DGD15-028

Standard Operating Procedure (SOP)

Asbestos: Risk Assessment and Removal/Encapsulation

Purpose

To detail requirements in relation to the management and removal of Asbestos Containing Materials (ACM), including:

  • Risk Assessment of ACM
  • Removal/Encapsulation of ACM

In order to make an informed decision on how to manage asbestos containing materials ACM, a risk assessment of (ACM) by a qualified person needs to be conducted.

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.

Scope

This SOP 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 SOP, ACM is taken to include suspected or presumed ACM when not explicitly stated.

Responsibilities

ACT Health Responsible Persons

ACT Health workers involved in coordinating or directing work involving the risk assessment, removal or encapsulation of ACM. In most cases this is the ACT Health contact person who the worker or contractor reports to or deals with, prior to commencing works (e.g. project officer from Business and Infrastructure (B&I) and Health Infrastructure and Planning (HIP)).

Responsibilities:

  • To remain aware of and follow the requirements detailed in ‘Attachment 1 –Flowchart - Risk Assessment and Removal/Encapsulation of Asbestos Containing Materials (ACM)’ and relevant sections of the Asbestos Management Plan.
  • Ensure that relevant workers and contractors are qualified to conduct risk assessment and removal/encapsulation of ACM.
  • Ensure that workers affected by the removal/encapsulation of ACM are consulted prior to such work commencing.
  • Ensure that the Asbestos Register is updated within 5 working days of notification of relevant information in relation to ACM (e.g. risk assessment or removal of ACM)

Relevant workers and contractors

Qualified ACT Health, ACT government workers, and contractors involved in the risk assessment, removal or encapsulation of ACM - e.g. Class A – Asbestos Assessor.

Responsibilities:

  • Ensure risk assessment, removal/encapsulation of ACM is conducted in accordance with current legislation, standards and guidelines.
  • In the event of an unplanned disturbance or release of ACM (e.g. air escape from ACM quarantined area) - immediately report the issue to the ACT Health Responsible Person.

For more detailed and comprehensive information on responsibilities, definitions and general information regarding ACM, refer to the Asbestos Management Plan (AMP).

Procedure

ACT Health Responsible Person is to:

  1. Engage a Class A - Asbestos Assessor to provide a report detailing:
  • Results of any ACM analysis/testing conducted
  • Asbestos Risk Assessment – including ACM condition and risk ratings
  • Asbestos Management Recommendation - e.g. safe to leave in situ, remove, encapsulate

2.Decide on how the ACM is to be managed by choosing one of the following options:

  • Leave ACM in situ – if report indicates safe to do so
  • Removal of ACM (preferred option)
  • Encapsulation of ACM

3.Engage a Class A - Asbestos Assessor to provide an Asbestos Control/Removal Plan detailing:

  • Removal/Encapsulation method
  • Location of required signage – e.g. warning signs
  • Independent air-monitoring requirements
  • Disposal arrangements as required

4.Prepare a Disturbance or Interference with Safety, Services or Traffic (DISST) form ensuring the following are attached:

  • Asbestos Control/Removal Plan - to describe the work to be carried out, including the methodology for removal/encapsulation and air quality monitoring processes as a minimum.
  • A detailed plan identifying the location of ACM
  • Specific Safe Work Method Statements & Safety Data Sheets (where relevant to the works).

5.Ensure that the DISST form signed off/approved by key stakeholders and workers affected by the proposed works are consulted.

6.During the works - make sure that there is a process for ensuring that the Asbestos Control Plan (as approved) is being followed/adhered to.

7.Once work is completed – ensure that another independent Class A - Asbestos Assessor conducts an inspection and provide an Asbestos Clearance Certificate.

Evaluation

Outcome Measures

  • Persons are not exposed to/contaminated by ACM, particularly airborne ACM
  • ACM is managed in accordance with legislative requirements and Codes of Practice
  • ACM is progressively removed from all ACT Health owned premises

Method

  • All incidents involving persons being exposed to/contaminated by ACM will be investigated in accordance with requirements under the ACT Health – Work Health Safety Management System (WHSMS)
  • Annual audit of ACM management as part of the scheduled auditing arrangements to ensure compliance with legislation and codes of practice
  • Annual review of asbestos register by WPS to determine progress in removal of ACM
  • The above information will be presented by WPS to the Tier 2 – Dangerous Substances Management Committee

Related Legislation, Policies and Standards

Legislation

Work Health and Safety Act 2011

Work Health and Safety Regulation 2011

ACT Dangerous Substances Act 2004

ACT Dangerous Substances (General) Regulation 2004

Code of Practice

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)]

Policy

Asbestos: Management and Control Policy

ACT Health Asbestos Management Plan

ACT Health Work Safety Management System

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

Asbestos: Accidental Disturbance or Discovery

Definition of Terms

ACT Health Responsible
Persons

ACT Health workers involved in coordinating, directing or performing work where ACM may be encountered or disturbed. In most cases this is the ACT Health contact person who the worker or contractor reports to prior to commencing works and during works (e.g. project officer from B&I or RDU).

Asbestos / The fibrous form of mineral silicates belonging to the serpentine and amphibole groups of rock-forming minerals, including actinolite, amosite, anthophyllite, chrysotile, crocidolite, tremolite or any mixture containing one or more of the mineral silicates belonging to the serpentine and amphibole groups.
Asbestos Containing Material (ACM) / Any material, object, product or debris that contains asbestos.
Asbestos Management Plan (AMP) / ACT Health’s Asbestos Management Plan covering the identification, risk evaluation, control and management of identified asbestos hazards, developed in accordance with Code of Practice for the Management and Control of Asbestos in Workplaces [ NOHSC: 2018(2005)].
Asbestos Register
Competent Person
Relevant Workers and
Contractors / Register listing all identified or presumed ACM in ACT Health premises.
A person possessing adequate qualifications, such as suitable training and sufficient knowledge, experience and skill, for the safe performance of the specific work.
Note: A licence may be required for some of the tasks described in this plan as requiring a competent person.
A list of competent occupations and there competencies is listed in Appendix F of this document.
ACT Health/ACT Government workers and contractors who perform work where accidental disturbance or discovery of ACM may occur.
Responsible Person / 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 section 18 of the Dangerous Substances Act 2004:
(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.
Attachments

Attachment 1: Flowchart - Risk Assessment and Removal/Encapsulation of Asbestos Containing Materials (ACM)

Disclaimer: This document has been developed by ACT Health, <Name of Division/ Branch/Unit> specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Attachment 1

SOP– Flowchart - Risk Assessment and Removal/Encapsulation of Asbestos Containing Materials (ACM)

Doc Number / Issued / Review Date / Area Responsible / Page
DGD15-028 / May 2015 / May 2019 / Workplace Safety / 1 of 7
Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register