File 08d.2 PFR Asbestos Investigation Findings 16.04.18 FINAL 002 Reda....pdf

STRICTLY CONFIDENTIAL

ASBESTOS INVESTIGATION

Summary of Findings Report

16 April 2018

To:
)
Plant and Food Research
Mt Albert Road
Mt Albert
Auckland

From:

Thompson & Clark Investigations Ltd
Ph:

@tcil.co.nz

link to page 3 link to page 4 link to page 4 link to page 6 link to page 8 link to page 8 link to page 9 link to page 10 link to page 11 link to page 11 link to page 11 link to page 12 link to page 13 link to page 13 link to page 14 link to page 14 link to page 15 link to page 15 link to page 18 link to page 19

Thompson & Clark Investigations Ltd                     Plant & Food Research
CONFIDENTIAL

  EXECUTIVE SUMMARY

On  13  February  2018, Thompson  &  Clark Investigations (T&C)  commenced  an  investigation  on
behalf of Plant and Food Research (PFR) into the recent discovery of asbestos containing material
located in the Plant room of the Annex building, 120 Mt Albert Road, Sandringham, Auckland. The
enquiry was initiated at the request of Worksafe New Zealand.

Refurbishment of the PFR Hamilton building and Annex Plant room commenced in 2015 with the
removal of Asbestos Containing Material (ACM) from the Plant room, followed by the six floors and
Risers within the principal building.

  were  appointed  as  the  contractors  to  undertake  the  refurbishment  process,
assigning
to undertake the removal of ACM and subsequent disposal of these
materials.

No  evidence  has  become  apparent  to  suggest  that  any  party  involved  in  the  asbestos  removal
process  and  subsequent  clearance  has  been  negligent,  however  through  a  lack  of  cohesion
between and within operating entities the issues as described below have arisen. This has been
further exacerbated by an apparent regression in communication and relationships between these
entities.

With significant legislative changes pertaining to asbestos removal, a requirement for an increase
in  PCBU  (Person  Conducting  a  Business  or  Undertaking)  engagement  across  all  contractor
responsibilities will be required going forward into the new legislative environment and forms part
of the recommendations in this report.

Recommendations arising from this investigation have been identified from an external perspective.
Included  is  the  continued  engagement  of  an  independent  asbestos  expert  throughout  the
remainder of the refurbishment project and the establishment of an overall governance document
specific to the removal of asbestos. Parallel to this are the obligations of the ‘Officer’, or CEO to
ensure  direct  involvement  in  this  risk  is  mitigated  through  robust  processes  and  contractor
awareness. Further, a lack of cohesion and communication is apparent between the various entities

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Thompson & Clark Investigations Ltd                     Plant & Food Research
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involved and a result of the exclusion of an overall governance process specific to the removal of
asbestos.

Despite this disconnect in processes, the risk to PFR staff and contractors is considered, and has
been assessed, to be very low.

This  report  discusses  findings  from  the  investigation  undertaken  and  makes  recommendations
based  on  information  discovered  during  the  course  of  this  inquiry.  External  contractors  were
requested  (by  TCIL  &  PFR)  to  participate  in  the  investigative  process  and  despite  best  efforts
neither party responded during the course of the 8-week enquiry to requests for interviews or written
questions provided by TCIL. It is not anticipated, however, that their input would greatly influence
the outcomes of this report.

  SITUATION

2.1. Background

Completed in 1972, the Plant and Food Research Hamilton building consists of a six-level design,
with a level seven plant/motor room. Immediately adjacent to the principal building is a two-level
Annex  building  containing  a  Plant  room  beneath.  A  seismic  concrete  wall  separates  the  two
structures.

As  is  common  with  construction  of  this  era,  asbestos  material  was  utilised  throughout  the
construction phase. This material provided high tensile strength, insulation benefits, is of a fibrous
nature and a strong heat resistance component is exhibited by the mineral. Due to the versatile
nature  of  the  product,  asbestos  was  widely  used  in  building  and  construction methods from the
1930’s until the mid-1980’s, when it was subsequently banned in New Zealand. Three principal
fibres: Chrysotile (white), Crocidolite (blue) and Amosite (brown) are present in the material and
have the potential to become harmful when airborne. Chrysotile is considered the least harmful of
the three fibrous components.

Prior to undertaking refurbishment of the Hamilton building, various alternatives were investigated
by  PFR  to  facilitate  business  continuity  requirements.  These  included  the  procurement  of
alternative  locations,  and  the  construction  of  Building  ‘F’  at  120  Mt  Albert  Road.  In  April  2012

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Thompson & Clark Investigations Ltd                     Plant & Food Research
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recommendations  were  presented  to  the  PFR  board  which  included  a  refurbishment  method  of
vacating upper levels of the existing Hamilton  building  while asbestos removal and construction
was  undertaken,  progressing  down  to  lower  levels.  This  became  the  methodology  for  asbestos
removal and construction refurbishment activities.

Asbestos  surveys  have  been  conducted  by
,  on  four  separate
occasions, the most recent being January 2018.  In a Survey report furnished in December 2014,
the  significant  presence  of  asbestos  was  highlighted  throughout  the  Hamilton  building.  This
included, but was not limited to, spray coating and debris throughout areas such as ceiling voids,
risers, motor room, gaskets and pipework. A high degree of contamination was highlighted, with
the  asbestos  fibre  type  physically  identified  as  friable  and  Chrysotile  in  nature.  This  report  also
referenced the presumption of the presence of SP Crocidolite fibres throughout.

Construction  and  refurbishment  of  the  Hamilton  building  commenced  in  early  2015  by

.  Included  in  this  contract  was  the  removal  of  ACM  from  the  Hamilton  building  and
adjoining Plant room. Areas including the lift shafts and Annex levels one and two were excluded
from the scope of this project – reason for this being that there was no refurbishment activity being
conducted in these areas at the time therefore presenting a low risk of contamination. The risk of
airborne asbestos fibres was considered low and the ACM used during construction was deemed
to be in a stable condition.

Removal of ACM began in the Annex Plant room, followed by the preferred methodology of clearing
the upper levels of the Hamilton building, then descending down levels as each floor was cleared
of asbestos. This reflected the document furnished to the PFR board in April 2012.

Focus on the removal of the ACM from the Plant room centred around the porous concrete cinder
block ceiling. Asbestos spray coating was removed from these blocks and remaining material that
could  not  be  practically  accessed  was  encapsulated  using  an  asbestos binding  compound. The
entire floor and walls of the Plant room were enclosed in black polythene sheets while the ceiling
was cleaned.

In  July  2015,  representatives  of
  conducted  visual  inspections  and  air
monitoring in the Plant room in accordance with accepted standards at the time. This occurred prior
to and immediately after the polythene sheeting was removed and was conducted using lighting

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Thompson & Clark Investigations Ltd                     Plant & Food Research
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from torches, as electrical lighting was unavailable at that time.  Initial asbestos tests included visual
and  air  monitoring  procedures,  followed  by  swab  sampling  conducted  on  the  1  July  2015.  Two
swab tests produced positive results. Amosite fibre was located at the South end of the Plant room
and  Chrysotile  on the West  side fire  hose reel.  Subsequent  testing  on  the  6  July  2015  at these
locations produced negative test results.

Upon  completion  of  the  clearance  procedures  in  July  2015  by
,  contractor  and  staff
access  to  the  Plant  room  was  permitted  in  order  for  construction  and  installation  of  utilities  to
commence. This included the installation of various plant, construction of walls and the instalment
of two galvanised flues from the Plant room through to the Annex ceiling inside a now sealed riser.
The asbestos removal and visual inspection report furnished by
on 1 July
2015, made reference to remaining asbestos fibres within the porous concrete cinder blocks and
in the gaps between these blocks. The porous nature of the blocks meant that it was impossible to
completely  remove  all  asbestos  fibres  without  removing  the  cinder  block  ceiling  altogether.
Therefore, the ceiling was encapsulated with an ABC (Asbestos Binding Compound).

Further  asbestos  removal  of  the  upper  levels  of  the  Hamilton  building  commenced  mid-2015,
followed by the associated construction phase of the project

Previous to these activities, it is understood that asbestos removal and encapsulation had occurred
at  the  adjoining  Cunningham  building  and  the  tunnel  connecting  the  two  buildings.    Lagging
material was removed from the services within the tunnel and encapsulating paint product applied
to the external walls of the Cunningham building.

2.2. Incident
From July 2015,
continued removal of ACM from the principal Hamilton building
and  the  subsequent  project  refurbishment  and  construction  followed  the  asbestos  clearance  at
various levels.

On 17 January 2018,
staff were instructed to commence survey work within the Annex
Building Plant room.
This request was made in order to reassure the PFR Site Manager of processes to date, before
continuing with the wider asbestos management survey.

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Thompson & Clark Investigations Ltd                     Plant & Food Research
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The  initial  visual  inspection  of  the  Plant  room  indicated  the  presence  of  asbestos  in  numerous
locations. Seven swab tests in the Plant room confirmed Chrysotile asbestos fibres were located
in various areas including dust to pipe work, door frames, machinery and floor areas. Further to
this,  five  ACM  samples  were  found  in  samples  between  the  ceiling  cinder  blocks,  on  electrical
casing, on columns and walls. Two samples in the tunnel indicated Chrysotile spray coating debris
on the floor and walls of the Plant room.

As  a  result  of  this  testing  regime,  Plant  room  access  was  restricted  and  a  notification  made  to
Worksafe New Zealand.

As a result of the Plant room asbestos findings, further monitoring and testing was conducted at
various locations within the Hamilton building.

Three swab tests were conducted in the Ground Floor Lobby area. These tests produced a positive
result  for  Chrysotile  asbestos  fibres.  On-going  air  monitoring  was  conducted  and  access  to  the
area restricted. This area had previously been cleared of ACM by
on 27
July 2015, allowing contractor and staff access to the area.

Removal of asbestos from the North Lift Motor room, level seven was initially outside of the scope
of  work  for  asbestos  removal  because  it  was  not  part  of  the  redevelopment  work.  Subsequent
activity in the motor room by various contractors later necessitated the cleaning of the North Lift
Motor  room  of  asbestos.
  provided  an  asbestos  Removal  Clearance
Certificate on 27 October 2017.

In January 2018, asbestos material was located between levels four and six of the Hamilton building
West  Riser.  This  area  was  also  the  subject  of  earlier  clearance  and
  had
completed cleaning in September and October 2015.

Asbestos in the form of sprayed ACM was located in the North lift Shaft between levels one and
four. Subsequently a swab in the North Lift produced a positive result and this area was restricted
to staff and contractors. PFR maintained regular air monitoring in this area and ensured on-going
Asbestos Surveys were conducted by
.

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Thompson & Clark Investigations Ltd                     Plant & Food Research
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  INVESTIGATION

3.1. Areas of Focus
The focus of this investigation has primarily been to establish the cause of contamination in the
Plant  room  and  subsequent  areas  during  the  refurbishment  and  construction  of  the  Hamilton
building.

Emphasis during the course of the enquiry has been placed on:
•  The asbestos removal methodology
•  Subsequent inspection reports
•  Activity in the Plant room after asbestos clearance
•  Further asbestos contamination within the Hamilton building
•  Associated risk to PFR staff and Contractors

Outside of the primary focus has been any on-going asbestos discoveries resulting from further
Asbestos Survey Reports as this risk is considered negligible.

Where  possible,  all  PFR  personnel  and  associated  Contractors  have  been  interviewed.  Refer
Appendix  C  –  Investigator  Jobsheet  which  contains  details  of  interviews  (including  private
information).

have been provided a list of questions relating to their
involvement in the asbestos removal process. To date a response to these questions has not been
received from either party. Where possible, documents of a corroborative nature have been used
to  support  findings  during  the  earlier  stages  of  the  investigation.  This  has  necessitated  the
requirement to draw some inferences where a supporting interview has not been conducted.

Past and current PFR staff have been interviewed about their involvement in the asbestos removal
process between 2014 and present.
have made available two principal
staff members for interview and have provided supporting documentation.
PFR  staff  interviewed  include:

.  Further  interviews  included
  of

  of
  and
.  Written  interview  questions  were
provided to representatives of
and
.

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Thompson & Clark Investigations Ltd                     Plant & Food Research
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Supporting documents have been obtained from over 300,000 items sourced from
, PFR
key personnel mailboxes or provided to the enquiry by contributors. These have been filtered down
to 94 relevant documents which are now included in the document schedule (Appendix A). These
documents, along with interviews have provided the foundation of the findings.

3.2. Legislation
The revised Health and Safety at Work Act 2015 and accompanying Asbestos Regulations 2016
imposed new changes & have formed an important aspect of the investigation.  Critical to this is
the  overlapping  responsibilities  for  management  and  staff  to  ensure  all  reasonably  practicable
steps are taken in the risk management process. The Act supports a strong overall governance
model and the obligations by introducing the PCBU and Officer definitions. These are defined in
the  Duty  of  Care  responsibilities  to  ensure  all  business  undertakings  are  accompanied  by
influencing and mitigating risk factors.

The Act imposed changes in the risk management process, necessitating the requirement for the
PCBU (Plant and Food Research) to consult, co-operate and co-ordinate activities to mitigate risk
to all staff and contractors under the influence of the PCBU.

These fundamental health and safety activities require:
•  The elimination of health and safety risk; or
•  Minimising  this  risk  through  the  implementation  of  controls,  as  far  as  is  reasonably
practicable.

A PCBU must ensure so far as is reasonably practicable that the health and safety of other persons
is not put at risk from work carried out as part of the business of undertaking

A duty holder (or PCBU) obligations to manage risk are limited to doing what is in their ability to
control and manage, along with what is reasonably practicable for them to do to manage the risk.
This is potentially moderated if the cost imposed to actively manage this risk is disproportionate to
the outcome.

Applicable to PFR is the specialised nature of asbestos management. Managing this risk under the
new Act may include the on-going engagement of an asbestos specialist, to provide a proactive

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Thompson & Clark Investigations Ltd                     Plant & Food Research
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and governing influence during the entire removal process. This is further reiterated by the nature
of the removal methodology and the need for business continuity.

The key question applicable to the change in legislation is:
What  is  known  or  ought  to  be  reasonably  known  about  the  hazard  associated  with  asbestos
removal and how effective are the current removal and containment processes in eliminating or
effectively controlling this risk?

The  approved  code  of  practice  for  asbestos  removal  further  highlights  the  relevant  point  that  if
asbestos  material  cannot  be  identified  but  the  presence  of  such  ACM  is  assumed  through  a
qualified professional, then this material must be considered identified and treated as such.

Further  requirements  by  Worksafe  New  Zealand  highlight  the  likelihood  of  asbestos  containing
particles and dust to be disturbed or become airborne during routine work, and consequently the
risk  to  workers  from  exposure  to  this  happening.    The  effectiveness  of  encapsulation  material
becomes important during this activity must be assessed. There is a proactive requirement by the
PCBU and Officer to ensure compliance and obligations are met.

Sections 48 and 49 of the Health and Safety at Work Act 2015 highlight the ramifications of failure
to ensure compliance is actively directed and influenced by the PCBU.

3.3. Risk
Significant research has been conducted around the carcinogenic risk of asbestos, however  on-
going studies have identified the often unpredictable nature of asbestos fibres through respiratory
exposure. The risk to individuals exposed to the fibres is complicated by an apparent latency period,
where associated disease such as Asbestosis and Mesothelioma may occur.

Asbestos  is  apparent  to  two  groups  –  Serpentine  Group,  which  consists  of  Chrysotile  or  ‘white’
asbestos  and  Amphibole  which  includes  Crocidolite  (Blue)  and  Amosite  (Brown).  Chrysotile
asbestos is considered the least harmful of the group, however recent studies have indicated this
is considerably influenced by such factors as smoking, signifying the original perception of a more
benign fibre may not accurately highlight the risk.

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Thompson & Clark Investigations Ltd                     Plant & Food Research
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Although presumptions were indicated that the PFR building contained all three types of asbestos
fibres, Chrysolite fibres are the dominant compound removed to date.

Between 16 January and 14 February 2018 extensive air monitoring was conducted.  No airborne
asbestos fibres were detected.

Maintenance activities conducted in the Hamilton building Annex Plant room presented the greatest
risk to contractors and PFR staff (limited to those staff conducting these activities within the plant
room).  The  effectiveness  of  the  encapsulation  in  this  area,  accompanied  by  the  nature  of  the
installation  and  maintenance  requirements  has  likely  had  a  significant  impact  on  asbestos
contamination identified in January 2018.

Encapsulation  is  considered  a  temporary  resolution  to  remaining  ACM’s  and  usually  only
considered when it is not practical or cost prohibitive to remove all ACM.
In January 2018, external swabs were taken of all louvre doors of the Plant room to establish if
asbestos  contamination  from  the  migration  of  airborne  fibres  had  occurred  to  the  surrounding
areas. The results of these swabs were negative indicating contamination was isolated to the Plant
room, however the risk to contractors and staff cannot be discounted.

3.4. Timeline
A Sequence of Events has been prepared to support findings of this investigation and to provide a
quick reference to relevant ‘events’ during the material time. Refer Appendix B.

  FINDINGS
Outcomes of this investigation have been based on interviews with key PFR staff and contractors.
  have  been  furnished  with  a  list  of  relevant  questions  relating  to  our
investigations, as has
. No response has been received to date from either party.
It is not anticipated however that their response will influence the outcomes of the investigation to
a large degree.

4.1. Alternative Options
Between  October  2011 and  June  2013  options  were  presented  to  the  Board  at  Plant  and  Food
Research with regards to the refurbishment of the Hamilton building, 120 Mt Albert Road, Auckland.

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At  this  time  the  building  presented  significant  structural  and  operational  concerns  including  the
deterioration  of  asbestos  material,  dated  facilities  and  compliance  considerations.    Alternative
options to maintain business continuity are explored, including the lease of a substitute premises
and the construction of building ‘F’ onsite. In April 2012 recommendations are made to the Board
which incorporated continued use of the Hamilton building by the operational staff and conducting
refurbishment  and  renovations  from  the  top  two  floors  first  and  rehousing  staff  as  construction
progressed  downwards.  Financial  and  operational  considerations  are  presented  with  the  Board
making a decision to proceed with the Hamilton Building being refurbished on a staged (floor by
floor) basis. With the benefit of hindsight, this decision may not have been the most effective.
(Document TC94 refers)

4.2. Removal Methodology
In March 2015 three Tender submissions were received by
for the removal and
disposal  of  asbestos  material  within  the  Hamilton  building  and  Plant  room.

were subsequently awarded this contract. The methodology for the removal of asbestos
was  based  on  Asbestos  Refurbishment  Surveys  completed  by
  in  2006
and 2010. The Program of Works for the building refurbishment provides further referencing for the
intended Removal Control Plan.

commenced asbestos removal and the Hamilton building Annex Plant room was
completed in June 2015. A subsequent Asbestos Removal Visual Inspection Report was submitted
to Arrow International after 6 July 2015, indicating no obvious asbestos debris or waste remaining.
Additional comments were made with regards to the asbestos remaining in the porous concrete
cinder blocks of the ceiling and the cracks between these blocks.

Asbestos removal processes then commenced in the West Riser and upper floors of the Hamilton
building.

On 26 February 2018,
of
was interviewed and outlined the current
adopted methodology around asbestos removal. Outlined during this interview is the adequacy of
the  approach  to  this  process,  given  it  is  primarily  adopted  around  the  refurbishment  and
construction plan, rather than the significant asbestos consideration. Indications are presented that
the asbestos methodology should be developed as a priority to avoid the current issues around
subsequent asbestos contamination.

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Thompson & Clark Investigations Ltd                     Plant & Food Research
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(Document  TC01,  TC03,  TC11,  TC08,  TC62,  Interview

,  Interview

refers)

4.3. Role Definition
In 2014, and over the subsequent three years, the role of Site Manager at PFR was performed by
. Over this time numerous considerations are given towards the risk to PFR staff
and contractors during the asbestos removal process from the Plant room and subsequently the
Hamilton building. These considerations are evident by the engagement of
in July
2014, and intermittently during this period. Email exchanges between the principal entities involved
in  refurbishment  and  asbestos  removal  indicate  a  lack  in  specific  role  definition  and  clarity.
Ownership  and  responsibility  for  overall  risk  management  of  the  removal  process  indicates  a
disconnect between PFR, the construction principal and asbestos removal contractors.
This is further highlighted by ACM discoveries and contamination as the project progresses.  Areas
outside the Scope of Work become relevant during removal and these issues are raised as they
are  presented  and  do  not  feature  in  any  overarching  governance  document.  Incidents  occurred
where up to three attempts were made to achieve clearance of specific areas, indicating a lack in
consistency in approach to the adopted methodology.
(TC58,  TC09  1-3,  TC21,  TC22,  TC25,  TC27,  TC28,  TC58,  TC60,  TC71,  TC74  Interview

, Interview
refers)

4.4. Intermittent engagement of expert
are considered by many in the asbestos industry as a pre-eminent authority in the
removal and management of asbestos in New Zealand.
is considered an expert in
his field and his qualifications and experience have been gained over a 35 year industry career.
During initial stages of removal at PFR, he was engaged in an ad hoc capacity, often remotely, to
provide advice to PFR staff and contractors.

provide experienced and qualified surveyors, with an IANZ accredited lab
facility. The surveys are conducted following Good Practice guidelines published by WorkSafe NZ.
Air Monitoring,  visual inspections and surface swab testing were performed by this organisation
on-site at PFR.

Contractor  methodology  was  based  on  Asbestos  Survey  Reports  provided  by

. The unique requirements for a business continuity capacity in the Hamilton building

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presented perpetual challenges. In order to successfully overcome these and avoid ongoing issues,
a holistic methodology was required to guide contractors throughout the entire process.
(TC62, TC03, TC11, TC37, Interview
refers)

4.5. Progressive Scope of Work
As outlined earlier in this report, a site-specific Scope of Work document for the removal of asbestos
during the PFR refurbishment contract has not been identified. Activities around further asbestos
discovery  and  contamination  was  of  a  reactive  nature.    The  qualitative  benefits  of  a  document
providing  a  progressive  scope  of  work  for  removal  contractors  has  become  apparent  over  the
course of the investigation.  As contractors have progressed in this project, further asbestos issues
have arisen through areas outside the initial scope of work but significant in the mitigation of risk.
Influencing  factors  again  include  the  construction  requirements  around  PFR  staff’s  on-going
operational  requirements.  Contractor  experience  with  projects  of  this  nature  is  an  important
consideration. This is reiterated through recurring asbestos contamination and further discovery of
ACM’s.  With  consideration  to  legislative  requirements  at  the  time  the  project  commenced,  a
proactive governance document, with a progressive scope of work capacity was not in existence.
(Documents TC24, TC25, TC33 refer)

4.6. PFR Response
Plant and Food Research  have progressed considerably to ensure obligations under the Health
and  Safety  at Work  Act  are  adhered  to. This  has  primarily  occurred since  the  appointment  of  a
proactive PFR Site Manager, resulting in the current issues highlighted since January 2018. The
implementation  of  a  robust  air  monitoring  regime  during  construction  and  asbestos  removal  is
accompanied by further Asbestos Surveys of a more vigorous and in-depth nature than documents
provided in 2006, 2010 and 2014. A transparent and informed approach has been adopted for staff
around  the  mitigation  of risk  associated  with  airborne  asbestos fibres,  complemented  by further
engagement of a recognised asbestos expert. Responsibilities have been accepted at an Officer
level,  under  the  Act.  PCBU  duty  of  care  obligations  to  ensure  all  steps  that  are  reasonably
practicable are taken to mitigate risk are complemented by strong input from  Health and  Safety
representatives onsite in the form of a parallel investigation into the recent contamination incident.
This is demonstrated by the Asbestos Management Plan review processes, utilising external expert
advice to incorporate crucial elements such as Trigger Response Action Plans.

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The recent appointment of a PFR Site Manager who has undertaken the specific responsibilities of
the refurbishment project has seen a more direct approach to asbestos removal activities and helps
address  the  overlapping  contractor  accountabilities  of  the  PCBU.  Something  that  has  been
previously absent. The due diligence of the PCBU includes activities conducted by contractors and
responsibilities include policy and planning, monitoring and reviewing.
(Documents TC02, TC03, TC04, TC11, TC25, TC64, TC69, TC81, TC84, TC87 refer)

4.7. Site specific risk assessment
A  document  produced  by
  and  furnished  to  PFR  in  July  2014  highlighted  the
recommendation around the use of power tools such as hammers, drills and sanders in the Plant
room.  With  the  requirement  for  ongoing  installation  and  maintenance,  a  task  specific  risk
assessment was recommended.

Between June 2015 and November 2018 PFR staff and contractors entered the plant room on thirty
documented occasions to conduct significant installation, repairs and maintenance.

Risk  mitigation  during  the  refurbishment  of  the  Plant  room  does  not  appear  to  have  been  an
established  process.  This  is  also  evident  in  subsequent  areas  within  the  Hamilton  building,
including  the  7th  floor  Lift  Motor  room,  Risers  and  Ground  Floor  Lobby.  Since  the  discovery  of
asbestos contamination in January 2018, this has been addressed, however the risk to workers in
this area should not be underestimated as the project progresses.
(Documents TC93 TC28, TC61, Interview
refer)

  RECOMMENDATIONS

Recommendation 1:
Establishment  of  an  overall  governance  approach  to  on-going  asbestos  removal  processes  to
ensure  obligations  are  adhered  to  under  HSAW  Act  2015.  Asbestos  operations  are  significant
enough to warrant the establishment of a working group and governance throughout the remainder
of the project. In retrospect, this would have been ideally implemented throughout the entire project
or  at  least  since  publication  of  the  2014  survey.  Although  not  legally  obligated  until  2016,  the
discovery in 2014 that asbestos presence throughout the Hamilton building was more significant
than originally scoped and warranted a more active role by PFR.

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See Figure 1 below as a suggested model:

  Figure 1
Recommendation 2:
Whilst a recently established Asbestos Discovery Incident Response Team ensures current health
and  safety  obligations  are  adhered  to,  this  is  of  a  reactive  nature.  A  proactive  approach  was
required  to  be  implemented  considering  the  new  legislative  requirements  on  01/04/2016.  This
would  have  ensured  a  mitigated  response  to  the  current  asbestos  issues.    By  following  the
guidance of a recognised asbestos authority, the subsequent issues associated with entity  silos

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Thompson & Clark Investigations Ltd                     Plant & Food Research
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may have been significantly allayed. This guidance would have ensured processes such as review
of encapsulation, Worksafe guidelines around encapsulation methods, Site Specific Reviews and
overall direction from the assigned Project Manager.

Recommendation 3:
Engagement of an asbestos expert to ensure continual improvement methodology is implemented
and  direct  involvement  during  further  removal  stages  of  cleaning  and  clearing  ACM’s.  This  is
recommended  to  occur  through  all  stages  of  the  project,  from  planning,  through  operational
removal,  to  final  clearance.  Increased  staff  and  contractor  awareness  around  current  risks
associated with the use of items such as power tools and migratory fibre contamination should be
incorporated in this engagement process.

Recommendation 4:
Ongoing  robust  clearance  process.  Since  the  discovery  of  ACM  in  the  Plant  Room,  detailed
Asbestos Clearance reports have been furnished by
. The content of recent
reports  (30/01/2018)  is  significant  when  compared  with  earlier  Surveys  (05/12/2014),  although
considered best practice at the time. The earlier report gives little focus towards remaining ACM’s
in the Plant room, with a total of three tests conducted, two of which were repeated after a positive
asbestos  result. When  considered  with  the  recent  Survey,  which  contains  significant  visual  and
swab  testing  results,  priority  should  be  placed  on  similar  clean  and  clear  processes.  This  is
particularly relevant given the contractor activity in the Plant room after

had provided a clearance report.

Recommendation 5:
The  implementation  of  a  robust  Contract  review  process  to  ensure  adequate  experience  is
demonstrated  during  the  procurement  stages  of  future  projects,  particularly  when  unique
undertakings  are  existent.  This  review  may  include  the  ability  for  contractors  to  demonstrate
adequate  site-specific  risk  assessments  with  asbestos  removal  and  experience  in  unique  and
challenging removal processes.

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Thompson & Clark Investigations Ltd                     Plant & Food Research
CONFIDENTIAL

  CONCLUSION

In  2015,  significant  changes  to  the  Health  and  Safety  at  Work  Act  were  implemented  into  the
workplace  on  01  April  2016.  This  along  with  the  Asbestos  Regulations  2016  and  concurrent
Worksafe  New  Zealand  guidelines  have  formed  a  significant  element  in  the  findings  of  this
investigation.

When removal of asbestos commenced in the Hamilton building plant room during the latter part
of 2014 and 2015, it is evident PFR have met their obligations under the governing legislation at
the time, The Health and Safety at Work Act 2015.

Changes  in  2016  have  required  a  contemporaneous  approach  to  be  implemented  with  matters
pertaining  to  Health  and  Safety.  This  has  not  initially  been  evident  with  the  asbestos  removal
conducted at Plant and Food Research. As the project has progressed, on-going isolated incidents
have seen a reactive response to risk mitigation, without a consistent approach by the duty holder
through resources and process.

It  is  important  to  acknowledge  that  even  without  the  existence  of  a  Health  and  Safety  incident,
governing  management  with  the  ability  to  exercise  significant  influence  over  the  business  or
undertaking, e.g. a Chief Executive, holds a responsibility. This does not become discharged and
the duty does not transfer to those who are merely advising or making recommendations.

There have been a number of broad factors that have led to asbestos contamination during the
refurbishment  of  the  Hamilton  building.  With  information  available  at  the  time,  the  decision  to
progress with a floor by floor removal and refurbishment methodology was considered the more
efficient way of performing these operations and was endorsed by the Board.  However, this has
resulted in a reduced consideration of the significance towards asbestos removal requirements and
indicated a priority on the construction and business continuity requirements.

With legislative changes to health and safety and asbestos management, there is no evidence that
these  changes  were  accompanied  by  clear  and  consistent  management  ownership  during  the
asbestos project. Accompanied by a high staff attrition rate within the construction contractor, these
factors  along  with  findings  already  specified  have  contributed  to  the  lack  of  sufficient  risk
management processes, resulting in further contamination.

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Thompson & Clark Investigations Ltd                     Plant & Food Research
CONFIDENTIAL

That  said,  it  is  important  to  reiterate  the  risk  throughout  the  project  has  been  considered,  and
assessed, as low.

It is apparent that no blame can be directed to a single party or individual and a catalogue of issues
over  a  significant  period  of  time  have  contributed  to  the  contamination  incident.  Adoption  of the
recommendations  set  out  in  this  report  would  prevent  further  health  risks  occurring  through
asbestos contamination during future refurbishment operations.


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