2020 03 02 Asbestos Management.pdf

POLICY

Asbestos Management

Policy Responsibilities and Authorisation
Department Responsible for Policy
Property and Infrastructure
Document Facilitator Name
Mark Whatnall
Document Facilitator Title
Health and Safety Advisor
Document Owner Name
Chris Cardwell
Document Owner Title
Executive Director, Facilities and Business
Target Audience
Waikato District Health Board employees
Committee Approved
Policies and Guidelines Committee
Date Approved
5 October 2017
Committee Endorsed
Executive Group
Date Endorsed
3 November 2017
Disclaimer: This document has been developed by Waikato District Health Board specifically for its
own use. Use of this document and any reliance on the information contained therein by any third party
is at their own risk and Waikato District Health Board assumes no responsibility whatsoever.

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POLICY

Asbestos Management

Policy Review History
Version
Updated by
Date Updated
Summary of Changes
06
Emma Barriball
1/08/2017

07
Mark Whatnall
5/10/2017
Revision of Acronyms

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POLICY

Asbestos Management

1.  Introduction
1.1  Purpose
The purpose of the Waikato District Health Board (DHB) asbestos management policy is
to ensure that where asbestos presence has been identified, it shall be managed in such
a way as to protect Waikato DHB employees, patients, visitors, contractors and others
from potentially hazardous exposure to Asbestos Containing Material (ACM).

1.2  Background
Asbestos is a natural product that has been used extensively over the years for both
domestic and industrial applications. Exposure to asbestos or exposure to airborne
concentrations of asbestos dust and fibres can cause asbestosis or pulmonary fibrosis,
lung cancer and mesothelioma.

1.3  Scope
This policy applies to all persons working within Waikato DHB, including contractors and
persons acting as agents of Waikato DHB or engaged in Waikato DHB activities in all
areas of the organisation.

2.  Definitions
Asbestos
Means a actinolite, amosite, chrysotile, crocidolite, fibrous anthophyllite or
tremolite; or a mixture containing a mineral as above; or a material
compose wholly or partly of any such mineral; or a material or article that is
contained by any such mineral
Amosite
Brown Asbestos, a straight, brittle fibre, light grey to pale brown
Anthrophyllite
A brittle white to brown fibre
Crocidolite
Blue Asbestos, a straight flexible blue fibre
Chrysotile
White Asbestos, a fine, silky, flexible, white to grey/green fibre.
Friable
Is a state where asbestos under ordinary conditions can be easily crumbled.
Safe systems of work  Safe systems of work can be defined as a formal procedure comprising a
systematic examination of a task in order to identify all the associated
hazards.
Then through Risk Assessment processes defines safe methods of work
and controls to ensure that the hazards are eliminated and/or the risks
minimised to an acceptable level.

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POLICY

Asbestos Management

3.  Policy Statements
The Waikato DHB policy for asbestos management is that, Waikato DHB, its employees and
agents, shall take all practicable steps to:
•  Maintain an active and comprehensive Asbestos Management Plan for the environmental
management of Asbestos containing material. The plan, which administered by Property
and Infrastructure (P&I), includes surveys, on-going identification, risk assessment,
removal, encapsulation and monitoring protocols in keeping with the requirements of the
Health and Safety at Work (Asbestos) Regulations 2016.
•  Ensure that there are effective emergency procedures for dealing with incidents within the
Asbestos Management Plan.
•  Ensure compliance with guidelines for the Management and Removal of Asbestos.
•  Ensure that there is an effective programme of Health Monitoring maintained by the Health
and Safety Service who also maintain a central register of persons exposed to asbestos in
the course of their work at Waikato DHB.

4.  Policy Processes
4.1  Roles and Responsibilities
All Staff
Abide by any signage, instruction regarding the presence/non disturbance of Asbestos
Containing Material. To report any concerns or uncertainties over any material that is
suspected to contain ACM to Health & Safety Advisor for P&I.

Managers
Escalate any concerns over potential ACM or disturbance of ACM to P&I Health and
Safety Advisor. Ensure areas of concern are effectively isolated prior to investigation by
P&I.

Employees of Property and Infrastructure
Attend Asbestos Awareness training provided in house at regular intervals by P&I Health
and Safety Advisor. Understand how to access Asbestos Register and be conversant with
building product types that may contain ACM. Report any concerns over any potential
ACM to Health & Safety Advisor (P&I) Ensure that there is no disturbance of any material
suspected to be ACM.

Contractors
Understand how to access advice and information through P&I Health & Safety Advisor.
Be conversant with building product types that may contain ACM. Report any concerns
over any potential ACM to Health & Safety Advisor (P&I) Ensure that there is no
disturbance of any material suspected to be ACM without prior written approval from P&I.

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POLICY

Asbestos Management

5.  Audit
5.1  Indicators
•  Six monthly monitoring to be undertaken of all ACM where there is a likelihood that
the material may become friable
•  Yearly monitoring of ACM that is not likely to become friable.

5.2  Tools
•  Survey reports
•  Air monitoring samples
•  Swabs

6.  Legislative Requirements
6.1  Legislation
Legislation relevant to this policy includes but is not limited to:
•  Health and Safety at Work Act 2015.
•  Health and Safety at Work (Asbestos) Regulations 2016

6.2  External Standards
•  The Approved Code of Practice for the Management and Removal of Asbestos.
Worksafe NZ 2016
•  Technical Bulletin Management and removal of asbestos (for Asbestos Removal
Supervisors) 2016

7.  Associated Documents
7.1  Associated Waikato DHB Documents
•  Waikato DHB Health and Safety policy (Ref. 0044)
•  Waikato DHB Hazard Management policy (Ref. 0051)
•  Waikato DHB Design and Construction policy (Ref. 1781)

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POLICY

Asbestos Management

Appendix A Asbestos Management Plan

1.  Introduction
2.  Buildings Survey
3.  On-going identification of ACM
4.  Risk Assessment
5.  Removal (Elimination)
6.  Encapsulation (Isolation)
7.  Monitoring
8.  Planned Inspections
9.  Communication
10.  Standards for working with ACMs
11.  Summary of Decision making for reasons/decisions about the management of Asbestos
12.  Procedures for dealing with incidents or emergencies

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POLICY

Asbestos Management

1.  Introduction
This Asbestos Management Plan, together with the Asbestos Management Policy and the
Building register has been prepared to guide the systematic, consistent and safe assessment
and management of asbestos containing material within Waikato District Health Board
properties or occupancies. Asbestos is identified and managed in keeping with the Asbestos
Management Policy (‘the policy) and this plan so that workers, patients and visitors are
protected from potentially hazardous exposure to asbestos containing material.

Management of asbestos containing material will be ongoing and will be supported by regular
visual inspections. Where there is any potential disturbances resulting from removal or other
activity then there will be, among other things, environmental monitoring for airborne asbestos
or Synthetic Mineral Fibres (‘SMF’) fibres.

P&I will take all practicable steps to identify and manage Asbestos Containing Material (‘ACM’)
on all Waikato District Health Board sites, both owned and leased. In doing so, it will ensure
that identification and assessment of risk arising from ACM identified Asbestos is recorded in
the Asbestos Register which is retained in the Operations Engineers’ office. This information,
together with the Policy and Plan, is canvassed with other Persons Conducting a Business or
Undertaking (‘ PCBU’)s  and workers where relevant and in keeping with the risk of exposure
to ACM. A record is kept of consultations with other PCBUs and this record is maintained by
the Health and Safety Advisor. In turn Waikato DHB will take all reasonably practicable steps
to verify the effective management of ACMs in buildings where it has a tenancy. The Asbestos
Register will identify what measures have been applied to the identified Asbestos, where
removed or encapsulated and the date the measure was applied. In addition, the register will
record the dates of inspection/review as well as the expected intervals for re-inspections/
review.

2.  Buildings Survey
Several surveys have provided a comprehensive picture of the distribution, type and condition
of ACM on the Waikato Campus and in addition the four ‘T’ Hospitals – Thames, Tokoroa,
Taumarunui and Te Kuiti. Smaller units have also been appraised including Matariki and
Rhoda Read.

Accessible areas of buildings have been inspected. Records indicating the different types of
asbestos are included in the Building Register. The Asbestos Register records the means of
control – for example – elimination, isolation, encapsulation and or monitoring.

3.  On-going identification of ACM
Product that is suspected of containing asbestos fibre may be identified through:
a)  Planned inspections
b)  Notifications
c)  Response to reports of damage or accident
d)  Renovation, demolition or other work that reveals hitherto unknown or inaccessible areas.
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POLICY

Asbestos Management

Where possible, samples of suspected ACM will be collected by registered competent
Asbestos removers for analysis and confirmation. The areas shall remain isolated and
undisturbed during the testing and decisions made to eliminate, isolate or minimise the
hazards.

4.  Risk Assessment
•  Significant/High risk: friable (unbonded) ACM that has deteriorated significantly. The
material is readily accessible and prone to further disturbance, or unsealed friable asbestos
material located in air conditioning systems.
•  Moderate risk: minor deterioration of the ACM is evident and/or the ACM is prone to
mechanical disturbance due to routine building activity and/or maintenance
•  Low risk: ACM shows no signs or very minor signs of damage/deterioration. Regular access
to the ACM is unlikely to cause significant deterioration, if the material is adequately sealed.
•  If materials of unknown composition, or materials suspected of containing asbestos, are
encountered on site, and are not documented in the existing asbestos register, such
materials are to be sampled and treated as asbestos until sample analysis confirms
otherwise. In the event that demolition or refurbishment works are to be carried out in areas
previously not inspected for the presence of asbestos, such as inaccessible wall cavities or
beneath floors, an inspection and risk assessment must be performed by an appropriately
qualified person prior to the commencement of the planned demolition or refurbishment
works.

5.  Removal (Elimination)
Asbestos has been removed from a large number of locations and this has been performed by
specialist asbestos removers with appropriate Certificates of Competence. Records of removal
air clearance tests are located in the Hazard and Compliance Co-ordinator’s office. Copies of
air clearance tests are also found on J
Drive>ESUPP>Compliance>Asbestos>Location>Buildings. All practicable steps will be taken
to remove all ACM which poses a risk through deterioration (into friable state) demolition,
renovation or other activity prior to the work being performed in keep with reg 29 of the Health
and Safety at Work (Asbestos) Regulations 2016.

6.  Encapsulation (Isolation)
Where it has not been feasible to remove ACMs, but necessary to control or prevent future
friability then asbestos is encapsulated so that the product is sealed and is significantly less
prone to crumbling, disintegrating, or other damage that would give rise to the release of
asbestos fibres. This will generally apply only to moderate or low risk work unless there are
exceptional circumstances.

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POLICY

Asbestos Management

7.  Monitoring
Monitoring of encapsulated or bonded asbestos, by means of visual inspection and air
sampling is carried out where there are concerns about the potential release of asbestos
fibres. Airborne asbestos fibres monitoring should be carried out during any asbestos removal
or rectification works, when persons access areas containing ACMs or to confirm background
concentrations of asbestos fibres are within safe levels. Whenever this monitoring is carried
out, the results are to be recorded in the Asbestos register. All monitoring samples will be
tested by a qualified Laboratory and the results passed back to Property & Infrastructure in
report format. Friable asbestos needs to be appropriately controlled and then monitored 6
monthly if not eliminated.

8.  Planned Inspections
Non-friable asbestos will be subject to at least an annual visual inspection by a competent
person. Friable asbestos will be safely controlled and, if not eliminated, then subject to a six
monthly review. The reports detailing the results of the reviews are recorded in the Hazard and
Compliance Co-ordinators Office and on J
Drive>ESUPP>P&I>Compliance>Asbestos>Location>Buildings. Where there is any suspicion
that the ACM has deteriorated to the point of being friable then the area will be safely isolated
and subject to testing and elimination, isolation or minimisation in accord with specialist advice
from a specialist remover with appropriate Certificates of Competence.

9.  Communication
1)  Where practicable, ACMs are to be labelled in keeping with the requirements of the Health
and Safety at Work (Asbestos) Regulations 2016.
2)  P&I staff will be trained, as will relevant contractors, in the fundamentals of asbestos
management including but not limited to:
•  Characteristics of Asbestos
•  Inspection and identification of Asbestos; and
•  How to access the Asbestos register; and
•  What to do in the event that you suspect presence of asbestos or suspect that controls
have failed.
•  Record training given
3)  Ensure that there is information provided to PCBU’s regarding Waikato DHB’s asbestos
management plan and the availability of the register. There is a commitment to ensure
adequate appraisal by Health and Safety Advisor of all plans that may involve the exposure
to asbestos containing material. Logs of communication with other PCBUs are recorded in
Appendix E

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POLICY

Asbestos Management

10.  Standards for working with ACMs
All maintenance on, or removal of, asbestos containing materials is only to be undertaken by
specialist asbestos removers who have appropriate certificates of competence and the
relevant classes for the intended removal. No other personnel workers or volunteer shall
undertake any work that involves the disturbance of asbestos materials. Some common types
of removal are prescribed below:

Asbestos Pipe Lagging/Contamination:
The following elements are to be validated by the P&I Health and Safety Advisor in all Safety
Management Plans and Work Method Statements that are to be submitted by the specialist
asbestos remover (in keeping with P&I’s standing procedures for high risk work). This list is
not exhaustive and services as a checklist for critical safety controls that would be expected in
the setting of this work activity. The task analysis will obviously be in the context of the specific
work environment and hazards arising and will be appraised by the Health and Safety Advisor
prior to the commencement of work.
•  Barricades with appropriate warning signs to be placed approximately 10 metres from each
work area.
•  At least 2 layers of 200 micron thick plastic sheeting to be placed on the floor of each
removal area and a plastic encapsulation is to be erected to form an airtight enclosure. All
openings such as vents, penetrations to be sealed.
•  4 stage wet decontaminator units to be set up in a central location and attached to the
encapsulation.
•  All persons entering the work area to wear disposable coveralls and approved respiratory
protective equipment.
•  The asbestos material and contamination is to be wetted prior to removal.
•  Following completion of asbestos removal the work area is to be detail cleaned using
vacuuming (HEPA Filters) and wet wiping. All framing, pipes, ducts. Other items to be both
vacuumed and wet wiped of all asbestos contamination.
•  Following cleaning the area is to be inspected to verify that all visible traces of asbestos
have been removed and all surfaces to be sprayed with a PVA sealant following completion
of the visual inspection.
•  Air monitoring to be carried out adjacent to the barricades and in the clean end of the
decontamination unit during the removal work and inside the work area at the completion of
PVA spraying.
•  On receipt of clearance air monitoring results of <0.01 fibres/ml of air the enclosure plastic
may be removed and disposed of as asbestos waste.
•  Copy of clearance certification to be forwarded to Property and Infrastructure, Hazard and
Compliance Co-ordinator on completion.

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POLICY

Asbestos Management

Asbestos Cement Sheet
The following elements are to be validated by the P&I Health and Safety Advisor in all Safety
Management Plans and Work Method Statements that are to be submitted by the specialist
asbestos remover (in keeping with P&I’s standing procedures for high risk work). This list is
not exhaustive and services as a checklist for critical safety controls that would be expected in
the setting of this work activity. The task analysis will obviously be in the context of the specific
work environment and hazards arising and will be appraised by the Health and Safety Advisor
prior to the commencement of work.
This procedure is, of course, only relevant, where the work envisaged will or is likely to disturb
the asbestos cement sheet. Other work in adjacent areas which does not disturb the ACM may
be undertaken without special precautions.
•  Plastic sheeting to be placed on the floor or ground of the area in which the work is to be
undertaken.
•  Barrier tape with appropriate signage is to be placed approximately 10 metres from the
work area so as to prevent unauthorised access.
•  All persons entering the work area to wear disposable coveralls and approved respiratory
protective equipment.
•  If asbestos cement sheet has to be disturbed, it is to be wetter to suppress any dust
generated from the work. Approved vacuum cleaners, with HEPA filters, are to be used
during the work to collect dust or debris generated by the work.
•  At the completion of the work the area is to be thoroughly vacuumed and all plastic and
disposable coveralls are to be sealed in the plastic bags for disposal.
•  Copy of clearance certificate to be forwarded to Property and Infrastructure on completion.

Bonded Asbestos Products such as Vinyl Floor Tiles and Electrical Backing Boards
The following elements are to be validated by the P&I Health and Safety Advisor in all Safety
Management Plans and Work Method Statements that are to be submitted by the specialist
asbestos remover (in keeping with P&I’s standing procedures for high risk work). This list is
not exhaustive and serves as a checklist for critical safety controls that would be expected in
the setting of this work activity. The task analysis will obviously be in the context of the specific
work environment and hazards arising and will be appraised by the Health and Safety Advisor
prior to the commencement of work.
•  Where appropriate, plastic sheeting is to be placed on the floor of the area in which the
work is to be undertaken.
•  Barrier tape with appropriate signage is to be placed approximately 10 metres from the
work area in order to prevent unauthorised access.
•  All persons involved in the maintenance work are to wear disposable coveralls and
approved respiratory protective equipment.
•  All dust and debris generated during work is to be collected and placed in plastic (double
bags) for disposal.
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Asbestos Management

•  At the completion of the work, the area is to be vacuumed (HEPA filter vacuum) and all
accessible surfaces cleaned using wet wipes. All plastic and disposable coveralls are to be
sealed in plastic bags for disposal.
•  Area to be inspected by a competent person (licenced asbestos assessor) to verify that all
visible asbestos debris has been satisfactorily removed.
•  Copy of clearance to be forwarded to building engineer on completion.

11.  Summary of decision making for reasons/decisions about the management of
Asbestos
•  Waikato DHB’s ultimate goal is for all sites to be free of ACM.
•  The removal of ACM during renovation, refurbishment and/or maintenance, will be a priority
(where practicable), in preference to other control measures such as enclosure,
encapsulation or sealing.
•  Reasonable steps will be taken to identify all possible locations of ACM. Where ACM is
identified or presumed, the locations must be labelled and recorded in the Building Register
•  A risk assessment must be conducted for all identified or presumed ACM
•  Control measures will be established to prevent exposure to airborne asbestos fibres and
will take into account the results of risk assessments conducted for the identified or
presumed ACM.
•  If ACM is identified or presumed, workers will be consulted, involved and information
provided during implementation of control measures.
•  Competent persons will be involved in the identification of ACM and conducting

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Asbestos Management

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Asbestos Management

12.  Procedures for dealing with incidents or emergencies
Emergency Response Procedures
Evacuation Event
An emergency associated with the potential for exposure to airborne asbestos fibres within a
building or across a section of campus site may necessitate the need to evacuate. Site
procedures for evacuation are to be conveyed to contractors and employees during the site
induction. The risks associated with any asbestos removal work should be assessed and
include contingencies in the case of an emergency.
Decontamination procedures can be temporarily waived in the event of an emergency
requiring evacuation. This is to be based on an informal risk assessment conducted at the
time.
Upon arrival at the evacuation point, emergency wardens and health and safety personnel are
to be notified of the status of the asbestos removal work and the assessed level of risk
associated.
Events likely to require evacuation during asbestos removal work include but are not limited to:
•  Fire evacuation
•  Chemical spill and contamination
•  Gas leak/contaminated atmosphere

Spills or Damage
Where suspected spills or damage has occurred to asbestos material, lagging, sealants,
covers etc the following is to be implemented wherever practicable by a specialist licenced
remover:
•  The site emergency contact number 99777 is to be used to report the location of the
potential contamination.
•  Competent workers are to respond (wearing suitable respiratory protection, gloves and
disposable coveralls), assess the risks associated with the spill and secure the affected
area, plant or equipment using asbestos warning tape and signs.
•  Ensure any exhaust extraction, air conditioning systems, fans, wind sources are controlled
to prevent further spread of the contamination.
•  The areas below and adjacent or above are secured and barricaded with asbestos warning
tape to prevent materials dropping or passing into those areas – (attention is paid to ledges,
tops of ducts/pipes, cracks in the floor, folds in the cladding, crevices and material in the
grid mesh flooring)
•  Use surface soaking sprays to wet down the material and obtain a bagged sample of the
suspect material, or
•  Use plastic sheeting and adhesive tape to seal or encapsulate the affected area or plant
•  Use materials such as plastic drop sheets, bunding material and or suitable adsorbent
material to contain the water spray and run off.
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Asbestos Management

•  Clean up the affected areas using suitable tools (soft brushes, mops, dust pans etc) and if
necessary vacuum using HEPA filters.
•  Apply sealant or repairs to the damaged areas to prevent further contamination
•  Inspect the work to ensure all suspect materials have been removed
•  All contaminated articles and clothing are to be bagged in suitable asbestos disposal bags
and be disposed of as asbestos waste
•  Set up an air monitor in the work area to monitor airborne fibre concentrations and secure
the work area until the results are obtained.
•  Send the sample off for testing and determine if it contains asbestos
•  Undertake further asbestos removal work to make the area safe using a safe work method
statement and an asbestos remover
•  Provide details of the material sample results and monitoring results to the workers involved
who may have been exposed.
•  Undertake medical assessments of the workers involved who may have been exposed and
provide copies of the assessments to the workers.
•  Maintain records of the incident reporting, investigation and health assessments within the
Asbestos Exposure Register.

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