ACT HEALTH

ASBESTOS MANAGEMENT PLAN

CONTENTS

1.INTRODUCTION

1.1What is the ACT Health Asbestos Management Plan?

1.2Purpose

1.3Principles

1.4Scope

1.5Legislation and Other Requirements

1.6Notifiable Incident Reporting Procedures to WorkSafe ACT

1.7Definitions

1.8Review

1.9What Does this Plan Contain?

2.ROLES AND RESPONSIBILITIES

2.1Definition of ‘Responsible Persons’ Under the Legislation

2.2ACT Health Responsible Persons

2.3Responsibilities

3.THE ASBESTOS REGISTER

3.1What is the ACT Health Asbestos Register?

3.2Asbestos Register Contents

3.3Access to the ACT Health Asbestos Register

3.4Updating the Asbestos Register

3.5Review of the Asbestos Register

4.MANAGING RISKS ASSOCIATED WITH ACM

4.1Identification, Inspection and Testing

4.2Asbestos Risk Assessment (ARA)

4.3Warning Signage and Labelling of ACM

4.4Checking the Asbestos Register Prior to Construction, Refurbishment and Maintenance Works

4.5Accidental Disturbance or Discovery of ACM or Suspected ACM

4.6Risk Assessment and Removal/Encapsulation of Asbestos Containing Materials (ACM)

4.7Progressive Removal of Asbestos

4.8Air Monitoring

4.9Consultation, Education and Awareness

4.10Buildings Assessed as Being ‘Free of Asbestos’

5.REFERENCES

APPENDICES

Appendix A - Definitions

Appendix B - Roles and Responsibilities

Appendix C - Information Required in the Asbestos Register

Appendix D - Compliant Warning Signs and Labelling

Appendix E – Standard Operating Procedures

Appendix F – Asbestos Licensing and Education Guide

1.INTRODUCTION

1.1What is the ACT Health Asbestos Management Plan?

The ACT Health Asbestos Management Plan is a set of measures designed to manage the health and safety risks associated with asbestos containing material(ACM) in buildings and facilities. Facilities with confirmed or presumed ACM, require anAsbestos Management Plan under the Dangerous Substances Act 2004.

1.2Purpose

The purpose of this plan is to:

  • Provide the framework and procedures to manage the health and safety risks associated with ACM in ACT Health facilities.
  • Prevent exposure of workers and others to ACM, particularly airborne ACM.

1.3Principles

The effective management of the ACM risks is underpinned by the following principles as detailed in the National Code of Practice for the Management and Control of Asbestos in Workplaces [NOHSC:2018(2005)]:

  • The ultimate goal is for all workplaces to be free of ACM. Accordingly, consideration should be given to the removal of ACM during renovation, refurbishment and/or maintenance, where practicable, in preference to other control measures such as enclosure, encapsulation or sealing.
  • Reasonable steps must be taken to label all identified ACM. Where ACM are identified or presumed, the locations must be recorded in a register of ACM.
  • A workplace safety risk assessment must be conducted for all identified or presumed ACM.
  • Control measures must be established to prevent exposure to airborne asbestos fibres and should take into account the results of risk assessments conducted.
  • If ACM are identified or presumed, there must be full consultation, involvement and information sharing during each step of the development of the asbestos control/removal plan – i.e. during the identification, risk assessment and establishment of control measures.
  • The identification of ACM and associated risk assessments should only be undertaken by competent persons.
  • All workers and contractors on premises where ACM are present or presumed to be present, and all other persons who may be exposed to ACM as a result of being on the premises, must be provided with full information on the work health and safety consequences of exposure to asbestos and appropriate control measures. The provision of this information should be recorded.

1.4Scope

This plan applies to all ACT Health staff and contractors and to all ACT Health owned facilities. In the case of commercial facilities that are not owned by ACT Health but that are occupied by ACT Health workers, it is expected that an equivalent level of protection will be provided by the person in control of the commercial facility (e.g. the landlord).

For the purposes of this plan, ACM is taken to include suspected or presumed ACM when not explicitly stated.

1.5Legislation and Other Requirements

The following is a summary of the legislation and other requirements relevant to the management of ACM are as follows:

  • Work Health and Safety Act 2011
  • Work Health and Safety Regulation 2011
  • Dangerous Substances Act 2004
  • Dangerous Substances (General) Regulation 2004
  • Environment Protection Act 1997
  • Code of Practice for the Safe Removal of Asbestos 2nd Ed [NOHSC:2002 (2005)]
  • Code of Practice for the Management and Control of Asbestos in the Workplace [NOHSC:2018(2005)]
  • Guidance Note on the Membrane Filter Method for Estimating Airborne Asbestos Fibres [NOHSC: 3003 (2005)].

1.6Notifiable Incident Reporting Procedures to WorkSafe ACT

The accidental disturbance and/or exposure to ACM or suspected ACM is considered a notifiable incident under the legislation (section 35 - Work Health and Safety Act 2011).

The following link provides instructions on how to notify WorkSafe ACT of the notifiable incident (‘Notifiable Incident Report Form’ – WorkSafe ACT).

In addition a Riskman ‘Staff AccidentIncident Report’ (SAIR) or ACT Government Accident Incident Report (AIR) is to be completed by ACT Health workers affected and/or by the ACT Health Responsible Person.

1.7Definitions

Definitions are provided in Appendix A.

1.8Review

This plan is to be reviewed at least every five years, or sooner as is required under section 326 of the Dangerous Substances (General) Regulation 2004.

1.9What Does this Plan Contain?

Key information provided in this Plan includes:

  • Roles and Responsibilities
  • The Asbestos Register
  • Managing Risks Associated with ACM
  • Incident Reporting Procedures
  • Standard Operating Procedures

2.ROLES AND RESPONSIBILITIES

2.1Definition of ‘Responsible Persons’ Under the Legislation

Section 18 of the Dangerous Substances Act 2004defines the ‘responsible person for a dangerous substance’ (responsible person) as follows:

(1)For this Act, a person is a responsible person for a dangerous substance if the person is --

(a)a person in control of the handling of the substance; or

(b)a person in control of premises where the substance is handled; or

(c)a person in control of plant or a system for handling the substance

(2)To remove any doubt, more than 1 person may be a responsible person for a duty under this Act.

Within this plan, the terms ‘Responsible Person’ and ‘ACT Health Responsible Person’ are taken to mean ‘Responsible person for a dangerous substance’ as described in the legislation.

2.2ACT Health Responsible Persons

There are a variety of situations where ACT Health workers would be considered an ‘ACT Health Responsible Person’ in respect of managing ACM. Examples include:

  • ACT Health workers that are involved with coordinating, directing or performing work where it is expected or it is likely that ACM will be encountered, disturbed or removed (e.g. project officers that coordinate building maintenance or redevelopment).
  • ACT Health Executive and Management who have control over buildings and/or are involved in decision making that may impact on managing ACM.

Workers considered ‘ACT Health Responsible Persons’ are defined throughout this plan and in relevant SOPs.

2.3Responsibilities

A list of responsibilities in relation toACM management is provided in Appendix B. Further responsibilities are detailed throughout this plan and in relevant SOPs.

3.THE ASBESTOS REGISTER

3.1What is the ACT Health Asbestos Register?

The ACT Health Asbestos Register (Asbestos Register)is a document detailing the presence or otherwise of ACM in specific locations in a facility, and contains the results (both positive and negative) of materials sampled and tested for the presence of asbestos.

The Asbestos Register provides an up to date record of the location of ACM within ACT Health premises, and information such as the:

  • ACM type - e.g.white asbestos (chrysotile), blue asbestos (crocidolite)
  • Condition- e.g. damaged/stable and intact
  • Results of asbestos risk assessments(ARAs) - e.g. high risk, removal recommended

Using this information, planned controls can be implemented to avoid exposure of workers and others, in areas where ACM is identified. For further information refer to Appendix E – Standard Operating Procedure – Asbestos: Checking the Asbestos Register Prior to Construction, Refurbishment and Maintenance Works.

For further information on requirements for the identification, inspection and testing of ACM refer to section 4.1.

3.2Asbestos Register Contents

Section 327 of the Dangerous Substances (General) Regulation 2004specifies the information required in an Asbestos Register. The required information is detailed in Appendix C.

IMPORTANT – Where a building, or location within a building, has been assessed as being free of asbestos this should be listed in the asbestos register as ‘location assessed as being free of asbestos’(Note: This is not necessary for buildings built after 31 December 2003). This is to allow immediate confirmation of the absence of asbestos at a particular location rather than only relying on determining the presence of asbestos at a particular location.

3.3Access to the ACT Health Asbestos Register

The ACT Health Asbestos Register is located in ACT Health Intranet, Sharepoint. The following is a summary of the requirements relating to access to the Asbestos Register as per section 328 of the Regulation.

  • All workers are to be made aware of the presence of the Asbestos Register (i.e. that there is an Asbestos Register available).
  • Prior to any work being undertaken that may expose a worker or others to airborne asbestos fibres the ACT Health responsible person is to make the Asbestos Register and accompanying ARAs accessible to:
  1. Workers and their representatives
  2. Any other employers within the premises
  3. Any person removing asbestos/ACM
  4. Any person engaged to perform work that may disturb asbestos/ACM, including presumed asbestos/ACM
  5. Any other person who might be exposed

Access to the Asbestos Register is to be coordinated by an ACT Health responsible person who will contextually explain the hazards, risks and control measures relevant to the ACM. For specific instructions refer to Appendix E – Standard Operating Procedure – Asbestos: Checking the Asbestos Register Prior to Construction, Refurbishment and Maintenance Works.

3.4Updating the Asbestos Register

The ACT Health responsible person is to ensure that the asbestos register is updated within five (5) business days of the following events:

  • Upon receipt of information from a licensed asbestos assessor that would necessitate the Asbestos Register to be updated (e.g. updated risk assessment, clearance certificate following asbestos removal from a licensed asbestos assessor).
  • Following a review of the Asbestos Register by a licensed asbestos assessor.
  • The identification of the location of the ACM changes e.g. room name changes
  • After an asbestos risk assessment review is conducted.
  • Any sample testing and/or air monitoring for asbestos fibre is carried out
  • The condition of the ACM changes between surveys (e.g. becomes damaged); or the ACM is removed.

Note – the above list is not exhaustive, there are numerous situations and events that would require the Asbestos Register to be updated.

Where the asbestos register is required to be updated, it is the responsibility of the division coordinating the asbestos risk assessment or review to ensure that the current asbestos register is updated to reflect the change (i.e. the asbestos risk register is to be directly updated rather than forwarding of information with the expectation that the register will be updated by another division e.g. B&I).

3.5Review of the Asbestos Register

A review of the Asbestos Register is to be undertaken by an appropriately licensed asbestos assessor, or sooner as per section 334 of the Regulation if:

  • There is evidence of which the person is, or should be, awarethat the risk assessment is no longer valid or adequate.
  • There is evidence of which the person is, or should be, awarethat the control measures set out in the risk assessment are no longer valid or adequate.
  • A significant change is proposed for the premises, or for workpractices or procedures, relevant to the risk assessment.
  • There is a change in the condition of the product.

4.MANAGING RISKS ASSOCIATED WITH ACM

Appropriate measures are needed to ensure that ACM risks are appropriately controlled. The following measures are based on the requirements of the Code of Practice for the Management and Control of Asbestos in the Workplace [NOHSC:2018(2005)].

4.1Identification, Inspectionand Testing

Following is a summary of requirements in relation to the identification, inspection and testing of ACM:

  • All ACM in ACT Health premises is to be identified, as far as practicable, and recorded in the Asbestos Register.
  • Presumed ACM - On occasion, suspected ACM may be difficult to access or sample in a non-destructive manner, and therefore cannot be tested or it is impractical to do so. As a precautionary measure, this material is classified as "presumed" to contain ACM – until proven otherwise (Section 9.2 of the Code of Practice for the Management and Control of Asbestos in the Workplace [NOHSC:2018 (2005)].
  • Inspections, risk assessments and sampling of suspected ACM or ACM should only be carried out by ACT government licensed asbestos assessors.
  • Only laboratories certified by the National Association of Testing Authorities (NATA) are to be used to undertake asbestos sample analysis.

4.2Asbestos Risk Assessment (ARA)

Asbestos risk assessments (ARAs) provide key information in relation to risks to workers and others by ACM in it’s current state, and guide decisions relating to working with and around the ACM. Only an appropriately licensed asbestos assessor can conduct a risk assessment. The minimum requirements for the written risk assessment are:

  • The condition of the ACM.
  • The likelihood of anyone being exposed to the ACM.
  • Whether the nature or location of any work to be carriedout is likely to disturb the product.
  • The result of any atmospheric monitoring at the premises.
  • Set out the control measures considered, or used, for control ofthe risks associated with the product.

4.3Warning Signage and Labelling of ACM

Following is a summary of requirements in relation to warning signs and labelling of ACM:

  • Engage a Licensed Class A Assessor to determine the number of asbestos labels required and where these should be positioned within the workplace.
  • Identify the presence of asbestos/ACM through labelling and communication.
  • Erect compliant signage and tagging to workplaces, plant, equipment and components where asbestos/ACM is present.
  • Erect warning signs and labels which comply with AS 1319 Safety Sign for the Occupational Environment.
  • Erect compliant signage at the entrances to work areas where asbestos/ACM is present.
  • Label asbestos/ACM consistent with the Asbestos Register.
  • Identify the presence of asbestos/ACM through labelling and communication.
  • Where labelling cannot safely or practically be applied to the asbestos/ACM (e.g. floor tiles, lagging) provide a prominent warning sign indicating the presence of asbestos in the immediate vicinity.

Refer to Appendix D for relevant examples of compliant warning signs and labels.

4.4Checking the Asbestos Register Prior to Construction, Refurbishment and Maintenance Works

Checking the ACT Health ‘Asbestos Register’ prior to construction, refurbishment and maintenance works is a legislative requirement and allows an informed decision to be made as to whether the work can commence or not.

Work cannot be authorised to commence where it is likely to involve the disturbance of Asbestos Containing Material (ACM) in the specified location of work. In this situation, appropriate risk control measures need to be taken prior to the work commencing e.g. removal of the asbestos by a qualified person prior to the required maintenance work starting.

For specific instructions refer to Appendix E–Standard Operating Procedure –Asbestos: Checking the Asbestos Register Prior to Construction, Refurbishment and Maintenance Works.

4.5Accidental Disturbance or Discovery of ACM or Suspected ACM

When there is an accidental disturbance or a discovery of Asbestos Containing Materials (ACM), or suspected ACM, workers and others may be placed at risk by exposure to the ACM.

Examples may include a contractor accidentally drilling into a material that they believe to be ACM, or a worker finding a damaged wall that they believe to contain ACM.

In this situation, appropriate measures need to be taken to ensure the health and safety of workers and persons who have been or may be exposed to ACM (e.g. isolating area and engaging a licensed asbestos assessor to conduct an inspection and risk assessment).

For specific instructions refer to Appendix E– ‘Standard Operating Procedure – Asbestos: Accidental Disturbance or Discovery

4.6Risk Assessment and Removal/Encapsulation of Asbestos Containing Materials (ACM)

To manage ACM, a risk assessment is conducted by a licensed Class A Assessor.

The ultimate goal is to have a workplace free of ACM, therefore removal is the preferred approach in the management of ACM. Where this is not possible or practicable, encapsulation of the ACM or leaving in-situ if deemed safe to do so, may be considered.

Any ‘asbestos removal work’ must comply with the Code of Practice for the Safe Removal of Asbestos 2nd Edition [NOSHC: 2002 (2005)].

For specific instructions refer to Appendix E– Standard Operating Procedure – Asbestos: Accidental Disturbance or Discovery.

4.7Progressive Removal of Asbestos

The ultimate goal is to have a workplace free of ACM, therefore removal is the preferred approach in the management of ACM. Where this is not possible or practicable, encapsulation of the ACM or leaving in-situ if deemed safe to do so, may be considered. Therefore, the following principles shouldguide decision making with the goal of the progressive removal of ACM:

  • Removal of ACM is the preferred approach rather than encapsulation or leaving in-situ (i.e. if low risk).
  • Opportunities to remove ACM are to be seriously considered when preparing future work programs including refurbishment and redevelopment, maintenance, and minor works.
  • Removal of ACM is to be prioritised in terms of its risk. High risk ACM would therefore receive priority for removal (e.g. friable ACM not encapsulated, deteriorating ACM).

4.8Air Monitoring

Air monitoring is a technique used to measure the amount of airborne ACM fibres in a specified area, to determine if the area is safe for workers and others, and, to determine any required measures to manage ACM risks. Generally, air monitoring is used in the following situations:

  • Following the discovery or disturbance of ACM in a particular location.
  • During asbestos removal work to ensure that planned control measures are working.
  • After asbestos removal to determine if a clearance certificate can be issued to re-enter the area.

The air monitoring is conducted by a competent person e.g.occupational hygienist in accordance with the NOHSC Guidance Note on the Membrane Filter Method for Estimating Airborne Asbestos Fibres [(NOHSC:3003 (2005)].

The Membrane Filter Method for Estimating Airborne Asbestos Fibres will detect all fibres including lint, other fibrous materials and asbestos fibres. Additional testing may be required to confirm the presence and number (if any) of asbestos fibres present.

The following table is provided as a general guide only on action that may be taken based on the results of air monitoring for ACM. The competent person (occupational hygienist) is to provide professional guidance on the results of and necessary actions based on air monitoring results.