Policy, Responsibilities & Procedures

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1 Health and Safety Services Policy, Responsibilities & Procedures for the management of Asbestos Containing Materials 1

2 Contents 1 Introduction Asbestos Policy Statement of Intent Policy Statement Responsibilities General University Employees Director of Estates & Facilities Management Head of Health & Safety Services Asbestos Co-ordinator University Health & Safety Committee Occupational Health Project Managers / Designers General Contractors and Sub-Contractors Asbestos Removal Contractors Asbestos Consultant Heads of School/Directorates/Units Building Managers Procedures for Damaged or Disturbed Asbestos Procedures for Feasibility Studies Procedures for Project and Other Planned Works Procedures for Routine Maintenance Work Authorisation to Work Procedures...20 Appendix 1 Authorisation to Work Procedures...22 Appendix 2 FMD Project Managers Flow Chart...26 Appendix 3 Emergency Action Plan: Accidental Release of Asbestos...27 Appendix 4 Labelling of Asbestos Containing Materials...28 This Document sets out the University of Reading s Policy and Procedures for managing and dealing with Asbestos Containing Materials (ACMs) in all of its premises. Health and Safety Services November

3 1 Introduction Some buildings owned or occupied by the University of Reading were built or refurbished at a time when the use of asbestos containing materials (ACMs) in their construction was common. During work it is possible that personnel could encounter asbestos. Work for the purposes of this document is deemed to include any activity that interferes with or disturbs the fabric of the building i.e. any work other than visual inspections. The presence of an ACM in itself does not constitute a danger. However, there is a potential risk to health if such material is disturbed and damaged. An isolated accidental exposure to asbestos fibres for a short duration is extremely unlikely to result in the development of asbestos related diseases. However, regular exposure even at relatively low levels can present a risk. As well as people employed in the building trades, inadvertent exposure (and consequent risk) can occur in other groups of people e.g. installers of I.T. systems, burglar alarms, smoke detectors, etc. Working with, and managing, ACMs is controlled by legislation, primarily the Control of Asbestos Regulations Responsibility for developing University policy and procedures for managing ACMs has been delegated to Health and Safety Services, Governance Directorate. The University Health and Safety Committee is responsible for approving the asbestos policy and procedures. Responsibility for managing work in accordance with University policy and procedures has been delegated to Facilities Management Directorate (FMD). 3

4 2 Asbestos Policy 2.1. Statement of Intent It is the policy of the University of Reading to ensure that, as far as is reasonably practicable, no persons are exposed to risks to their health due to exposure to any ACMs that may be present in any of the properties it owns or occupies Policy Statement The University Asbestos Policy conforms with the Health and Safety at Work Act 1974 and the Control of Asbestos Regulations The Policy and Procedures will apply to all premises and all individuals employed and/or engaged by the University without exception. The University Asbestos Policy is to: ensure the prevention of exposure to risks associated with ACMs ensure that any ACMs that may be present in any of its buildings are maintained in a condition so as to prevent the possibility of any harm to health occurring promote awareness of the risks from ACMs and the University Asbestos Management Procedures through training and induction of relevant staff provide adequate resources to ensure the provision of appropriate information, instruction and training commit to compliance with all relevant health and safety and environmental legislation, Approved Codes of Practice, and Health and Safety Executive (HSE) Guidance Notes, including the safe disposal of asbestos waste ensure that all properties built before 1990 are surveyed to identify any ACMs that may be present therein and to prepare and maintain an Asbestos Register for all buildings. This Register will be reviewed regularly and will be updated after any treatment and/or removal works have been undertaken ensure that all properties built after 1990 but before 2000 are assessed to establish whether a survey may be required, or alternatively conduct a desk study of construction materials to establish that no ACMs were used in construction. Where a reasoned argument that no ACMs are present cannot 4

5 be developed, the property will be surveyed as previously described. Properties built after this date will not require assessment implement an effective asbestos management plan in order that appropriate measures such as encapsulation, labelling, inspection, working with, or removal of, the material can be undertaken ensure that an appropriate system is maintained and implemented for the management of all ACMs identified in the Register. Such a system is to be capable of recording the risk, the needs and priorities for treatment and/or removal, and to provide a history of actions taken ensure that all Contractors and Sub Contractors engaged to carry out work on any of the University buildings are made aware of the presence or suspected presence of ACMs by highlighting this on works orders, providing access to the Asbestos Register, and other means, and are advised of the appropriate precautions and procedures to be followed ensure that information regarding the presence of asbestos is contained in tender documentation as may be appropriate ensure that only the University s Asbestos Co-ordinator, or competent HSE Licensed and UKAS accredited Asbestos Consultants, are employed by the University to carry out surveys and sampling and to supervise abatement works, and that no work is subcontracted ensure that all such works are carried out strictly in accordance with HSG 248 Asbestos: The analysts guide for sampling, analysis and clearance procedures and industry best practice ensure that only competent HSE Licensed Contractors are employed by the University and that they carry out all asbestos abatement works strictly in accordance with HSG 247 Asbestos - The Licensed Contractors Guide and industry best practice and that no work is subcontracted, including analytical work regularly review the Asbestos Management Policy and Procedures. 5

6 3 Responsibilities 3.1. General This Asbestos Policy and Procedures Document should be read in the context of the University s Health and Safety Policy and Safety Guide 2 Health and Safety Management and Organisation Any work which might interfere with the fabric of any of the University s premises MUST be notified to FMD, and through FMD, the Asbestos Coordinator, in advance of any intended works (see Section 8 Authorisation to Work Procedures and Appendix 1) All staff must be made aware of, and familiarise themselves with this Policy and Procedures document, insofar as it is relevant to their roles and responsibilities Responsibility for this Policy and Procedures document, the provision of competent advice on the management of asbestos, monitoring, audit and review is delegated to the Head of Health and Safety Services, Governance Directorate Ensuring that all work with ACMs is managed in accordance with this Policy and Procedures document is delegated to the Director of Estates & Facilities Management All managers and staff must comply with the instructions of the Asbestos Coordinator, in relation to the management of ACMs on University premises University Employees All persons employed by the University of Reading will be responsible for: ensuring that any work that may disturb or damage ACMs is avoided reporting to their Building Manager and FMD any materials suspected of containing asbestos where the material has become disturbed and/or damaged or where staff, Contractors and/or Sub Contractors are likely to undertake work, which may affect that material notifying FMD of any intended work which may interfere with the fabric of any premises of the University by completing the Authorisation to Work 6

7 request form. No work must be allowed to progress until an Authorisation to Work request has been received and approved by FMD, in consultation with the Asbestos Co-ordinator (see Appendix 1) Director of Estates & Facilities Management Will be responsible for: the safe operation of FMD activities, including consideration of asbestos issues, within the operational and investment estate under FMD s control devolving the principal functions of asbestos management to the FMD Deputy Directors responsible for maintenance, projects, and Halls making applications for necessary resource allocation from the University s central bodies ensuring that FMD staff have suitable initial and refresher training with respect to asbestos issues to comply with legislation and ensure a high level of asbestos awareness Head of Health & Safety Services Will be responsible for: ensuring the development and maintenance of University procedures for the management of asbestos ensuring that a representative number of projects involving work with asbestos are audited in conjunction with the Asbestos Co-ordinator, investigating and reporting to the University Health and Safety Committee on any alleged incident of accidental asbestos exposure and for ensuring reporting of incidents under RIDDOR, where appropriate notification to the Occupational Health Service should any member of staff be involved in an incident of accidental asbestos exposure in order that occupational health advice can be given if required monitoring & auditing the effectiveness of the University s policy & procedures for managing the risk from asbestos. 7

8 ensuring that the professional competence of those advising on asbestos management is maintained in conjunction with the Asbestos Co-ordinator, liaison with HSE as required Asbestos Co-ordinator He/she will be responsible for: maintaining an effective asbestos management strategy, in order that appropriate measures are taken for labelling, inspection, working with, encapsulation or removal of asbestos materials providing competent professional advice on ACMs and their treatment to those with responsibilities under this policy ensuring that regular inspections of ACMs are undertaken, and updating the Asbestos Register to reflect the current condition. This will include making a Material and Priority Risk Assessment in accordance with HSG 227 A comprehensive guide to Managing Asbestos in premises, and assessing, reviewing and recommending management actions following inspection findings, changes of legislation or current good working practice programming surveys in University s premises to identify any ACMs that may be present, and updating the Asbestos Register providing advice to Project Managers on commissioning of asbestos surveys including identifying the required scope of works and method statements ensuring that any Type 3 surveys received are reviewed maintaining the Asbestos Register for all University premises. All records of ACMs must include a Material Risk Assessment in accordance with HSG 227. This will involve: undertaking Priority Risk Assessments following inspections; including photographs with documentary records; ensuring that records include details of where any previously identified materials have been encapsulated, modified or removed; ensuring that records include copies of air clearance documentation (either on the project file pre-2009, or on the Wren Asbestos Register from 2009 onwards); 8

9 records are maintained of all non asbestos materials where they have been sampled, and identification of areas not surveyed; ensuring that the Asbestos Register is updated promptly following receipt of all survey results ensuring that the asbestos register is updated following completion of any works on ACMs including providing the relevant Project Manager with details of residual asbestos hazards remaining in the vicinity of any proposed work providing information on ACMs as required reviewing and updating (in conjunction with the Head of Health & Safety Services) this Policy and Procedures document reporting any incident of alleged asbestos exposure to the Head of Health and Safety Services and assisting with any investigation assisting the Head of Health and Safety Services in liaison with the HSE promoting awareness of the hazards of ACMs and the University s Asbestos Management Procedures by advising on, and providing, appropriate training and induction, to University staff as required, and in particular to those whose work might bring them into contact with ACMs monitoring to ensure that Project Managers, Building Managers, and staff are aware of their responsibilities under this policy where appropriate, taking samples of any suspected materials, in accordance with prescribed procedures, and arranging for the analysis of the samples by a test house with the appropriate UKAS accreditation assisting the Procurement Department to ensure that only competent and licensed asbestos removal Contractors are engaged to carry out work with ACMs assisting the Procurement Department to ensure that only competent and UKAS accredited and HSE licensed Consultants are employed to provide services in conjunction with identifying and working with ACMs ensuring that all asbestos identified as being safe to leave undisturbed is adequately labelled where required in accordance with Appendix 4 of this 9

10 document. NB This does not mean that all ACMs will be labelled see Appendix attending in accordance with the Emergency Action Plan: Accidental Release of Asbestos (see Appendix 3) and taking such actions as are required to ensure safety maintaining his/her professional competence, including a thorough understanding of all relevant legislation, codes of practice, guidance and good practice University Health & Safety Committee Will be responsible for: periodically reviewing the effectiveness of the Asbestos Policy and Procedures reporting annually via the Senior Management Board and University Strategy & Finance Committee to the University Council on the effectiveness of the Policy, Procedures and actual working practices reporting immediately to the Chair of the University Health and Safety Committee, and the Senior Management Board if any serious deficiencies are identified in the University s management of asbestos Occupational Health Will be responsible for: providing occupational health advice to management and staff on issues relating to asbestos ensuring that any accidental exposure is recorded on the employee s medical notes and retaining the medical notes for a period of forty years after the date of final exposure Project Managers / Designers Will be responsible for: ensuring that the University Asbestos Policy & Procedures Document and any associated guidance is adhered to. 10

11 ensuring that roles, responsibilities and management structures for the project with regard to ACMs are clearly communicated to all relevant parties ensuring that, before feasibility/design work is started on a project, the Asbestos Register is consulted and sufficient information is obtained on any ACMs within the working area to safely carry out the works. Where intrusive works are planned the Asbestos Co-ordinator must be consulted on the requirement for, and the scope of, any surveys to be commissioned. Surveys should be procured from one of the approved framework partners in accordance with the Asbestos Framework Guidance for Project Managers, or undertaken by the University Asbestos Co-ordinator where he/she deems it appropriate. A minimum of 6 weeks should be allowed to enable surveys, sampling, analysis and reporting to take place ensuring that the extent of the survey requirements are clearly communicated to the Asbestos Consultant and to include satellite areas outside the main work area where service connections may be made ensuring that un-surveyed areas and areas of no access are mapped against proposed works to ensure that the extent of the works does not impinge on these areas of no access and, if so, these areas are surveyed before the start of the works providing a copy of the Type 3 survey report to the Asbestos Co-ordinator to enable the Asbestos Register to be updated stopping any works and informing staff if suspected materials are discovered during the course of the works and immediately seeking advice and direction from the Asbestos Co-ordinator ensuring that if asbestos is identified, which will be disturbed during the works, that the Asbestos Co-ordinator is consulted on the legislative consequences and optimum course of action, and that the advice of the Asbestos Co-ordinator is followed ensuring, where directed by the Asbestos Co-ordinator, that an Asbestos Consultant is commissioned to prepare a scope and specification including a schedule of all abatement works for ACMs as a set of separate tender documents ensuring that only HSE licensed asbestos contractors and UKAS accredited HSE licensed consultants from the University s Framework List are used, and 11

12 that the asbestos elements of work are exempted from any value engineering processes other than where advised by the Asbestos Co-ordinator ensuring that separate contracts are issued for asbestos remediation works and subsequent asbestos testing/monitoring informing all relevant staff, Contractors and Sub Contractors of the presence of any known asbestos which may affect the works. Additionally, contractors must be instructed to consult the Asbestos Register in order to familiarise themselves with the location of any known asbestos, non-accessible areas, or restricted areas in the premises ensuring that all Risk Assessments, Method Statements and Notices (as may be required under the Control of Asbestos Regulations 2006) are in place, and copies are submitted to the Asbestos Consultant for assessment, before any work is allowed to start on site. Where an Asbestos Consultant is not appointed the information must be submitted to the Asbestos Co-ordinator for assessment and approval. Copies of all such documentation must be available for inspection on site at all times for the duration of any asbestos related works permitting the works to start if the Asbestos Consultant, where appointed, or the Asbestos Co-ordinator, is satisfied with the proposed safe system of work and associated documentation not permitting the work to start, in the event of unsatisfactory initial documentation, until the Asbestos Consultant or Asbestos Co-ordinator is satisfied with the modified documentation providing information to the Asbestos Co-ordinator to enable the Asbestos Register to be updated. Such information must be provided as it becomes available, which may be near the beginning, during or at the end of a project. Copies, where applicable, of asbestos surveys, bulk sample analysis and certificates of reoccupation must be forwarded to the Asbestos Coordinator and a copy retained for the project file. Copies of reassurance or back ground air monitoring should not be passed on but must be retained in the project file following any asbestos abatement work and BEFORE subsequent works can commence, ensuring that all relevant staff, Contractors and Sub Contractors are made aware that the asbestos register has been updated and specifically 12

13 highlighting the residual asbestos hazards that remain in the proposed work area General Contractors and Sub-Contractors Will be required to: ensure that they are fully familiar with current legislation relating to the management of ACMs ensure that they have a clear understanding of the University s Asbestos Policy and Procedures, including specific responsibilities and management structure on the project that they are engaged for ensure that all staff employed by them have received an appropriate level of asbestos awareness training consult the University Asbestos Register for the premises when planning the work and immediately before work starts informing all relevant staff, Contractors and Sub Contractors of the presence of any known asbestos which may affect the works including highlighting any residual asbestos hazards that remain in the proposed work area ensure that where work may be affected by, or involves, ACMs that an HSE licensed contractor from the University s Framework List is engaged to carry out the work ensure that any relevant risk assessments, method statements and statutory notices are in place before work commences if any suspect materials is encountered, to immediately suspend operations and to contact the FMD Project Manager for further instruction, or in his/her absence, the Asbestos Co-ordinator provide copies of all test certificates, Certificates of Reoccupation and evidence of correct waste disposal to the Project Manager within 5 (five) working days of the completion of the work Asbestos Removal Contractors must be approved by FMD before any order is placed or contract awarded Asbestos Removal Contractors Will be responsible for:- 13

14 ensuring that they have a current license from the HSE to work with the type of asbestos indicated ensuring that they have current and adequate insurance cover for the asbestos works to be undertaken ensuring working practices are in compliance with current legislation and all associated Approved Codes of Practice and Guidance Notes attending site to assess and prepare quotations against asbestos work specifications. The contractor must raise any issues relating to health and safety, or potential additional costs, on the project to the instructing officer/project manager attending site meetings as may be required providing a written Method Statement and Risk Assessments to the Project Manager and the Statutory Authority. The Risk Assessments and Method Statement must indicate the resources and timetable allocated to the project. Emergency procedures must be discussed, and agreed, with the Asbestos Consultant/Asbestos Co-ordinator and the premises Building Manager/Area Health and Safety Coordinator(s), as appropriate, before work commences providing statutory notice to the Health and Safety Executive as may be required prior to the commencement of any asbestos related works or, by agreement with the Project Manager, applying for a waiver against the minimum notice period. Such request for a waiver should not be made without the written instructions of the Project Manager. Copies of all such notices must be submitted to the Project Manager before work commences carrying out their obligations under the contract, including maintaining high standards of safety and hygiene in asbestos works and all related work areas and supplying labour, materials and equipment of the highest standard, complete with all supporting documentation as may be required arranging transport and disposal of asbestos waste materials in accordance with legislative requirements and providing copies of all Consignment Notes to the Project Manager carrying out regular inspections of the work environment. Any defects found, or any reported by the University s representatives, must be rectified immediately. 14

15 complying with the University s Policy specific to Authorisation to Work procedures and with all reasonable requests from FMD identifying to FMD, or their appointed representative, any additional elements of work which are to be agreed. The Method Statement must be updated accordingly liaising with the Asbestos Consultant to ensure the satisfactory progress of the works providing copies of all test certificates, Certificates of Reoccupation, evidence of correct waste disposal to the Project Manager within 5 (five) working days Asbestos Consultant Will be responsible for: maintaining, and demonstrating UKAS accreditation to ISO and 17025, and an HSE supervisory license maintaining adequate insurance cover for the tasks to be undertaken providing support to the Project Manager as may be required reviewing and commenting, when requested by the Project Manager on asbestos works such as: specifications, Contractor s and/or Sub Contractor s Method Statement, work procedures, etc carrying out analytical works and inspections as agreed with the Project Manager. Where site conditions alter, the Asbestos Consultant will be required to amend the level of testing and inspections to ensure that all information relevant to the continued health and safety of the Contractor and building occupants is obtained reporting to the Project Manager or his representative, any defect or noncompliance relating to the Contractor s and/or Sub Contractor s performance, including suitability of the work area, adherence to the Method Statement, Statutory Instruments, and the University s Asbestos Policy and Procedures. Where the Project Manager is not immediately available the surveyor/analyst will be expected to take such measures as may be deemed necessary to ensure the continuing health and safety of Contractors and Sub Contractors and building occupants. The surveyor/analyst should seek advice from the Asbestos Co-ordinator if 15

16 required. Any actions taken must be reported to the Project Manager as soon as reasonably practicable checking areas on completion of asbestos remedial works to ensure that the contractor has completed his scope of works and all affected areas have been left in a satisfactory condition carrying out air monitoring tests as may be required by the Project Manager or his representative, or as identified in the Risk Assessment reporting to the Project Manager and others as may be appropriate, any aspects of asbestos management encountered on site which could give rise to health risks e.g. breaches of the Asbestos Policy and Procedures, suspect or damaged asbestos issuing formal reports, including Certificates of Re-occupation, to the Project Manager on completion of any site works Heads of School/Directorates/Units All persons with responsibility for activities within buildings have a duty in respect of those premises to ensure that: all staff, students, service users, visitors and others who are likely to interfere with the fabric of the building are given the necessary information regarding the Asbestos Management Policy and Procedures to ensure that they are not put at risk of exposure to ACMs ensuring that staff, students, service users etc. do not undertake work that may expose them to ACMs through the FMD help desk, alerting the Asbestos Co-ordinator when any previously unknown asbestos is found, or suspected, in order that an assessment can be made and appropriate action taken FMD is notified of any intended work which may interfere with the fabric of any premises of the University by completing an Authorisation to Work Request Form. No work must be allowed to progress until an Authorisation to Work certificate has been received (see Appendix 1) any contractor, sub contractor, member of staff or anyone else (paid or otherwise) carrying out any works on or within any building of the

17 University has consulted with, and obtained an authorisation to proceed from, FMD before work progresses new equipment or apparatus erected, installed purchased or gifted on behalf of the School is free of asbestos material Building Managers Will be responsible for: providing information to building occupants on ACMs if required notifying the Asbestos Co-ordinator if they identify that ACMs in their building/area are not in good condition or have been damaged alerting the Asbestos Co-ordinator when any previously unknown asbestos is found, or suspected, in order that an assessment can be made and appropriate action taken taking appropriate steps to maintain safe access and egress where existing means of access and escape are temporarily affected by asbestos working enclosures. 17

18 4 Procedures for Damaged or Disturbed Asbestos It is the responsibility of all staff to report to FMD if they suspect that disturbed or damaged ACMs may be present in a building owned or occupied by the University, or if hitherto unidentified material is suspected of containing asbestos. FMD can be contacted via the Help Desk on (Monday to Friday 8.30am to 4.30pm) and on at all other times. The Help Desk will inform the Asbestos Co-ordinator, who will then give advice Where a material is suspected of containing asbestos, the Asbestos Coordinator should make arrangements for the material to be tested Where damage to any material known to contain asbestos has taken place, and it is likely to have given rise to a controlled release of asbestos fibres into the workplace, the Emergency Action Plan should be invoked (see Appendix 3) FMD will arrange for air monitoring tests (measurement of airborne fibre concentrations) and analysis to be carried out. Analysis will determine the level of any potential contamination, or to provide reassurance that unacceptable contamination has not occurred Details of air test results will be available for inspection & record purposes for building occupants Remedial action will usually be required when airborne fibre levels exceed 0.01 f/ml. The nature of the remedial work will be advised by the Asbestos Co-ordinator When remedial action becomes necessary after exposure, the relevant facts may have to be reported to the HSE in accordance with RIDDOR. The Head of Health & Safety Services and/or the Asbestos Co-ordinator will advise on, and ensure compliance with, this requirement Where damage occurs to materials which have not been confirmed as containing asbestos (prior to the completion of a survey and the issue of a register) but which the building manager suspects may contain asbestos, then advice should be obtained from the Asbestos Co-ordinator as soon as possible. 18

19 5 Procedures for Feasibility Studies Before any feasibility work is started on any project the Asbestos Coordinator must be consulted and information obtained on any ACMs within the premises. He/she will provide advice on the potential impact of known ACMs on the project and give direction on the type and extent of additional survey work that might be required. Before surveys can be commissioned, the detailed scope of the proposed scheme must be provided by the Project Manager or his representative along with copies of relevant drawings. A minimum of 6 weeks must be allowed to enable surveys, sampling, analysis and reporting to take place. 6 Procedures for Project and Other Planned Works The Project Manager must interrogate the Asbestos Register before commencing any work that may interfere with the fabric of any University owned or occupied building. If no asbestos is identified then the works can proceed with caution, bearing in mind the possible presence of ACMs not identified in the Asbestos Register. If the work is intrusive in nature and likely to significantly disturb the fabric of the building the Asbestos Coordinator must be consulted. He/she will give direction on the type and extent of additional survey work that might be required If asbestos is identified, which is likely to be disturbed by the works, the Project Manager must adhere to the procedures in this document and any associated guidance. The flow chart at Appendix 2 must be followed. 7 Procedures for Routine Maintenance Work Reactive and preventative maintenance work is normally carried out by inhouse University staff When a job requisition is received which involves work that will interfere with the fabric of a University building, it is the maintenance operative s responsibility to interrogate the Wren Asbestos Register to determine whether asbestos is present. If no asbestos is identified then the works can proceed with caution, bearing in mind the possible presence of ACMs not identified in the Asbestos Register. 19

20 If the register shows asbestos is present then the maintenance operative must immediately advise their Supervisor, who will inform the Direct Labour Manager The Direct Labour Manager will liaise with the Head of Projects or his/her representative regarding removal of the asbestos. The Asbestos Co-ordinator must be consulted on the most appropriate abatement action When the asbestos abatement works have been completed by a licensed asbestos removal contractor (from the University Framework List) the Head of Projects or his/her representative will inform the Direct Labour Manager. A Certificate of Reoccupation will be issued if appropriate The Direct Labour Manager will advise the Supervisor that the maintenance work may proceed The Wren Asbestos Register will be updated by the Asbestos Co-ordinator Where a suspect material is uncovered during the course of routine maintenance all work must stop. The area should be made secure and the Asbestos Co-ordinator informed. He/she will arrange for a sample to be taken. If the material is confirmed as an ACM the Direct Labour Manager will be informed and actions will proceed as detailed in onwards. 8 Authorisation to Work Procedures See Appendix Under no circumstances shall any work which will, or may, interfere with the fabric of any University building take place without prior consultation with, and authorisation from, FMD Authorisation to Work procedures, in conjunction with this Policy and Procedures Document, apply to all works that are not specified and monitored directly by FMD. These procedures will require Schools/Directorates/Project Managers to obtain written approval for any works which they propose to undertake that interferes with the fabric of any University owned or occupied building Schools/Directorates are required to: (i) undertake prior consultation with FMD regarding any works which may interfere with the fabric of the building. This includes those 20

21 which may impinge on Planning, Building Regulations or any other statutory requirements. Where any works do impinge on such statutory requirements, then FMD will require copies of any approved documentation for record purposes. (ii) submit a completed Authorisation to Work request form and must ensure that it includes:- all information requested. a comprehensive description of the work, supported by material specifications, drawings or any other documentation sufficient to adequately describe the intentions. details of the time-scale of the project i.e. anticipated commencement / completion dates. where appropriate, details of the intended designer. (iii) (iv) fully comply with the University s Asbestos Policy and Procedures. ensure that all work not involving asbestos based materials will fully comply with University Authorisation to Work procedures once approved, using compatible components or materials to ensure safe operation and function In order to monitor and audit compliance of the works, FMD reserve the right to visit the premises, at any time, subject to normal premises operating procedures, and shall be afforded:- (i) (ii) access to all parts of the building. access to records relating to the works undertaken. 21

22 Appendix 1 Authorisation to Work Procedures Background This document explains the procedures under which building occupants must seek authorisation from FMD for any work they plan to undertake, without FMD supervision, which might disturb the fabric of the building. These procedures do not apply to any work supervised by the FMD. Authorisation Procedures When staff, students or other building occupants plan to carry out any work which might disturb the fabric of the building the attached Authorisation to Work request form must be completed and submitted to the FMD Help Desk. FMD will review the proposed work to determine whether it can safely be carried out without FMD supervision. Under normal circumstances FMD will aim to process these requests within 5 five working days and issue a written response. No work should be commenced until it has been authorised, in writing, by FMD. Assessment Criteria The criteria listed on page two of the Authorisation to Work request form will be used to determine whether work can be undertaken without FMD supervision. As a general guide work of a complex nature, which significantly interferes with the building fabric, or which requires any input from a contractor, will normally need to be supervised by FMD. In addition any project which involves disturbance of asbestos-based materials or other hazards, affects fire safety or has any other legislative implications will also require FMD supervision. Carrying Out Authorised Works When work has been authorised to proceed without FMD supervision, it is important that, should any problem subsequently be encountered that was not originally identified, the project is referred back to FMD for advice. Particular attention should be paid to the following areas: - 22 Asbestos: The person responsible for supervising the work should be aware that asbestos surveys are not destructive and do not show details of any

23 concealed asbestos-based materials. Should there be reason to believe that materials encountered whilst carrying out the work might contain asbestos they should be presumed to do so until proven otherwise. All work should stop immediately and FMD must be informed. Buildings Structure & Engineering Services: Should it prove necessary to disturb the structure of the building or any engineering services, prior approval must be obtained from FMD. Fire Safety: Under no circumstances should any work be carried out which interferes with fire detection systems, fire compartmentation or the means of escape from the building. FMD must be consulted if there are any doubts about the proposed works in relation to fire safety. External Contractors/Consultants: Should it be found that external contractors or consultants are required in order to undertake the proposed works then FMD must be advised. 23

24 FACILITIES MANAGEMENT DIRECTORATE AUTHORISATION TO WORK REQUEST CLIENT REQUEST FOR AUTHORISATION TO WORK Person responsible for the work: Name of School, Hall etc: Tel. Number: Building name / number: Floor level: Room number(s): Date of application: Description of the proposed work: Elements of the building likely to be disturbed: (e.g. walls, doors, electrical systems etc.) Who will undertake the proposed work? Please forward to: - Facilities Management Directorate Help Desk Tel: Facilities Management Building Fax: Whiteknights PO Box 235 Reading RG6 6BW FACILITIES MANAGEMENT DIRECTORATE AUTHORISATION (For Facilities Management Directorate Use) Name: Signed: Date: Work Authorised / Not Authorised to Proceed (delete as applicable) Reason (if Not Authorised) : 24

25 FMD AUTHORISATION RECORD (For Facilities Management Directorate Use) BUILDING & ENGINEERING Asbestos identified in the working area? Intrusive asbestos survey required? Other hazards identified? Structural implications? Building fabric adversely affected? Fire safety / means of escape affected? Disability Discrimination Act non-compliance? Electrical / IT systems affected? Heating / ventilation affected? Water / waste services affected? Other piped services affected? CONTRACT & FINANCIAL Will contractors be used to carry out any part of works? Will consultants or other specialist advice be used? Will any materials be obtained from non-approved suppliers? HEALTH & SAFETY Will specialist risk assessment be required? Will method statement be required? f FMD staff should note that i the answer to any of the above questions is Yes then the project should not be authorised to proceed & should be supervised by ESD. Authorisation Checks by: Name : Signed: Date: 25

26 Appendix 2 FMD Project Managers Flow Chart Receive outline brief No Is asbestos likely to be present? Yes Consult with Asbestos Co-ordinator Proceed with caution Commission Type 3 survey for all Discover suspect material? parts of the building likely to be Suspend work disturbed Consult Asbestos Co-ordinator Arrange analysis Include Asbestos Consultant as part of design team No Is analysis positive? Yes Ensure information is forwarded to Asbestos Co-ordinator to allow the Asbestos Register to be updated. Asbestos Consultant provides detailed schedule of ACMs to be abated Tender evaluation, notification and mobilisation period Asbestos Consultant provides full analytical support through to removal Notes ACM = asbestos Containing Material 4 stage clearance & completion documentation To health & safety/ project file 26

27 Appendix 3 Emergency Action Plan: Accidental Release of Asbestos In the case of an uncontrolled release of asbestos fibres into the workplace all persons MUST be kept away from the affected area. The following emergency action plan must be followed: Initial Response 1. The Site Manager (or other Senior Site Operative) should initially take control of the situation. 2. The Site Manager should arrange to clear the area of all personnel and, where possible, isolate the area by closing and taping doors. 3. The Site Manager should charge an individual with the task of prohibiting entry to the affected area. 4. The Site Manager should, as soon as practicable, inform the FMD Help Desk ( ), or the Security Control Room ( ) if the incident is out of normal working hours. 5. The Site Manager must advise the Building Manager, or in their absence the Departmental Secretary, Senior Technician, Area Health and Safety Co-ordinator, and other key occupants where appropriate. Planned Response & Remedial Works 6. The FMD Help Desk will inform the relevant Project Manager and the Asbestos Coordinator. 7. The Asbestos Coordinator, or a designated Asbestos Consultant, will access the affected area with appropriate personal protective equipment and decide on any remedial action required. 8. In the event of a major release the Project Manager should consider implementing the Major Incident Plan. If there is any doubt this should be discussed with the appropriate FMD Deputy Director, or in their absence the Director of FMD, the Head of Projects or the Head of Business & Maintenance Services. 9. The Project Manager, in consultation with the Asbestos Co-ordinator or Asbestos Consultant, will organise any necessary remedial work. 10. The Project Manager must make arrangements to inform all persons who might have been exposed to the uncontrolled release of asbestos of their potential exposure. 11. The Project Manager must make arrangements to keep the area clear of anyone not involved in the remedial action, until air monitoring has confirmed that fibre counts are at acceptable levels. 12. The Project Manager must report all incidents to Health & Safety Services, who will, if necessary, make a report under RIDDOR. All queries on the above procedure should be forwarded to the Asbestos Coordinator via the FMD Help Desk ( ). 27

28 Appendix 4 Labelling of Asbestos Containing Materials The core strategy of the Asbestos Management Policy is to provide access to an up to date Asbestos Register supported by an effective authorisation to work procedure. It is recognised that this system can be supported by the use of labelling of ACMs in some instances. The position of warning signs and labels is beneficial in decreasing the chance of inadvertent damage and exposure. However labelling may not always be considered appropriate in certain environments, particularly where they may cause undue anxiety to the occupants. The labelling of ACMs will be considered on a case by case basis. Areas where ACMs will be labelled will include: Areas only likely to be accessed by maintenance operatives and contractors such as boiler and plant rooms, loft spaces, ceiling voids and ducts. Areas where it is considered that there is a higher than usual risk of the ACM releasing fibres if disturbed such as sprayed materials. Areas where it is considered that there is a higher than usual risk of ACMs being disturbed such as lining to columns in a high traffic area. Historically, some ACMs falling outside the above descriptions have already been labelled. It is recognised that to remove these labels whilst the ACMs remain is likely to lead to confusion and to the potential accidental disturbance of the material. These will be considered on a case by case basis by the Asbestos Co-ordinator and removed only where the ACM in question is considered a low risk material. The installation of warning labels is intended to support the Asbestos Management Policy. It does not relieve those with duties under this policy from the requirement to consult the Asbestos Register prior to any work. 28

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