Unsealed AIB, or encapsulated lagging and sprays.
3
Unsealed lagging and sprays.
1
White (Chrysotile) only
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Asbestos
Brown (Amphibole asbestos excluding crocidolite)
D
2
Composition
and mixtures (not blue) Act
3
Blue (Crocidolite) and mixtures or type unknown
Total
A+B+C+D = Material Score
Total Score
Material Risk
Rating
Risk Interpretation
Information
Friable and or unstable ACM sources.
10 or more
High
Require urgent removal or prompt
removal as soon as practicable
ACM sources have an increased
Official likelihood of being disturbed. May be
7-9
Medium
managed in situ with increased asbestos
controls. Programmed for removal prior
under
to major disturbance i.e. renovation, or
following management approval.
ACM sources have minimal likelihood of
5-6
Low
being disturbed. May be managed and
maintained in situ within agreed controls.
Consider removal where practicable.
Released
ACM sources considered non-friable and
4 or less
Very Low
in good condition, i.e. low probability of
disturbance. Manage and monitor in situ
within agreed controls and per AMP.
Asbestos Exposure and Disturbance Risk Assessment
Exposure and access assessment is performed in consultation with stakeholders to
ensure required detail is provided and considered to perform an effective review.
46 | P a g e
Exposure and Disturbance Risk Assessment Table:
Category
Variable
Score
Examples of Activity
Normal Occupant Activity
0
Rare disturbance activity (e.g. little used store
room)
1
Low disturbance activities (e.g. office type
Main type of activity in area
activity)
2
Periodic disturbance (e.g. industrial or vehicular
activity which may cause contact with ACMs)
3
High levels of disturbance, (e.g. fire door with
asbestos
Likelihood of Disturbance
0
Outdoors
Location
1
Large rooms, warehouse or well-ventilated areas
2
Rooms up to 100 sq. metres in area
3
Restricted or confined areas
0
Usually inaccessible o
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r unlikely to be disturbed
Accessibility
1
Occasionally likely to be disturbed
2
Easily disturbed
Act
3
Routinely disturbed
0
Smal amounts or single items (e.g. strings,
gaskets)
Extent/Quantity
1
Less than 10 sq. metres area, or 10 metre pipe
run
2
10 to 50 sq. metres area or 10 to 50 metres pipe
Information
run
3
More than 50 sq. metres, or 50 metres pipe run
Exposure Potential
0
None
Official
Number of occupants
1
1 to 3
2
4 to 10
3
More than 10
under
0
Infrequent
Frequency of use of area
1
Monthly
2
Weekly
3
Daily
0
Less than 1 hour
Average time area is i
Released n use
1
1 to less than 3 hours
2
3 to less than 6 hours
3
More than 6 hours
Maintenance Activity
0
Minor disturbance (e.g. possibility of contact when
gaining access)
Type of maintenance
1
Low disturbance (e.g. changing light bulbs in
activity
asbestos insulating board ceiling tiles)
Medium disturbance (e.g. lifting one or two
2
asbestos insulating board ceiling tiles to access a
valve)
47 | P a g e
High levels of disturbance (e.g. removing a
3
number of asbestos insulating board ceiling tiles
to replace a valve or for re-cabling, or leak repair)
0
Unlikely – almost never
Frequency of maintenance
1
Less than once a year
activity
2
Less than once a month
3
More often than once a month
Selection of a risk score is dependent on the understood level of risk. Where initial
assessment does not appear to fit defined example, a higher score is selected on further
review of potential risk for the identified task/exposure etc..
Final assessment score is achieved by adding occupancy score with the average of exposure,
disturbance and maintenance activity scores.
Asbestos Risk and Prioritisation
- 03032020
Final risk and remediation prioritisation considers the combined material assessment and
priority assessment scores, and any additional feedback obtained during consultation with
Act
stakeholders, including external asbestos specialists (assessor and removalist).
Where risk assessment indicates a requirement to remove priority should be assigned to
removing ACM at the earliest opportunity. Where it is not practical alternate remediation
activity needs to be undertaken to reduce risk of asbestos fibre release in combination with
Information
a level of asbestos safe work process and controls.
Official
1.8
CM Health Asbestos Site Summary – Feb 2018
Middlemore Site
Survey
Asbestos
No.
Building /Site Name
Year
Present
under
1
Galbraith
2017
2
Bray
2017
7
Poutassi
2017
11
McIndoe
2018
Released
31
Colvin Complex
2017
27
F&E Management
2017
30
Esme Green
2017
40
Oral Health
2017
43
Transformer Room
2018
5
Scott
2018
21
Energy Centre
2018
25
Projects
2017
48 | P a g e
26
Project Management
2017
32
Pink Palace
2017
41
Boiler House
2018
4
MRI/CT
2017
9
Creche (Tree House)
2018
10
Tiaho Mai
-
12
Kidz 1st
2017
20
Dangerous Goods
2018
28
Gas Store
2018
45
RMO Lounge 1998
2018
47
Filter Shed
2018
51
Edmund Hillary
2018
52
Harley Gray
2018
53
Trade Workshop
2018
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54
Ko Awatea
2018
55
Energy Centre
2018
Act
Western Campus Site
38
Western Campus
2017
3
Renal Home Training
2017
34
Smoke Free Services
2017
46
Multi-storey Car Park
2017
Information
48
Contaminated Waste
2018
49
Storage Shed
2018
50
Storage Shed
2018
Official
Community Facilities
13
Bairds Road (incl. ASRU, Tamaki Oranga & PH)
2017
16
Pukekohe Hospital
2017
under
19
Franklin Memorial Hospital
2018
18
Papakura Maternity
2018
Awhinitia
76
2017
Public & Community Health
Released
-
72 Victoria St (Gp House)
2018
67
Manukau Super Centre
2017
83
4 Salas Place (Gp House)
2018
84
9 Sheehan Ave (Gp House)
2018
9
Botany Maternity
2018
65
Botany Super Clinic
2018
66
Howick Home Healthcare
2018
94
225 Buckland Road Dental
2018
49 | P a g e
95
Botany Downs Dental
2018
96
Browns Road Dental (MSC)
2018
Legend:
Multiple ACM sources identified, ranging from low – high risk asbestos material
Multiple ACM sources identified, ranging from low – med risk asbestos
material
Multiple ACM sources identified, consisting low risk asbestos material
No Asbestos Containing Material Identified
Overarching Safe Work Processes
Asbestos Related Work Procedure – Low Risk Works
Equipment:
PPE, P2 fitted respirator, plastic drop sheet 200 micron, duct and wide
PVC tape, asbestos waste bags, asbestos certified vacuum, wet wipes,
- 03032020
spray bottle with detergent and water (set to mist), safety signage and
barriers
Act
Scope:
The
Asbestos Related Work Procedure – Low Risk Works is to be applied
when undertaking asbestos related work assessed as
Low risk, and no
defined safe work process is available for the proposed work task.
Low risk asbestos related work may only be undertaken by personnel who
have completed a minimum of asbestos awareness and practical training,
Information
have a fitted approved respirator, have assessed the asbestos register and
consulted with CM Health’s asbestos support.
Procedure:
1.
Review asbestos report for the work area and work to be
undertaken
Official
2.
Consult with CM Health’s asbestos support confirming work is low
risk, unless pre-approved or permitted to perform agreed work
activity without consultation.
under
3.
Confirm work and work process to be undertaken, equipment and
PPE required etc.
4.
Inform staff/manager in work area of activity to be undertaken,
including any access or restrictions necessary whilst performing
work, and precautions to be undertaken to ensure safety of staff
Released and associated occupants
5.
Cordon off work area where work is to be carried out and where
required request occupants to remove themselves from work area
until approval to re-occupy has been given
6.
Set up work area in accordance with risk assessment, safe work and
asbestos controls identified, and any additional requirements
provided by on site asbestos support. This may include the
placement of drop sheet to the floor an.
7.
Don required PPE and RPE, ensuring respirator is fit checked before
commencing work.
50 | P a g e
8.
Commence and complete required work in accordance with safe,
agreed controls and work methods, noting any variation in asbestos
material and condition from that reported
9.
On completion of work task ensure area is clean and free from any
debris or dust using agreed safe methods. Place any waste
generated into a suitable asbestos waste bag and dispose as
asbestos waste.
10. Remove PPE worn by agreed safe methods, placing into a suitable
asbestos waste bag, and dispose as asbestos waste
11. Remove respirator, clean and store safely
12. Remove cordon and inform work area safe to re-occupy and any
additional instruction necessary
Report any variation to the ACM detail described in the asbestos register
entry to the asbestos administrator.
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Act
1.8.1
Asbestos Related Work Procedure – Moderate Risk Works
Equipment:
PPE, P2 fitted respirator, plastic drop sheet 200 micron, duct and wide PVC tape,
asbestos waste bags, asbestos certified vacuum, wet wipes, spray bottle with detergent
and water (set to mist), safety signage and barriers
The
Information
Scope:
Asbestos Related Work Procedure –
Moderate Risk Works is to be applied
when undertaking asbestos related work which has been assessed as having a
Moderate Risk of generating a smal amount ACD or ACM debris (considered
minor), and no defined safe work process is available for the proposed work
task.
Official
Moderate risk asbestos related work may only be undertaken by personnel who have completed
a minimum of asbestos awareness and practical training, have a fitted approved respirator, have
assessed the asbestos register and consulted with CM Health’s asbestos support.
under
Released
51 | P a g e
Procedure:
1. Review asbestos report for the work area and work to be undertaken
2. Consult with CM Health’s asbestos support confirming work is moderate risk,
unless pre-approved or permitted to perform agreed work activity without
consultation.
3. Confirm work and work process to be undertaken, equipment and PPE required
etc.
4. Inform staff/manager in work area of activity to be undertaken including any
access or restrictions necessary whilst performing work, and precautions to be
undertaken to ensure safety of staff and associated occupants
5. Cordon off area where work is to be carried out and where required request
occupants to remove themselves from work area until approval to re-occupy has
been given
6. Set up work area in accordance with risk assessment, safe work and asbestos
controls identified, and any additional requirements provided by on site
asbestos support. Ensure floor and other surfaces are suitably protected from
potential debris/dust using plastic sheeting. - 03032020
7. Don required PPE and RPE, ensuring respirator is fit checked before commencing
work.
Act
8. Commence and complete required work in accordance with safe and agreed
controls and work methods, noting any variation in asbestos material and
condition from that reported
9. On completion of work task ensure area is assessed to ensure only minor
debris/dust generation. Proceed and clean area using agreed safe methods
ensuring area is free from any visible debris or dust. Place all waste generated
Information
into a suitable asbestos waste bag and dispose as asbestos waste.
Note: If dust and or debris is observed to be greater than minor, consult CM
Health’s asbestos support and the Hazardous Substance, Safety and Compliance
Manager, Follow requirements provided.
Official
10. Remove PPE worn by agreed safe methods, placing into a suitable asbestos
waste bag, and dispose as asbestos waste
11. Remove respirator, clean and store safely
under
12. Remove cordon and inform work area safe to re-occupy and any additional
instruction necessary
Report any variation to the ACM detail described in the asbestos register entry to
the asbestos administrator.
Released
1.8.2
Asbestos Related Work Procedure – Elevated Risk Works
Equipment:
PPE, P2 fitted respirator, duct and wide PVC tap, footwear without laces or cover
shoes, plastic drop sheet 200 micron, asbestos waste bags, asbestos certified vacuum,
wet wipes, spray bottle with detergent and water set to mist, safety signage and
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barriers, containment unit, additional equipment and or air monitoring as
determined
Scope:
The
Asbestos Related Work Procedure – Elevated Risk Works is to be applied when
undertaking asbestos related work which has been assessed as having an
Elevated Risk of generating a higher concentration of ACD and debris (considered more than minor)
or removing ACM < 2m2 during proposed work and, can be safely managed using
increased safe work and asbestos controls; and no defined safe work process is
available for the proposed work task.
Elevated risk asbestos related work may only be undertaken by personnel who have
completed a minimum of asbestos awareness and practical training, have a fitted
approved respirator, have assessed the asbestos register, consulted with the onsite
asbestos support and are under the direct supervision of CM Health’s asbestos support
or has been deemed ‘competent’ to undertake the required activity without
supervision.
Procedure:
1. Review asbestos report for the work area and work to be undertaken
- 03032020
2. Consult with CM Health’s asbestos support person and the Has Subs, Safety and
Compliance Manager, confirming work is classed as Elevated Risk, unless pre-
Act
approved (permitted) to perform agreed work activity without consultation.
3. Confirm work and work process to be undertaken, equipment and PPE required
etc.
This may include the requirement for a containment cell, air monitoring and
additional controls.
4. Complete asbestos work permit
Information
5. Inform staff/manager in work area of activity to be undertaken including any
access or restrictions necessary whilst performing work, and precautions to be
undertaken to ensure safety of staff and associated occupants
6. Cordon off area where work is to be carried out and where required request
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occupants to remove themselves from work area until approval to re-occupy has
been given
7. Set up work area in accordance with risk assessment, safe work and asbestos
controls ide
under ntified, and instruction provided by the onsite asbestos support. If a
containment cell is required CM Health’s approved asbestos removal contractor
or competent worker shall erect.
Note: Where air monitoring is required, work may only commence once air
monitoring has been set up and, approval to commence work is given.
Released
8. Don required PPE; ensuring respirator is fit checked before commencing work.
9. Commence and complete required work in accordance with safe and agreed
controls and work method, supervision and instruction provided, noting any
variation in asbestos material and condition from that reported
10. Upon completion of work commence site clean-up in accordance with agreed
safe method and instruction provided. Decommission containment cell if used.
Place all waste generated into an asbestos waste bag and dispose as asbestos
waste
11. Remove PPE worn by agreed safe methods, placing into a suitable asbestos
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waste bag, and dispose as asbestos waste
12. Remove respirator, clean and store safely
13. Advise the Has Subs, Safety and Compliance Manager of works completion.
Note: The work area cordon may only be removed once the asbestos supervisor
confirms their agreement to remove and, where air monitoring has been
completed approval to re-occupancy has been granted
14. Provide air monitoring results to workplace and workers where performed.
Report any variation to the ACM detail described in the asbestos register entry to
the asbestos administrator.
1.8.3
Emergency Asbestos Procedure - Overview
Equipment: Minimum – PPE (P2 fitted respirator (disposable if fitted respirator unavailable for
‘threat to life’ emergencies). Recommended, duct and wide PVC tape, cover shoes,
plastic sheeting (200 micron), asbestos waste bags, asbestos certified vacuum, wet
- 03032020
wipes, spray bottle with detergent and water set to mist, safety signage and barriers,
containment unit, additional equipment and or air monitoring as determined.
Act
Scope:
The
Emergency Asbestos Procedure is to be applied when:
An uncontrolled excess release of asbestos material, including dust, occurs during
approved related work, defined safe work process or facility failure, i.e.
considerably more than minor; or
Critical work must be carried out, in a location known to present a high risk of
releasing ACM or ACD, which cannot be delayed due to a need to maintain life/life
Information
preserving services; and, limited time to initiate appropriate asbestos controls.
Activity undertaken in accordance with this procedure should be performed by personnel
who have completed a minimum asbestos training, are in possession of a fitted P2
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respirator; and, have consulted with CM Health’s asbestos support; and where possible
under their direct supervision.
NOTE: Emergency work involving asbestos is to be delayed as long as practically possible
under
to ensure appropriate consultation, the highest asbestos controls can be determined,
initiated and utilized etc.; unless there is an imminent ‘threat to life’ whereupon the
highest available controls and safe work procedures must be used to preserve life.
Procedure:
1. Immediately cordon off/secure area, and evacuate if occupied
Released
Note: Where it is not possible to consult, notify Facilities, and or Duty manager
(after hrs), to progress consultation and requirement for additional
asbestos controls and support etc. Commence work using the highest
level of PPE and asbestos controls available. (minimum coverall and fitted
respirator)
2. Where time permits consult with CM Health’s asbestos support and or the Has Subs,
Safety and Compliance Manager. Confirm work and safe work process required and
to be undertaken, equipment and PPE required etc.
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3. Inform staff/manager of work area if not already undertaken (This may require
additional resource e.g. Duty manager +/- security
4. Set up work area in accordance with consultation and emergency risk assessment.
A containment cell should be set up prior to the commencement of any work unless
‘threat to life’ is imminent; and where possible, cessation of mechanical air
handling.
Note: Air monitoring shall commence at the earliest opportunity
5. All required personnel to don full asbestos PPE including fitted respirator; ensuring
respirator is fit checked before commencing work.
(Where a ‘threat to life’ is imminent and a fitted respirator is not available, a
disposable P2 respirator may be used briefly to alleviate immediate risk. This
must be replaced with a fitted respirator as soon as practicable)
6. Commence and complete required work in accordance with safe and agreed controls
and work methods, and or supervision and instructio
- 03032020
n as provided/obtained to
minimise release of and potential exposure to airborne asbestos.
Act
At the earliest opportunity CM Health’s asbestos support service shall take charge of
any asbestos work necessary, in collaboration with the senior engineer on site to
ensure the emergency situation does not result in significant disturbance of asbestos
dust/debris and, required site clean-up and disposal of asbestos waste (including PPE
etc.) occurs in accordance with agreed safe practice, asbestos regulation and
required notifications. Information
7. CM Health’s asbestos support service shall in consultation with the Duty, Facilities
and or Has Subs and Compliance managers determine monitoring, assessment and
additional management, i
Official ncluding required asbestos remediation required. The
Facilities and or Has Subs and Compliance manager will initiate and ensure these
requirements are communicated and achieved before the site is released for re-
occupation and or use.
under
8. Required clearances obtained, air monitoring results provided to all involved parties
9. Site cleared for re-occupation and/or use by CM Health’s asbestos specialist or
supervisor as determined
10. Incident reported, and investigation performed as per CM Health policy and
Released
procedure.
11. Staff potentially or having been exposed to airborne asbestos provided OHSS
consultation. Other parties informed to seek follow up with their GP/employer if
contractor on site.
12. Update asbestos register
Permit To Work – Asbestos Related Work
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WORK PERMIT: Asbestos Related Work
To access and undertake work in areas known or presumed to have asbestos material (ACM)
present; and perform work that may create or disturb minimal amounts of asbestos containing
dust.
NOTE:
Asbestos Related Work may only be undertaken by suitably trained and
competent personnel, and receipt of Permit approval.
SECTION 1: Job Detail
Date/s for Works/ Activity: ………………………………………………………
Times: …………………………………
Location and brief description of work:
…………………………………………………………………………………
1.1 Wil the proposed work disturb or generate asbestos containing dust?
Yes / No
(Proceed to Section 2 if response is NO)
1.2 Is asbestos dust generation or disturbance to be deemed more than minimal?
Yes / No
- 03032020
Section 2: Safe Method of Work (SMOW)
2.1 Is an approved CMH
SMOW to be used to undertake the required work?
Act
Yes / No
Confirm which
SMOW is to be used: ………………………………………………….…
(Proceed to Section 3 if response is YES)
2.2 Has a job specific
SMOW been developed for the proposed task?
Yes / No
Information
2.3 Has the delegated CMH representative from facilities provided
SMOW approval?
Yes / No
If any response is NO, complete Part 2 over page and or obtain required
authorisation below
Official
SMOW Authorisation: (
SMOW may only be authorised by the facilities manager or their delegate)
Section 3: Permit Approval: (Approval may only be obtained from the facilities manager or their delegate)
Does the worker have
under the required asbestos training and competencies required to
perform the work safely and in accordance with all H&S legislation?
Yes / No
Are all procedures and work tasks to be undertaken authorised?
Yes / No
Have all hazards and risks been identified, communicated and mitigated?
Released
Yes / No
Permit approval may be provided if all requirements have been achieved
Section 4: Worker Confirmation
I confirm the activity or work authorised wil be undertaken in accordance with the requirements of this permit and
approved safe method, CMH policy and procedures.
Signature: …………………………………………………………. Date: ………………………………………………..
Print Name: ………………………………………………… Company Name: …………………………………………………........
NOTE:
All activity or work MUST STOP immediately if new asbestos materials are
discovered or significant dust generation occurs.
Section 5: Cancellation of Permit (To be completed by Permit Approver or Worker completing work)
I confirm activity or work authorised in this permit has been carried out and completed safely in accordance with
the safe method, with no asbestos material identified, fibres disturbed; and the work area has been secured.
Signature: …………………………………………………………….. Date: ……………………………………………..
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Safe Method of Work
- 03032020
Act
Information
Official
under
Released
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Document Outline
