ASBESTOS POLICY STATEMENT AND MANAGEMENT PLAN

Transcription

1 ASBESTOS POLICY STATEMENT AND MANAGEMENT PLAN Version Current Version 2017 Author Name Job Title Date EIA Approved Approved Date Approved by: University Health and Safety Committee Date for 6 month review by Review: Ian McManus (Duty Holder) Director of Estates Page 1 of 132

2 Contents ASBESTOS POLICY STATEMENT AND MANAGEMENT PLAN... 1 Section 1 - Manchester Metropolitan University Asbestos Policy Statement... 3 Section 2 - Manchester Metropolitan University Asbestos Management Plan Introduction Asbestos Legislative Framework Management Process, Strategy and Action Plan Structure, Roles and Responsibilities Approved Suppliers and Authorising Engineer Support Identification and Assessment of Asbestos Containing Materials Asbestos Abatement Work Process for Gaining and Supplying Information (Maintenance and Project Works) Exposure to Unidentified Materials or Accidental Damage to Known ACMs Including Out of Hours Emergencies Training Requirements and Communication Performance Monitoring, Auditing, Performance Reviews and Management Reviews 43 APPENDIX 1 - Reviews and Amendments to Asbestos Management Plan APPENDIX 2 - Current Persons Appointed To Key Roles Identified APPENDIX 3 - Emergency Procedures Flowcharts APPENDIX 4 Scope of Works Template (ASB001) APPENDIX 5 Project Planning Form (ASB002-1/3) APPENDIX 6 - Emergency Incident Reporting Form (ASB003) APPENDIX 7 Suspected Exposure to Airborne Fibres (ASB004) APPENDIX 8 - LARC Audit Form -Example Audit Documentation APPENDIX 9 Statement of Cleanliness (ASB006) APPENDIX 10 Visual Inspection Form (ASB007) APPENDIX 11 Visual Inspection Following Non-Licensable Asbestos Works Form (ASB008) APPENDIX 12 Asbestos Compliance Team Surveying Record Form (ASB010) APPENDIX 13 Air Monitoring 4SC Audit Form (ASB011) APPENDIX 14 Third Party Inspection of Four Stage Clearance Procedures (ASB012) APPENDIX - 15 Audit of Asbestos Management Plan (ASB013) APPENDIX 16 Asbestos Compliance Team Document Review (ASB014) APPENDIX 17 - Site Access Permit Requirements Page 2 of 132

3 Section 1 - Manchester Metropolitan University Asbestos Policy Statement The University acknowledges that it has an explicit duty to assess and manage the risks from asbestos under the Control of Asbestos Regulations For the purposes of managing asbestos, these regulations shall apply to all premises controlled by the University, and shall include student bedrooms and all other areas within Student Halls of Residence. It is the Policy of the University to Prevent, as far as is reasonably practicable, the exposure of employees, contractors, and any other persons, to asbestos fibres. Carry out periodic assessments of the ACMs present within all buildings and to determine their condition (via Asbestos Surveys), including regular condition inspections and asbestos re-inspection surveys. Record all information accurately and regularly update changes. Ensure that the information is disseminated successfully to those who may be affected or are potentially at risk and to freely provide information upon request. Implement a management plan which aims to control the risk from ACMs through remedial works. Treat all asbestos equally, ensuring that NO ACMs are removed or worked on by University personnel, including non-licensable materials. Encourage all staff to work towards a positive asbestos culture where everybody recognises and understands their responsibilities. Carry out annual information sessions, promoting asbestos awareness. To regularly review the Asbestos Management scheme (annually, minimum). The Asbestos Management Plan aims to: Provide a working document detailing how the University aims to manage known asbestos material across the University. Clearly outline the roles and responsibilities of University personnel Outline how the asbestos register is derived, maintained and communicated Ensure that there are emergency procedures in place Provide practical guidance and support for projects It is the responsibility of all personnel to be familiar with the procedures contained within the Asbestos Management Plan, to comply with these procedures, current legislation, official guidance and good practice. The Asbestos Management Plan has clear and designated responsibilities and managerial accountability for the safe management of asbestos and those who may be at risk. In respect of this the University shall - Manage the risks from asbestos so far as is reasonably practicable to prevent exposure, or reduce to as low as reasonably practicable, to airborne asbestos fibres to those who work in our premises, or to others who rent, live in, visit, maintain, refurbish or demolish them. The activities of the University shall be carried out in accordance with statutory provisions specifically the Health and Safety at Work etc. Act 1974, the Management of Health and Safety at Work Regulations 1999, the Control of Asbestos Regulations 2012, the Construction (Design and Management) Regulations 2015 and the Page 3 of 132

4 Workplace Health, Safety and Welfare Regulations We regard compliance with these provisions as a minimum. The University shall ensure that it has an up-to-date asbestos register for the properties it directly manages or has management duties within. The University shall conduct regular audits of its approved Asbestos Management Plan and aim to ensure that the processes and training around the plan are monitored and amended as required. This will ensure that the potential for exposure to asbestos to University staff, contractors, students and visitors is prevented, or where this is not possible reduced as low as is reasonably practicable and ensures that all activities are undertaken in a safe manner. The University shall manage asbestos by carrying out an assessment of all our properties and undertaking Management Surveys to all. Management Surveys shall be undertaken by a UKAS accredited consultancy and will be verified by a UKAS accredited laboratory to ISO and ISO (Analyst and Fibre counting standards). The University shall review all survey reports for adequacy on completion and identify shortfalls in adequacy that need to be addressed. Particular attention shall be paid to any limitations identified in the report that affect the ability of the University to manage asbestos risks. For property constructed or modified pre 2000 this should involve at least a Management Survey to HSG264 standards. For property constructed prior to 2000 to be demolished or refurbished, a project specific Refurbishment / Demolition Survey will be mandatory. Where asbestos is identified or presumed and the risk assessment shows there is no immediate risk, measures will be put in place to monitor and manage the material. Where a material is identified or observed to be in a condition where it poses a risk of exposure to persons then control measures will be put in place to reduce the risk of exposure. Areas where asbestos containing materials in poor condition are present will be restricted until such time as suitable abatement works have been undertaken and the area deemed to be safe to reoccupy. Where refurbishment works are planned, wherever possible all asbestos containing materials contained within the project area will be removed. Events, which may limit the removals of all asbestos materials from a refurbishment area may include physical limitations, such as asbestos being located within the structural fabric of the building or where cost will be prohibitively high as to make the project unsustainable. Budgetary factors alone should not be the main consideration when it comes to asbestos removal works. Where it is deemed that not all asbestos can be removed from a project area then consideration must be taken to minimise the risk from remaining materials within the design for the refurbishment. For routine activities, e.g. maintenance operations carried out by University subcontractors, the University shall: Make any survey we have available to those carrying out the work in advance of their starting work and if no information is available, or there is any doubt as to the quality of the information, arrange for a suitable and sufficient survey to be undertaken. Page 4 of 132

5 Identify the risk associated with the presence of the asbestos material that needs to be managed by the University and / or the subcontractor, before work starts. If residual risks are present, aim to ensure that the subcontractor is competent to carry out work with asbestos and has produced a suitable and sufficient risk assessment & method statement (RAMS) and notified HSE if applicable. The RAMS documentation will be reviewed for suitability by the Asbestos Compliance Team or the Authorising Engineer prior to authorisaion for works to commence being given. Aim to ensure that works can only commence once the University are satisfied that the risk has been appropriately assessed and adequate controls have been implemented to effectively control the identified risk. Storage of information on asbestos: The University shall place all of its information concerning asbestos within a serviced Asbestos Register controlled by the Appointed Person and Dutyholder The University shall store all asbestos information including registers, risk assessments, sample reports, assurance and monitoring records, clearance certificates, safety method statements and waste consignment notes for a minimum of 40 years. All such information shall be readily accessible. Responsibility for compliance with this policy rests with the person in overall control of the portfolio (the Dutyholder Director of Estates). The Vice Chancellor has ultimate responsibility for Health and Safety across the University and as such shall ensure that : Suitably competent and experienced persons into the positions of Dutyholder (Director of Estates), Appointed Persons and Responsible persons, as described within the Asbestos Management Plan in such a manner as their responsibilities can be enacted and the processes and procedures put in place to reduce the risk of exposure to asbestos. Persons who commission or undertakes building and maintenance work understand that they have a duty to manage and shall liaise with the Appointed Persons in advance of construction/works. The University shall make training available to Staff and contractor training competence will be monitored and managed in regards to asbestos through a training needs analysis and training matrix. Have Emergency Procedures, which be conveyed to all staff and contractors through bespoke awareness training, toolbox talk or induction so that all persons working on University property know how to respond should unintentional exposure to asbestos occur. Duty to co-operate. All persons who are not Dutyholder, but control access to the University premises, must co-operate with the University to enable the University to manage asbestos. Where the University shares control of premises with other occupiers, the lease should identify the party responsible for maintenance/repair. Where responsibility is unclear we should discuss the course of action with the other parties involved. If no agreement Page 5 of 132

6 can be reached in advance of the planned works then the University must at least carry out an assessment of the areas we occupy. This policy will be reviewed bi-annually or more frequently if appropriate and a compliance report will be produced and issued to all concerned parties. More frequent reviews may be triggered by instances such as, but not limited to, alteration to key members of staff, incidents which may highlight deficiencies in the policy, alteration to work practices or procedures or failure to meet Action Plan targets. Page 6 of 132

7 Section 2 - Manchester Metropolitan University Asbestos Management Plan Page 7 of 132

8 1.0 Introduction 1.1 Background Manchester Metropolitan University (the University) is housed across two main campuses, All Saints campus in Manchester and Cheshire campus in Crewe. The age of buildings owned by the Manchester Metropolitan University across the All Saints and Cheshire Campuses is such that asbestos was employed routinely during their initial construction and subsequent refurbishment or maintenance works. In addition, a number of the faculties operated by the Manchester Metropolitan University are such that asbestos was also employed routinely in equipment and this may still be present within. 1.2 Asbestos and its health effects? Asbestos is a term used for the fibrous forms of several naturally occurring silicate minerals which have been exploited for their useful properties of flexibility, high tensile strength, incombustibility, low thermal conductivity and resistance to chemical attack. There are six varieties of asbestos currently named in the legislation; Serpentine Group - Chrysotile (White Asbestos) Amphibole Group - Crocidolite (Blue Asbestos) Amosite (Brown Asbestos) Fibrous Anthophyllite Fibrous Actinolite Fibrous Tremolite The three main types used in the UK are Chrysotile, Crocidolite and Amosite. Asbestos-containing products have been widely used in buildings as construction materials, fireproofing (insulating board or spray coating materials), thermal and electrical insulation, soundproofing, roofing products, wall and roof panelling (insulating board and cement), flooring products, gasket and mastic sealing materials, heat-resistant materials etc. When asbestos is disturbed or damaged, the fibres are released into the air and are respirable which creates a risk to human health. Airborne fibres will not be released if the asbestos containing materials are in a good condition and are not disturbed. Any activity within areas adjacent to asbestos containing materials may lead to disturbance of the material, this could include maintenance or mechanical activities or moving or disturbing asbestos containing materials to access an area. Asbestos is classified as a class 1 carcinogen by the World Health Organisation (WHO). All forms of asbestos may cause asbestos related diseases including asbestosis (scarring of the lungs affecting a person s ability to breathe), lung cancer and mesothelioma (cancer of the lining of the lung or peritoneum. In order to reduce the risk of exposure to asbestos fibres and therefore the possibility of developing an asbestos related disease the University has an obligation to managed its asbestos containing materials so that they are maintained in a good condition and addition management controls are introduced where the potential for exposure to asbestos fibres is increased, for example where a material is in poor condition or the possibility of disturbance is higher due to the nature or location of the materials. Page 8 of 132

9 2.0 Asbestos Legislative Framework The University recognises its legal responsibilities in regards to asbestos. The control of asbestos is governed by a number of regulations made under the enabling act, The Health and Safety at Work Act The principle of these regulations is to assess hazard and risk and then introduce suitable management controls to minimise this risk. The University also has a duty to take account of people not directly employed by them but who could be affected by the asbestos containing materials present within property portfolio (including Employees of other Employers, people occupying buildings, members of the Public etc.). Any asbestos-related matters associated with The University property portfolio (including leased properties where dutyholder responsibilities apply) or University equipment shall be performed in accordance with all relevant Acts, Regulations, Approved Codes of Practice and industry standards, including, but not limited to, the following: The Health and Safety at Work etc. Act 1974 The Control of Asbestos Regulations 2012 The Management of Health and Safety at Work Regulations 1999 (as amended) The Hazardous Waste Regulations 2016 The Site Waste Management Regulations 2008 The Construction (Design and Management) Regulations 2015 The following documents. Produced by the HSE are designed to assist dutyholders and others with responsibilities under this plan in fulfilling their duties: Work with materials containing asbestos. Control of Asbestos Regulations, ACOP L143 HSE Control of asbestos regulations guidance e.g., HSG227, 247 and 248 Asbestos essentials publications; introduction and task manual, HSE. Asbestos: The Survey Guide, HSG264 Asbestos related HSE web pages - Asbestos Liaison Group memos: HSE Technical Working Group (TWG) Meeting Minute appendices Page 9 of 132

10 3.0 Management Process, Strategy and Action Plan 3.1 Management Process The key function of this Asbestos Management Plan (AMP) document is to set out the required procedures in order to: Meet the University legal requirements in relation to asbestos. Manage identified and presumed asbestos as part of both a short term and medium to long term strategic plan, ensuring that resources, budgets and funding are allocated in a way that is commensurate with identified levels of risk and also the development strategy of the University. Manage emergency situations involving unplanned disturbance of Asbestos Containing Materials (ACM) or potential exposure to airborne fibre. Identify or presume and record, within a reasonable timescale, the location and presence of ACM within the portfolio and maintain these records within a suitable register, including a material risk score for each ACM identified. Identify works that may have fallen outside the requirements of this plan. Provide, via suitable means. Information on ACMs identified or presumed to University staff, contractors, maintenance workers and all relevant third parties who may require it. Employ competent staff, strategic consultants and other relevant parties to effectively manage potential risks from asbestos. Implement, maintain and continually improve our management of asbestos, including reviews of this plan and policy and the processes surrounding it. 3.2 Strategy for Compliance Compliance to the Control of Asbestos Regulations 2012 (CAR) will be achieved through presuming all materials contain asbestos unless known to the contrary and managing those materials accordingly. The University will: Identify the persons responsible for managing asbestos across the University s portfolio and identity the responsibilities under this Management Plan. Use the Asbestos Management Plan to prevent, or where this is not possible, reduce exposures to as low as reasonably practicable for employees, contractors, maintenance workers and all relevant third parties by managing the asbestos containing materials within University managed properties or equipment and also construction and development sites. Undertake Management Asbestos Surveys for all properties across the property portfolio. This includes any workplace for University staff, contractors and students and also any University managed properties where landlord responsibilities apply or where it is deemed that a tenant will be supplied with suitable asbestos management information. Vacant properties will also require an Asbestos Management Survey unless refurbishment is planned prior to re-occupation. Where acquisition of property is undertaken then there will be a requirement to obtain suitable information in regards to asbestos. All existing asbestos information will be reviewed through the acquisition process, however the University will also utilise one of its approved consultancies to undertake, as a minimum a Management Survey of the property. Where refurbishment is planned for an acquired property then a specific refurbishment survey will be planned and undertaken. Compile an action plan based on the finding of the management survey program with realistic timescales for all asbestos compliance targets. Undertake Refurbishment or Demolition Asbestos Surveys ahead of any work that will disturb elements of a building not covered by a previous Management Survey. Undertake asbestos remediation to materials identified from surveys as appropriate in a timely manner using Family Investment Office Approved Licensed Asbestos Contractors. Manage and maintain an asbestos register and undertake resurveys or reinspections or any other management action based deemed necessary on the information supplied within. Update the register and asbestos survey report when additional survey information or removal works are undertaken, the condition of asbestos containing materials is altered or additional asbestos Page 10 of 132

11 containing materials are identified. Aim to ensure that our staff and other relevant parties are competent to meet their roles and responsibilities under this document. Training is to be developed and organised by the Authorising Engineer, in conjunction with the University. 3.3 Action Plan 2017/2018 The Action Plan is set out to ensure a proactive approach to asbestos management and compliance, and meet the University s strategic and operational objectives for asbestos and the estate. The action plan will also incorporate the Central Removals Strategy (under development), as detailed within Section 7.2 of this Management Plan. This will be reviewed periodically to ensure compliance and as a part of the bi-annual review of the Management Plan, and is set out in Appendix 1. The Action Plan is currently in development and will be circulated for agreement prior to issue and input into this document. Where deemed required, due to extents, location, condition or nature of Asbestos Containing Materials within buildings it may be required to produce a building specific Asbestos Management Plan for certain buildings. This plan would highlight the re-inspection regimes identified for specific materials and also highlight management and on site controls introduced to manage the materials and reduce exposures to asbestos fibre to staff, contractors, students and visitors. The requirement for building specific Asbestos Management Plans will be highlighted as part of the review of existing data as part of the programme of developing the action plan and central removals strategy and will be highlighted as part of this process. Page 11 of 132

12 4.0 Structure, Roles and Responsibilities The University has an explicit duty to assess and manage the risks from asbestos. The Board of Governors of the University are ultimately responsible for the implementation of the University's Asbestos Management Plan. The Estates Directorate are the department responsible for the management of asbestos. 4.1 Asbestos Compliance Team The Asbestos Compliance Team is currently made up of the Appointed Person Asbestos Control Officer (Strategic), Appointed Persons Asbestos Control Officer (Operations, Manchester & Cheshire), the Compliance Co-Coordinator (asbestos), the Authorising Engineer (Asbestos) and the Asbestos Compliance Team Project Support. The Asbestos Compliance Team report to the Assistant Director of Estates Management. The Asbestos Compliance Team will be responsible for the strategic and operational management of asbestos throughout the University s portfolio and equipment. The responsibilities of the persons who form the team are described within the section below alongside those other persons identified to have responsibilities as part of the AMP. 4.2 Asbestos Management Structure Figure Current Structure of the Estates Directorate in terms of Asbestos Management. Page 12 of 132

13 4.3 Roles and Responsibilities This section identifies those who have responsibilities under this Asbestos Management Plan and what those responsibilities are. The University will employ suitably trained and competent persons to administer its responsibilities in terms of asbestos management, which includes the provision of a third party Authorising Engineer who will oversee all aspects of asbestos management within The University. Figure above gives detail of the Structure of the Asbestos Compliance Team and wider Estates Directorate Structure in terms of Asbestos Management. The Vice Chancellor and the University Executive Group have overall oversight and responsibility for Health and Safety at the University, including the management of asbestos. This will include the supply of suitable and sufficient resource in order to achieve this. The Director of Services has overall control of the University s Services Group (Estates, IT Services and Facilities). As such they have responsibility to appoint suitable and competent persons as heads of the departments identified, which will include the Director of Estates, who has been identified as the person with overall responsibility for management of asbestos across the University Estate. Main Duty Holder Role Director of Estates Responsibility Overall responsibility for the Estates Directorate Ultimately accountable for asbestos management across the University s land, buildings and permanent equipment Appoint suitably competent Authorising Engineer Appoint suitably technically qualified and competent persons to allow the responsibilities of the AMP to be discharged Request Authorising Engineer undertakes audits and evaluation of appointed persons performance and competence. Ensure adequate time and resource is allowed for responsible persons to undertake their responsibilities under the AMP Responsible Persons Role Director of Services Assistant Director of Estates (Management) Responsibility Allocation of funding for the Asbestos Management Plan Appoint a competent Duty Holder for Asbestos Assist the Duty Director carry out their responsibilities Resource, Manage and monitor performance of the Asbestos Compliance Team Ensure annual inspection, auditing and reporting against Overall Contract management responsibility Management of Appointed persons (asbestos) Compliance with this management plan, asbestos register and associated procedures. Ensure staff or contractors under the control of Estates Services do not disturb Asbestos containing materials. Ensure staff or contractors under the control of Estates Services are suitably trained and competent in asbestos related matters, as set out within the AMP Assistant Director of Estates (Development) Assist the Director is his responsibilities Resource and funding for project works Project Contract management Responsibilities for sufficient competence of Projects and Development team Compliance with this management plan, asbestos register and associated Page 13 of 132

14 Director of Facilities Director of Information Systems and Digital Services procedures. Ensure staff or contractors under the control of Estates do not disturb Asbestos containing materials. Ensure staff or contractors under the control of Estates are suitably trained and competent in asbestos related matters, as set out within the AMP Compliance with this management plan, asbestos register and any associated procedures. Ensure staff or contractors under the control of the Facilities department do not disturb Asbestos containing materials. Ensure staff or contractors under the control of the Facilities department are suitably trained and competent in asbestos related matters, as set out within the AMP Appointing suitable persons to liaise with the Asbestos Compliance Team to plan so suitable asbestos information is available prior to any works which may alter spaces or disturb asbestos and introduce suitable controls or plan abatement if required Report any incidences of disturbance of ACMs or potential exposures of the Facilities department staff or contractors to the Asbestos Compliance Team Ensuring contractors under control of the Facilities department comply with University permit and induction requirements and suitable and sufficient asbestos information is supplied as part of this process. Compliance with this management plan, asbestos register and any associated procedures. Ensure staff or contractors under the control of IT Services do not disturb Asbestos containing materials. Ensure staff or contractors under the control of IT Services are suitably trained and competent in asbestos related matters, as set out within the AMP Appointing suitable persons to liaise with the Asbestos Compliance Team to plan so suitable asbestos information is available prior to any works which may alter spaces or disturb asbestos and introduce suitable controls or plan abatement if required Report any incidences of disturbance of ACMs or potential exposures of IT Services staff or contractors to the Asbestos Compliance Team Ensuring contractors under control of IT Services comply with University permit and induction requirements and suitable and sufficient asbestos information is supplied as part of this process. Authorising Engineer (Asbestos) Working alongside the MMU Asbestos Compliance Team the Authorising Engineer will undertake the following tasks: Development of the University s Asbestos Policy and Management Plan Review and Audit of AMP Review and audit of Procedures relating to asbestos management Revision of AMP and procedures Provide Assurance to University over asbestos management Development Training needs and associated training courses Production of scoping and specifications for asbestos abatement and survey projects throughout the University Advice over all matters asbestos to the Asbestos Compliance Team and other persons Assist other persons identified within the section in the day to day and strategic requirements in regards to asbestos management Audits of all persons involved in Asbestos Management throughout the University Page 14 of 132

15 Appointed Person Asbestos Control Officer (appointed person - Strategic) Appointed Person Asbestos Control Officer (appointed person Operations - Manchester) Asbestos Contact (Operations - Cheshire) Compliance Cocoordinator Asbestos Compliance Team (Project support) Raising of Orders in relation to works on asbestos Working alongside Authorising Engineer to develop specifications Working alongside Authorising Engineer to audit, review and amend AMP and associated documentation Development of financial planning for strategic asbestos management and budget for asbestos compliance team, profiling of budgets Development of asbestos abatement strategy throughout Manchester and Cheshire campuses Management of training requirements in line with AMP and development of budget for undertaking this. Liaison with Appointed Persons (Operational Manchester and Cheshire) in relation to day to day asbestos management and implementation of the AMP Cover for responsibilities of Appointed Person (Operational) across campuses in their absence Day to day implementation of AMP at Manchester Campus Management of the Asbestos Register across the University estate Auditing of consultant and contractor works Management of ACMs onsite Working alongside Authorising Engineer to produce specifications and scoping documents for asbestos related works. Commissioning of works relating to asbestos, including liaison with other involved parties including approved consultants and contractors. Review of asbestos information received Liaison and implementation of AMP with other departments Ensure all asbestos related incidents are reported and recorded in line with University procedure. Oversee operations of Asbestos Contact (Cheshire) Review asbestos data and development abatement budget requirements for high risk ACM removal Supply all staff/contractors with suitable information prior to works commencing Liaison with other departments surrounding asbestos management (abatement etc.) Liaison with Appointed Person Strategic and cover for this person in their absence Day to day implementation of AMP at Cheshire Campus Auditing of consultant and contractor works Management of ACMs onsite Commissioning of works relating to asbestos, including liaison with other involved parties and approved consultants and contractors. Working alongside Authorising Engineer to produce specifications and scoping documents for asbestos related works. Supply all staff/contractors with suitable information prior to works commencing Any gaps in management operations in Cheshire will revert to Appointed Person in Manchester for approval Support Appointed persons in their responsibilities under AMP Assist with training needs analysis for staff and contractors in regards to asbestos Assist with planning training courses and scheduling including arranging with managers and staff. Document management including storing of documentation within correct filing structure Receiving and distributing documents as required Archiving of documentation, both electronic and hard copy file Uploading or amending of data in MiCAD where required Assisting Appointed Person Asbestos Control Officer in asbestos service requests Managing and arranging contract progress meetings with all parties Page 15 of 132

16 Estates Directorate Project Managers/Maintenance Managers & Supervisors Direct Labour Organisation (DLO)/Contractors UKAS Approved Asbestos Consultancy Suppliers Project management Assist, by the provision of information, individual designers, or consultant project managers in the evaluation of any maintenance, renovation or construction activities in respect of the presence of asbestos containing materials. Identification and bringing to the attention of appropriate staff any suspect material Ensure all contractors working on asbestos are aware of and meet the requirements of the AMP through induction, Site Access Process and Works processes Ensure project personnel (including contractors) are inducted Liaison with Asbestos Compliance Team to seek advice and request survey and removal works to assist project works. Ensure all contractors are aware of the University AMP and are competent to be able to undertake the task in line with the requirements within. This should include suitable asbestos awareness or any other training that will be required (as highlighted within Section 5). Collation of certification will be required in regards to this. Copies should be supplied to the Asbestos Compliance Team Request suitable Risk Assessments and Method Statements in regards to asbestos for all projects Undertake suitable and sufficient training for their undertakings within the remit of the Estates Directorate Ensuring day-to-day compliance with this management plan, asbestos register and any associated procedures. Check or are in receipt of information from the asbestos register for the location of applicable work in properties constructed before the year 2000 and before any works commences. Ensuring that any works that may disturb or damage ACMs are not undertaken. Reporting any accidents/incidents involving suspect asbestos containing material, non-conformances associated with this plan and the register via the University s accident reporting system and to the Asbestos Compliance Team. For example, any material suspected to contain asbestos where the material has been damaged or disturbed or where staff/contractors are likely to undertake work that may affect such materials. As and when required: Provide a management consultancy service in the areas of asbestos management and abatement Undertake surveys and sampling, where requested, in accordance with current legislation Review and comment on projects where asbestos works may be necessary including the provision of information for any building projects and on contractors method statements Supervision of asbestos removal works including, but not restricted to, attending pre-start, progress and completion meetings Report to the Asbestos Compliance Team any defects or non-compliances relating to the Licensed Asbestos Removal Contractor s (LARC) performance, including suitability of work areas, adherence to method statement and compliance with College policy Checking areas on completion of works to ensure that the LARC has completed his scope of works and all affected areas have been left in a satisfactory condition. Issuing completion reports, including all clearance documentation to include a minimum of analysis confirmation or applicable survey reference, technical specification or scope of works, method statement, clearance certification and consignment notes. Updating and issuing asbestos surveys, including update of plans where applicable, following the removal or reduction of risk of asbestos containing materials. Providing training programs for University staff. Bringing to the attention of the Asbestos Compliance Team any concerns regarding the management of ACMs. Page 16 of 132

17 UKAS Licensed Asbestos Removal Contractors University Health and Safety Team University Human Resources Department Complying with current legislation and ACOPs and guidance Removal and/or encapsulation of ACMs in a safe and controlled manner without increasing risk of exposure to asbestos fibre to staff, students and visitors etc. Attend site, as directed by the Asbestos Compliance Team, or Authorising Engineer, for the making safe of any uncontrolled disturbances of ACMs Assisting with any other matter in regards to asbestos abatement or assisting approved consultants undertake survey works as requested by the Asbestos Compliance Team Assist Compliance Coordinator in arranging Asbestos related training and toolbox talks. Report any related incidents to the HSE (RIDDOR) Support and provide technical input into any investigations surrounding asbestos incidents Assist Asbestos Compliance Team in issuing Safety Alerts following Asbestos Incidents Provide general support and guidance to the Asbestos Compliance Team as required. Maintain incident and injury reports and investigations for asbestos related incidents. Provide mechanism for the recruitment of competent Human Resource to manage asbestos as highlighted in this plan Organise provision of health surveillance, support, counselling to employees Provide assistance during incident investigations Human Resources Advisory Team maintain health surveillance records for all employees Page 17 of 132

18 5.0 Approved Suppliers and Authorising Engineer Support The University has engaged the services of an external asbestos consultant, WSP UK Ltd, to act as Authorising Engineer to assist with the development of the asbestos policy, Asbestos Management Plan and associated procedures and processes, asbestos management, training and strategy development. The Authorising Engineer is to be available to offer advice to staff or other interested parties surrounding asbestos. All areas of asbestos management are to be approved by the Authorising Engineer prior to implementation. The duties of the Authorising Engineer are highlighted within section 4.3 of this Asbestos Management Plan. Additionally the University has, through procurement, appointed a number of external asbestos specialist contractor to assist with its responsibilities in regards to asbestos management. 5.1 UKAS Approved Asbestos Consultancy and Analytical Services The University has enrolled the services of a number asbestos surveying consultancies to undertake asbestos related services throughout the University portfolio. All analytical consultancies used by the University are to be UKAS accredited for the services required (ISO & ISO 17025) and must also be able to prove themselves and their employees hold sufficient experience and competence to be able to undertake the services requested. Consultancies must be able to supply evidence of this if requested (items such as qualifications, evidence of audits and previous experience of works within similar locations for other organisations). The approved consultancies should also be able be able to prove they can provide adequate resource to undertake the tasks requested within timescales set out by the University. At present the University has two approved suppliers for consultancy services. The requirement for number of consultancy supplier will be reviewed based on current and anticipated requirements and will be decided as part of the next procurement process. The performance of all asbestos consultancies will be carefully monitored by the Asbestos Compliance Team and the on a regular basis through review of documentation received and on site audits of performance (through Forms ASB005, 010 and 011). Where required, improvement actions will be issued with suitable timeframes for response included. Performance improvement audits or request for evidence of improvement may be undertaken or requested following the issue of performance actions. Regular progress meeting will also be arranged for all suppliers. 5.2 UKAS Approved Licensed Asbestos Removal Contractors (LARC) All asbestos removal works to the University s property portfolio or equipment within will be undertaken by an approved licensed asbestos removal contractor. The University approved suppliers will be selected via procurement process. As part of this process the LARC the LARC must be able to demonstrate competence using criteria which will be set out in the specification. However, some activities, such as those highlighted in section 5.4 may be undertaken a non-licensed contractor. The process for these types of activity are highlighted within section 5.4 of this AMP. At present the University has a sole approved supplier for LARC services. The requirement for number of consultancy supplier will be reviewed based on current and anticipated requirements and will be decided as part of the next procurement process. It is anticipated that there will be the requirement for more than one supplier. Approved consultant and LARC providers will be reviewed via audit regularly by the Asbestos Compliance Team or Authorising Engineer and any performance improvements actions highlighted. Further audit and review by the Authorising Engineer will be undertaken to confirm that actions have been taken and implemented and this will be documented using the forms mentioned above. The contractors are responsible for informing the University any Performance or Prohibition Notices that have been served upon them by the HSE or any other incident which may impede the conditions set out above. Regular progress meetings will Page 18 of 132

19 be scheduled for all approved suppliers. 5.3 Use of UKAS Approved Suppliers In order for the University to adequate control the management of asbestos across the portfolio all asbestos surveying, analytical or removal works must be undertaken by one of the approved suppliers. This should be the case even when works are being undertaken as part of a larger refurbishment or demolition project which is being managed by a third party Principal Contractor. All deviations from this process should not be undertaken until such time as approval from the Asbestos Compliance Team has been gained and agreed measures to capture information for and from the works has been agreed. The rationale for not using one of the approved suppliers should be provided as part of the request. 5.4 Works undertaken on Asbestos by Non Licensed Contractors The University recognises that some activities involving work on Asbestos Containing Materials will be undertaken by contractors other than the approved University LARC suppliers. An example of this would be the painting of asbestos insulating board panel walls as part of a routine maintenance program. In such cases the works can be undertaken by a contractor not holding a license for works with asbestos. Such contractors must be able to prove they have suitable training and competences (e.g. Task Specific Non Licensed Works with Asbestos training, over and above general Asbestos Awareness training, undertaken by a competent training provider) to undertake the works proposed, be able to produce suitable method statements and risk assessments to undertake the works (including suitable controls, waste management and managing emergency situations) which follows current guidance and best practice and be able to follow them in practice. The contractor must also be able to prove they have suitable insurance cover to undertake the works. The works must fall into the non-licensed category (not Non Notifiable Licensed Work, which must be undertaken by the LARC) of works and must meet the criteria as described in CAR 2012, regulation 3(2). The Asbestos Compliance Team must approve any contractor wishing to undertake any such works (including a review of all training and insurance documents, which will include a request for previous experience of similar works and possible references from other clients. Such works are to be commissioned in the same way as licensed asbestos abatement works, as described within section 7.3 of this AMP using Form ASB001/1. The Asbestos Compliance Team will give final approval any activities being undertaken on asbestos containing materials by non-licensed contractors. This will include review method statements and risk assessments and reviewing the current asbestos register to confirm the condition of the materials. If it is deemed that the works cannot be undertaken then the Asbestos Compliance Team will inform the commission person of the rationale and complete the relevant Hold Point on Form ASB001/2. In such circumstances the University s approved LARC supplier must be used to undertake the task instead. The commissioning person will be responsible for requesting works from the LARC supplier, a new Form ASB001/2 will be required in such circumstances. Page 19 of 132

20 6.0 Identification and Assessment of Asbestos Containing Materials 6.1 Buildings Containing Asbestos Containing Materials All buildings across The University portfolio which were constructed prior to 2000 may contain asbestos containing materials, even within areas which have been refurbished after the use of asbestos containing materials was prohibited. The University has identified all buildings in which asbestos containing materials may be present, these are presented in the table below. Manchester Campus Cheshire Campus 18/19 Market Place College House Admin Bellhouse Building Couzens Salutation Delaney Grosvenor Building Frances Wood Ormond Building Student Union and Lecture Theatre Number 70 Oxford Street Lodge Righton Building Laurence Building All Saints Building Wilson Building Cambridge Halls North Valentine Building Cambridge Halls South Harley Building Cavendish Hall Davenport Cavendish Teaching Halfway House Chatham Building Barlow Building Geoffrey Manton Building Library Building Sir Kenneth Green Library Seeley Building Old Student Union Building Student Zone John Dalton East Digital Media/Student Drop in Centre John Dalton Central Ground Staff John Dalton Tower Brock Building John Dalton West Chester Street Stores Chatham Tower Platt Lane 3G Dome Platt Lane Complex Platt Lane Leisure Dome Benzie Building (connection to Chatham) 6 Great Marlborough Street, Manchester 6.2 Existing Information for Buildings Containing ACMs At present information in regards to the location of any asbestos containing materials is saved in a number of places through the University s central servers. It is the aim that by June 2017 all existing and historic information will be collated and stored within the central Asbestos Compliance Team folders (this will be reviewed by all involved in the process and timescales amended if required). All existing information will remain in its current location and a copy will be made. A spreadsheet document will record the location of the original document and this will be held within the asbestos information folder for the relevant building. 6.3 Surveying Methodology throughout the University Portfolio HSE guidance document HSG264 gives detail of types of survey which may be undertaken to locate the presence of any asbestos containing materials. In most cases, the Management survey will have three main aims: it must as far as reasonably practicable locate and record the location, extent and product type of any presumed or known ACMs; it must inspect and record information on the accessibility, condition* and surface treatment of any presumed or known ACMs; Page 20 of 132

21 it should determine and record the asbestos type, either by collecting representative samples of suspect materials for laboratory identification, or by The Asbestos survey should also give detail of items, which do not contain asbestos, through activities such as sampling or surveyor experience. Areas of limitation should be reduced as far as reasonably practicable at planning stage, so planning of investigations into areas such as lift shafts, electrical installations etc. should be undertaken and suitable persons put in place to allow this to happen, e.g. lift engineers, electricians. There are three main types of survey used to identify the presence of asbestos containing materials within buildings as described within HSG264. These are known as Management Survey Refurbishment Survey Demolition Survey All surveys undertaken throughout the University portfolio must be undertaken by one of the approved United Kingdom Accreditation Services (UKAS) accredited asbestos consultancies. This includes all works undertaken as part of larger refurbishment or demolition project which are being managed by a Principal Contractor. A Management Survey is for the purpose of managing asbestos-containing materials during the normal occupation and use of premises. A Management Survey aims to ensure that: Nobody is harmed by the continuing presence of asbestos containing materials in the premises or equipment; That the asbestos containing materials remain in good condition; and That nobody disturbs it accidentally The Survey must locate ACM that could be damaged or disturbed by normal activities, by foreseeable maintenance, or by installing new equipment. All Asbestos Management Surveys across The University property portfolio should include inspections within ceiling voids where access is available, loft spaces, under floor coverings (where it will not cause significant damage or safety hazards) and within accessible floor hatches and within lift shafts. Targeted intrusive inspections are also to be made within areas within plant rooms and risers where it is thought asbestos containing materials may be present. Elements such as, but not limited to, fixed boxings, floor trenches, cable conduits and below non asbestos insulating materials should be inspected as far as reasonably practicable where safe to do so. Details of any intrusive inspections are to be detailed within the Management Survey report. The Management survey will supply enough information to allow simple and routine maintenance or installation works to proceed and should be read and understood by all undertaking works prior to any activity being undertaken, should that element have been suitably inspected. Therefore the survey should include the information on any areas not accessed and any caveats and limitations of the survey undertaken with as much detail as possible provided. The cleaning or painting of non-asbestos materials, or fixing or drilling into building elements made entirely from solid brick, metal, wood or PVC (i.e. a non-asbestos material) would not normally require a refurbishment or demolition survey so long as the intrusion or disturbance does not extend beyond these materials and a management survey has already been undertaken. Caution should be taken for potential asbestos coatings to brick, block or other surface beneath paint coatings. The scope of Management survey programme is to be confirmed prior to commencement of works. The appointed consultancies are to submit scoping documentation for approval by the Asbestos Compliance Team and any amendments are to be agreed between all parties. Asbestos Management Surveys have been completed to all buildings identified within section 6.1. with the exception of the Cambridge Halls buildings. Where an Asbestos Management survey has not yet been completed a Type 2 Asbestos survey is available to provide information on the location of asbestos containing materials. These reports should be treated with caution due to their age and the scope of works agreed at the time of the surveys. The Asbestos Compliance Team are to provide the surveyor with the site layout, building plans, building Page 21 of 132

22 specifications or architect's drawings (latest versions with correct space identifiers), and any history of asbestos work; point out site hazards, including means of safe access and to arrange for building managers to provide keys to areas etc. The Asbestos Compliance Team are also to provide the surveyor with the most up to date information asbestos information. All surveyors must use the correct room/space reference provided by the University when capturing data on site to allow for the data to be collated into an electronic asbestos management database system. Where more extensive maintenance or installation works, refurbishment or demolition activities are planned CAR then a Refurbishment or Demolition survey will be required. CAR 2012, Regulation 5, states: an employer shall not undertake work in [demolition,] maintenance, or any other work which exposes or is liable to expose his employees to asbestos in respect of any premises unless he has carried out a suitable and sufficient assessment as to whether asbestos, what type of asbestos, contained in what material and in what condition is present or is liable to be present in those premises. A refurbishment or demolition survey is used to locate, as far as reasonably practicable, all asbestos containing materials within the areas where works are to be undertaken. A refurbishment or demolition survey is fully intrusive identified within the scope of works (Appendix 4 and 5), or the whole building in the case of a demolition survey. The surveys will involve intrusive inspections to all areas, including those which are difficult to reach. All refurbishment or demolition surveys will require suitable and sufficient planning between all parties concerned. A survey scoping document will be produced and issued to the surveying consultancy by the person commissioning works using form ASB002 for all refurbishment or demolition surveys. This will give a breakdown of the works planned within each space or area. Whenever possible, the scoping document should be supplemented with an on-site pre-start meeting with the asbestos surveyor to agree the exact scope of the refurbishment or installation works and therefore the exact scope of the survey that will be required and also highlight any hazards and requirements. The asbestos consultant will plan the works, including the requirement for assistance from third party contractors, e.g. scaffold supplier and other high level access equipment etc. or the assistance from the University s approved LARC and submit a survey scoping document. The survey scope produced must be approved by the Asbestos Compliance Team or the Authorising Engineer prior to works commencing, in agreement with the persons commissioning the works. Thought should be given to the protection of areas, equipment or furniture which is outside the scope of the planned survey works. Due to the intrusive nature of refurbishment or demolition surveys these will only be undertaken in unoccupied areas in order to reduce the risk to staff, students or other persons occupying the areas where investigations are being undertaken. Following on from the completion of the refurbishment survey The University shall procure the internal maintenance department to make safe/suitably repair any areas where intrusive inspections have been undertaken, should it be agreed that this will be the case of the consultancy will not be undertaking the works. Should asbestos containing materials be identified during the survey that require immediate attention prior to the area being reoccupied then the University s approved LARC will be procured to undertake remedial works and make areas safe to reoccupy prior to full removal works being undertaken. In such circumstances reassurance air monitoring will be undertaken prior to reoccupation. After completion of survey works a visual inspection must be undertaken by Asbestos Compliance Team to ensure the area is safe for reoccupation. This should be documented in Form ASB006. It may be agreed that the consultancy surveyor undertake this activity and complete suitable documentation. The Asbestos Compliance Team will have to undertake suitable audits of the surveyor undertaking the inspections. Where buildings are planned for demolition consideration should be made in regards to the potential for asbestos containing materials to be present within the ground below floor slab or other covering and a suitable scope and specification should be designed to undertake suitable investigation. Details of any previous known structures on sites where demolition is planned should be supplied to the asbestos surveyor. Under no circumstance should any person not involved in survey works be present within an area whilst Page 22 of 132

23 intrusive inspections are being undertaken. 6.4 Reinspection/Resurvey Regimes The University has taken the decision to resurvey all buildings identified within Section 6.1 will be resurveyed on an annual basis rather than undertaking reinspection surveys of known ACMs. The rationale for this is that due to the ever changing nature of spaces and asbestos remediation or removal works a reinspection survey alone would not give full representation of ACMs within the properties. Undertaking a resurvey of buildings will allow for all information to be captured as the layout is at the time of the survey. It will also mean that all up to date information, including updating of plans, will be held in one report location. Where ACMs require reinspection more regularly than an annual inspection due to type, location or condition then reinspection regimes of these materials will be determined on a case by case basis and the reinspection period recorded until such time as removal or remediation works are undertaken. The reinspection schedule will be recorded on the Amendment to Condition spreadsheet for the building in the first instance and reinspections shall be undertaken by one of the University s approved consultancies. Note shall be made of inspection dates and detail to any change in condition recorded. Should it be deemed necessary further management controls may require implementation following a reinspection. Once the University has an electronic management database implemented this process will be managed through the system. In addition to annual resurvey of all buildings where ACMs may be present a resurvey request for a full or updated management survey will be undertaken after any major refurbishment works to allow for an up to date record to be held. 6.5 Asbestos Register The asbestos register forms up to date records of all known asbestos containing materials within any location across the University portfolio. Where removal works have been undertaken, the condition of the asbestos containing materials alters or additional materials are identified then the register must be updated as soon as reasonably practicable. The register also holds information on areas or items which are presumed to be asbestos containing, for example materials which could not be accessed during survey works and also areas which have not been accessed and therefore are presumed to be asbestos containing unless such time as it can be proven otherwise. Information from the asbestos register will be made available to all the require it. By summer 2017 The University aim to have the asbestos register held internally using the electronic database system. The information will be updated into MiCAD by the University s approved consultancy suppliers and initial information will be inputted from the Management survey programme currently being undertaken by AEC Ltd and this will form the baseline data for the electronic asbestos register. As an interim measure the asbestos register is held on the Strategic Management Services Building Plan Sharepoint link: The Sharepoint site will host the latest versions of the management survey and will also host all Refurbishment and Demolition surveys for each building and also copies of all asbestos removal information. In order to keep an up to date record of any removal works undertaken will be documented within a spreadsheet document, named Amendments to Condition. The Amendment to Condition spreadsheet will be available for each building and will list all known locations of ACMs from the existing asbestos Management Surveys and any additional ACMs identified within refurbishment surveys which have not been previously identified. The spreadsheet will also highlight any asbestos removals undertaken within the building with note made of any item removed or part removed and any caveats identified within clearance documentation. The spreadsheet will also identify any changes in the condition or surface treatment of the materials. In order to keep the register up to date the University requires that all refurbishment and demolition survey information, bulk sampling information and documentation surrounding asbestos removal works be returned Page 23 of 132

24 to the Asbestos Compliance Team within 10 days of the completion of works. The Asbestos Compliance Team will then file the information within the relevant folders of the Sharepoint site and update the Amendments to Condition spreadsheet accordingly. When amendments are uploaded to the Sharepoint site it shall be set in such a way that all who require access to the information are informed that amendments have been made in the form of a system produced detailing that updated documents are available. Should the interim system still be in place by the time the annual management resurveys are undertaken to buildings identified within section 6.1 then the previous surveys and Amendment to Condition documents will be archived within the Sharepoint. All documents will also held on the Estates Directorate servers at the following link:..\..\08 Asbestos Records Management Regular audits of the asbestos register will be undertaken by the Asbestos Compliance Team or the Authorising Engineer based on information held, compared to the information in the Amendment to Condition documents. Any errors identified shall be corrected and a note of the change made Amendment to Spreadsheet within the audit tab with a description of the reason for alteration and any additional requirements. 6.6 Record Keeping The Asbestos Compliance Team shall maintain detailed records of all activities and work permits relating to asbestos works, which have been undertaken through the University s property portfolio. The records kept shall include: Copies of all asbestos survey reports, including updates and amendments;* Training records in relation to asbestos for staff and contractors; Records of any asbestos abatement works performed on site; * Certificates of Reoccupation and other documents stating an area is safe to reoccupy after asbestos removal works;* Asbestos air monitoring and SEM results.* Records of management plan reviews and audits. Face-fit test and inspection records for Respiratory Protective Equipment (where required).* Significant correspondence, incident reports and other significant documentation in regards to matters surrounding asbestos within buildings or other matters John Dalton East Plenum inspection reports* Records for personnel suspected to have been exposed to asbestos (confidential records, Data Protection Act may apply) *Records should be kept for a minimum of 40 years. The information should be stored within the relevant folders of the R Drive (Staff2Staff). Should the location of the data alter then this should be detailed within this AMP. Where applicable, paper copies of the documentation should be stored in accordance with the University s archiving system in addition to the electronic version. 6.7 Requesting Surveying or Sampling Procedures Page 24 of 132

25 All requests for asbestos surveys, sampling or abatements should be directed through the correct channels to ensure that all requests are properly processed and to capture all changes to the condition or extent of asbestos containing materials. The commission person is responsible to requesting works and should use Asbestos Works Planning Checklist (Stage 1) (ASB001/1) to plan and commission all works. The Asbestos Compliance Team must be included in all correspondence (using the Asbestos Compliance Team inbox, and should be invited to all planning and scoping meetings. The Asbestos Compliance Team will also be required to complete various Hold Points throughout the commission and works process to confirm that the works requested and suitable, sufficient and are also undertaken in a safe manner. The Asbestos Compliance Team will not allow planning to proceed to the next phase until such time as they are satisfied and all information has been received. Scoping for works should be detailed using supporting document ASB002 and should be detailed on a room by room basis and should include for auxiliary works which may be required, such as running cabling to existing connection points. The Asbestos Compliance Team will inform the commissioning person as to whether additional asbestos information is required at the initial planning stage based on the scoping document produced. Should it be required, the commissioning person is responsible for appointing the consultancy to undertake the asbestos survey works and are also responsible for issuing Purchase Orders for works after review of proposals for works. The commissioning person and the asbestos consultancy are responsible for ensuring that adequate information is available to allow for the works to proceed safely and to allow for all areas covered by the scope to be adequately inspected. Under Construction, Design and Management (CDM) Regulations 2015, when planning works it is imperative that adequate time is allowed for the planning, undertaking and reporting of a refurbishment or demolition survey and also for the subsequent removal of any asbestos containing materials which may have been identified within the areas inspected. It may also be required for liaison with other parties when working on larger projects to determine what effect asbestos surveying or removal works will have project timescales. Details on how the University manages asbestos abatement works, including works following on surveys, can be found in section 7 of this AMP. 6.8 Budgetary Requirements for Asbestos Survey and Sampling Page 25 of 132

26 All management asbestos survey and additional sampling procedures required as part of the compliance requirement will be procured through the Asbestos Compliance budget. All project related survey works, including refurbishment and demolition surveys are to be funded as part of the project budget and managed by the commissioning person. IT Services and Facilities will also be required to finance survey and investigations as required to allow them to undertake activities required as part of their remit in the same manner from their own budgets. Regular budgetary reviews will be required to be undertaken between the Dutyholder, the Assistant Director of Estates, the Finance Director and the members of the Asbestos Compliance Team to ensure that this and other areas of the AMP of sufficiently funded to allow compliance against set procedures to be suitably managed and maintained. 6.9 Capital Projects Works There is a responsibility under CDM 2015 to provide relevant information upon a project. The University employs a team of professional engineers and project managers (commissioning persons) who represent it on all projects. In relation to buildings constructed prior to year 2000 relevant information includes information about asbestos. Sufficient planning is required to ensure that this information is available pre-tender, and will be collated by the Principal Designer as part of the preconstruction phase plan. The procedure for planning survey information is set out within section 6.7 of this document. For all projects a project specific refurbishment or demolition survey will be required where the building was constructed prior to 2000 and the fabric of the building or infrastructure is likely to be affected by the works. All works in relation to asbestos should be undertaken by one of the University s approved suppliers (both LARC and consultant), even if the project is being managed by a third party Principal Contractor. Funding for all asbestos related works should be considered within the budget of the project and should include provision within the project to remove all asbestos containing materials, as far as reasonably practicable, from within all areas within the project area. Wherever possible the aim should be that no restrictions to maintenance activities within refurbished areas once the project has been completed. All projects, irrespective of the procurement route employed shall adopt the procedures set out within this document On Site Management (Labelling and Signage) Strategy It is known that asbestos is an emotive subject and that labelling all areas with asbestos warning labels with cautionary text attached may create emotive issues. At the same time it is recognised that relevant persons, such as maintenance or inspection staff will need to be informed of the possible presence of Asbestos Containing Materials within an area that is to be worked in or accessed. With this in mind the University is to adopt the following measures to be used as an addition to the other asbestos management actions which are in place across the University s portfolio. Room spaces and ceiling voids will be treated as separate locations for the purposes of the labelling regime and shall be labelled as such. Labels shall be produced from a waterproof or plastic material, a minimum of 50mm x 50mm and will be attached using a strong adhesive material. These will be located to the top right hand corner of the entrance door to each area for the room space and to the ceiling as close to the entrance door within a room for the ceiling void reference. The labels will be colour coded but also of different shape so that they can still be distinguished by those that may be colourblind or from pictures which may be copied in black and white. The following labels will be applied throughout the University portfolio. Page 26 of 132

27 Asbestos Materials in a poor condition are present within this area and access has been restricted. The Asbestos Compliance Team should be contacted prior to accessing or undertaking any works. Asbestos Materials are present within the area. All available asbestos information should be reviewed prior to any works or access proceeding within. Project specific asbestos information should be reviewed prior to any works and all works should be undertaken in line with agreed method statements with any necessary controls enacted. Caution should always be taken so not to disturb ACMs within the area and caution should also be taken in case any additional unknown ACMs are encountered No known Asbestos Containing Materials have been identified within the area. Any works or access into the area should still proceed with caution in case any previously unknown materials are encountered In addition to the colour coded labelling all asbestos containing materials within non-public areas, such as ceiling voids, service risers and plant room areas will be marked with a statutory asbestos warning labels, as displayed below. The labels which are to be used comply with CAR 2012 (Schedule 2) and as displayed below. In certain circumstances the Asbestos Compliance Team may feel that all access to a room or area will require prohibiting until such time as abatement works are undertaken or additional controls are put in place to allow limited access to be permitted. In such circumstances the Asbestos Compliance Team will attach suitable signage, as displayed below, to all access points to the area. Page 27 of 132

28 The Asbestos Compliance Team may also deem it necessary to put additional methods of restricting access, such as changing locks to doors. The University will request the services of an approved consultant to undertake the direct labelling of asbestos containing materials within non-public areas. A decision of the affixing of the colour coded markers will be finalised and may be undertaken by consultant or utilising the internal DLO. It is anticipated that the labelling exercise will commence in April 2017 and be completed by June As part of the implementation of the MiCAD asbestos management database the Asbestos Compliance Team will investigate the possibility of using the systems mobile functionality to develop a system of on site management through the use of QR Codes or similar, which will enable the user to identify any asbestos containing materials within a specific location. The system mentioned above will remain in place as a backup even if such a system should be implemented Safe Systems of Work Within Contaminated Area At present the University, through the Asbestos Compliance Team and Authoring Engineer, are looking to developing procedures to allow for Safe Systems of Works to allow for access, undertaking of required works and decontamination following completion. This will include suitable training (both classroom and practical), assessment of works, provision of suitable PPE/RPE, development for a Permit System for such works and other associated factors surrounding works involving Asbestos. Once developed these will be issued within this AMP and suitable training course developed. At the current time the University will restrict access to any area where asbestos in a poor condition is present. Should maintenance or other works be required in such areas then the approved LARC supplier to attend site and plan abatement works to allow for maintenance activities to be undertaken. Information surrounding restricted access will be highlighted by the Asbestos Compliance Team using the signage described in Section The information will also communicated via other methods, such as or internal Safety Message. Page 28 of 132

29 7.0 Asbestos Abatement Work All asbestos abatement works undertaken on the University property portfolio or equipment within will be undertaken by one of the approved LARC suppliers. Wherever possible, all asbestos containing materials identified or presumed within areas where refurbishment is planned will be removed, whether they will affect refurbishment or not. 7.1 Control Actions Although desirable, it is known that, for a number of reasons, be they physical or financial, it will not always be possible to fully remove all asbestos containing materials from within a space during asbestos abatement works. It is therefore judged that the following control or abatement actions may also be taken to assist the University in its asbestos management. These actions may also offer solutions to assist within planning of larger remediation projects to allow for suitable planning or where re access is required to an area to undertake maintenance or inspection. All activities will be undertaken by the University s approved LARC supplier irrespective of the scale or type of work. Should any further control actions be identified which may be required to assist with asbestos management then these will be discussed and agreed with the Asbestos Compliance Team prior to any works being undertaken. Leave in place: The identification of asbestos in a building does not automatically require its immediate removal. Asbestos in a good condition and not prone to damage can generally remain in place as long as suitable management procedures are in place. The asbestos will need to be inspected on a regular basis (as described within section 6.4) to ensure its integrity is maintained. Should any change in condition be identified that may result in the possibility of asbestos fibre release further control actions will be required t to be undertaken. Sheeting out / separation of contaminated areas. In some areas, contamination may be limited to a defined area. In such circumstances the area can be sheeted out by the erection of timber and suitable gauge flame retardant polythene screens or plasterboard and overlaying of the floor. This is by no means a permanent solution but can be considered as a holding measure in order to allow continued access and maintenance. This technique may be used to create a clean route within a contaminated area in order to allow access through restricted areas to non-restricted. In some cases it may be that a temporary separation involves some element of removal or abatement to allow for the clean area to be produced. For example a clean route through a plant room to access equipment where regular inspection/maintenance is required. A robust inspection regime will be required to any kind of temporary separation to ensure that the structures integrity is maintained. It may also be prudent to undertake periodic air monitoring within such areas. All maintenance works will be undertaken by a LARC with inspections of integrity being undertaken by the Asbestos Compliance Team or an appointed consultant. A record of inspection should be maintained for the duration of the time the structure is present, with a suitable document being produced to record such instances. This should be saved within the relevant folders within the Asbestos folder for the building on the R (Staff2Staff) Drive. Permanent separation. Where a contaminated area adjoins an area which is free from contamination it may be possible to permanently divide the two areas. A record should be kept of such areas and it should be prominently marked so that all know the area is not accidentally encroached. Encapsulation. The sealing of an outer coating of an asbestos containing material using a sealing compound or paint (such as ET-150 encapsulant). Encapsulation protects the asbestos containing material for minor physical or mechanical damage and seals any exposed edges. A suitable level of encapsulant needs to be applied to asbestos containing materials in order to provide a suitable level of protection. Page 29 of 132

30 Encapsulated materials will require regular inspection to monitor the condition of the encapsulant and repair where required. Encapsulation of asbestos containing materials will not be suitable where it is likely that the materials are to be regularly disturbed or exposed to regular hot temperatures (over 80 o C) or as a long term solution compared to repairing or removing severely damaged materials. In such circumstances a permanent or temporary separation would be more suitable if full removal cannot be achieved. An inspection of encapsulated areas should be carried out by either an approved consultancy or the Asbestos Compliance Team at the time of works to document that a suitable level of encapsulation has been undertaken Localised Decontamination. This option will be notifiable to the HSE as asbestos abatement work in some cases. It may be possible to clean loose debris from an area to allow access but will not allow for all maintenance activities to be undertaken as asbestos containing materials will still be present. This category should therefore only be considered where absolutely necessary and when a full strip will not be achieved for a few years or is not practical at the present time (e.g. insufficient timeframes or physical restraints to work). This methodology is also inappropriate where asbestos residues are present upon plant and equipment that may be accessed and disturbed regularly. 7.2 Central Asbestos Removal Strategy Based on the information provided within the latest Management Survey reports the Asbestos Compliance Team is developing a Central Asbestos Removals Strategy, which is defined as the undertaking of asbestos removal where the report indicates that access within an area should be prohibited or removal works should be undertaken. This strategy will takes into account the recommendations of the UKAS Asbestos Consultancy (rather than relying solely on the Material or Priority scores provided within reports), the nature and condition of the material, the location, the access requirements of an area and the impact prohibiting access to an area will have on future foreseeable works. Where is has been deemed upon review that identified or presumed ACMs are not to be removed although recommended within the report comment will be made by the Asbestos Compliance Team or Authorising Engineer as to why the is the case. Once the strategy has been developed it will be included as part of this Management Plan. The Central Asbestos Removals Strategy is a live document and may be amended as new information becomes available, especially from annual management survey reports but also from refurbishment or demolition surveys (where ACMs are not being removed as part of project the survey was commissioned for) for from sampling investigations where additional ACMs are identified. Asbestos removal works undertaken as part of the central removals strategy will be commissioned directly by the Asbestos Compliance Team and will be liaison with other parties will be made through the scoping and planning process. Funding will have to be approved to allow the Central Asbestos Removals Strategy to be successfully undertaken and managed. 7.3 Project/Maintenance Led Asbestos Abatement Works In addition to the Central Asbestos Removals Strategy, project or maintenance related asbestos abatement works are also to be undertaken where and when required. These works may be as part of a larger project or allow maintenance to be safely undertaken. In line with the University s policy on asbestos removal all asbestos containing materials are to be removed from within areas where maintenance or project works are to be undertaken wherever possible. Where it is not possible for all asbestos containing materials to be removed remaining materials will be suitably managed. The person commissioning project works is responsible for commencing planning around asbestos abatement using Asbestos Works Planning Checklist (Stage 2) (ASB001/2) (Appendix 5). The Asbestos Compliance Team must be included in all correspondence (using the Asbestos Compliance Team Page 30 of 132

31 inbox, and should be invited to all planning and scoping meetings. The Asbestos Compliance Team will also be required to complete various Hold Points throughout the commission and works process to confirm that the works requested and suitable, sufficient and are also undertaken in a safe manner. The Asbestos Compliance Team will not allow planning to proceed to the next phase until such time as they are satisfied and all information has been received. The Asbestos Compliance Team will inform the commissioning person as to whether additional. The commissioning person is responsible for appointing the LARC and consultancy to undertake the asbestos abatement works and associated analytical works and is also responsible for issuing Purchase Orders for works after review of proposals for works. Should it be that an asbestos containing material cannot be removed but maybe disturbed as part of planned works then further planning and the appointment of the University s approved LARC supplier will be undertaken to assist with developing a scheme to allow works to be safely undertaken. This may include, but is not limited to partial removal, decontamination of areas to create a clean area for works, controlled installation of items to asbestos containing or protection of asbestos containing materials within an area. All requests for asbestos abatement are to be managed by the commissioning person, with advice from the Asbestos Compliance Team utilising the Asbestos Works Planning Checklist (Stage 2), Form ASB001/2 (example located within Appendix 5). In the majority of instances it will be required that the University s approved LARC supplier will require a site visit (as highlighted within Form ASB001/2) with all interested parties, including a representative from the asbestos compliance team, to determine the scope and plan the works. A number of factors may determine how and when the abatement works are undertaken and it is important that the works are undertaken safely and do not compromise the safety of others within surrounding areas. The Asbestos Compliance Team or the Authorising Engineer will produce a specification for the works once the scope has been agreed which will dictate minimum standards and working practices which are to be adopted during the project which will be issued to the approved LARC provider. The University will determine if the CDM Regulations apply to the works. The specification documentation should be produced using document ASB009/1 or ASB09/2 (documents currently in development) Prior to works commencing the commissioning person/asbestos Compliance Team will require the LARC to provide copies of plans of work for the abatement works planned for review to compare against the requirements of the specification. During the review any other areas of concern will be raised with the LARC and amendments agreed. Once all amendments have been made the Asbestos Compliance Team will raise an order for the works to commence. The works should be notified to the HSE as required by CAR 2012 and copies of the relevant notifications supplied to the University. For all asbestos removal works deemed as licensable under CAR 2012 full time on site analytical support will be requested from one of the University s approved suppliers. The role of the analytical cover will include: Undertake on site project management of the asbestos abatement project on the University s behalf, managing quality and progress of the project, Undertake compliance audits of the LARC during works against the agreed Plan of Works, Witness smoke test procedures, Undertaking background, leak and reassurance air monitoring during the course of the project, Undertaking personal air monitoring to persons involved in the project including the LARC, consultants and other parties Undertake Four Stage Clearance procedures following completion of abatement works and prior to reoccupation of an area and associated Decontamination Unit Clearance Certification. For lower risk works the level of analytical cover may be reduced. This will be identified by the Asbestos Compliance Team should it be the case. For the majority of asbestos works the presence of an approved consultant will be required at the end of works to confirm that the works have been undertaken to a satisfactory standard. The consultant will be required to issue a suitable Statement of Cleanliness form or Page 31 of 132

32 similar to confirm that all works have been completed and the area is safe to reoccupy. In all cases where a consultant is not utilized a member of the Asbestos Compliance Team must undertake an inspection prior to an area being reoccupied. This must be recorded using document ASB008 and must be correctly filed. The person undertaking the inspection will first have had suitable auditing from the Authorising Engineer to ensure they are competent to undertake the task. The Asbestos Works Planning Checklist (Stage 3) (ASB001/3) sets out the requirements for the University during and after abatement works. During abatement projects the University s Asbestos Compliance Team or the Authorising Engineer will also undertake unannounced compliance audits of both the LARC and the analytical consultant. This will be captured using Forms ASB005 and ASB011 (currently in development) and will be stored in the relevant project folder within the asbestos server. Any deviations from procedures or Plan of Works or Specification will be recorded and works halted if required until such time as issues have been remediated. The Authorising Engineer may appoint, at the request of the Asbestos Compliance Team, an independent analytical consultant to undertake a quality assurance audit prior to certificate of the reoccupation being issued. This should be undertaken following Stage 3 of a four stage clearance but before any removal of the enclosure structure is undertaken. Further checks should be undertaken prior to Stage 4 being signed off but at the completion of works. Quality Control Audits are to be recorded on Form ASB012. Following on from the completion of asbestos abatement works the consultant will be required to liaise with the LARC who has undertaken works and is to supply a completion report document to the Asbestos Compliance Team. This shall comprise of the following documentation as appendices: Specification documentation for asbestos abatement LARC Plan of Works (signed version) and Consultant RAMS documents ASB5 Notification Waste Consignment Notes related to project Smoke Test Certification Airborne Fibre Certification and Bulk Sampling Certificates Certificate of Reoccupation or Statement of Cleanliness documentation Once MiCAD has been fully implemented then electronic information should be updated to reflect the abatement works. Until this time the Amendment to Condition spreadsheet should be updated to reflect changes. The Asbestos Compliance Team and Commissioning person are responsible for collating information during asbestos abatement works. The commissioning person is responsible for receiving documentation following completion of works. All information must be passed to the Asbestos Compliance Team for review and filing within the correct folders on the Asbestos Server 7.4 Equipment Containing Asbestos Where equipment held within the University s property portfolio is suspected to be asbestos containing is identified and is required for removal this should be requested in the same fashion of for removal of asbestos within the fabric of the building. Should it be suspected that equipment is asbestos containing advice should be sought from the Asbestos Compliance Team. It may be required that an inspection of some equipment is undertaken prior to maintenance or dismantling works being undertaken. Over time it is the aim of the University to develop and maintain a register of all equipment, which may not have been identified during the course of survey inspections, held which is suspected to be asbestos containing. To achieve this, a request for information will be sent to all faculties and responses logged. At present any items of equipment will be added the Amendment to Condition register for the building. Once the MiCAD system is in place then this information will be transferred into the system. Where required, equipment may be added into the reinspection register for the building. 7.5 Budgetary Requirements for Asbestos Abatement Page 32 of 132

33 Abatement works undertaken as part of the Central Asbestos Removal Strategy will be procured through the Estates backlog, minor and capital projects. All project/maintenance related asbestos abatement works are to be procured through the budgets of the individual departments. Page 33 of 132

34 8.0 Process for Gaining and Supplying Information (Maintenance and Project Works) Any person who is likely to carry out work upon the building fabric or infrastructure, enter areas not usually accessed or work within buildings known to contain asbestos will need relevant asbestos information. Information on asbestos will need to be provided to the University s staff and external contractors commissioned to carry out work on behalf of the University. The information must be suitable and sufficient to allow the task to be undertaken safely and without disturbing asbestos containing materials. This will be undertaking using the following methods. 8.1 University Direct Labour Organisation (DLO) Maintenance Works Figure Process flow of Maintenance works planning All maintenance activities are entered onto the Planon system. Asbestos information is not stored on Planon and therefore asbestos information will have to be reviewed prior to works commencing. By June 2017 it is planned that all asbestos information will be held in the MiCAD system which will supply information and be able to link information onto the Planon job ticket. As shown in figure (above) the supervisor raising the work order will assess the nature of a maintenance activity and the age of the building. All managers and operatives have received suitable asbestos awareness training. Where appropriate, an activity will be placed on hold pending an asbestos survey or visual assessment. The Asbestos Compliance Team will be able to assist in reviewing requirements if required. Page 34 of 132

35 Where no sufficient survey information is available, an Asbestos Works Planning Checklist (Stage 1), Form ASB001/1 will need to be commenced and additional survey works planned, as described with Section 6.7. For some requests a visual assessment of areas where works are to be undertaken may be sufficient, in such circumstances this could be undertaken by the Asbestos Compliance Team. A record of the visual assessment should be completed using document ASB007. Once complete a member of the Asbestos Compliance Team will review the findings of the assessment and advise accordingly. Any asbestos abatement or other additional controls are required to allow the task to be safely completed will be communicated by the Asbestos Compliance Team. Should the Supervisor raising the works be satisfied that suitable information is available to allow the task to proceed without any further survey or visual assessment then the task should be issued to the DLO operative undertaking the works. Any comments on ACMs should be entered in the with job description. The operative should also review the known asbestos information for the area being worked in, adjacent areas and also works route prior to commencing works. 8.2 External contractors Maintenance and Project Activities The commissioning person instructing the work activity is responsible for providing relevant asbestos information to those undertaking the work. The contractor undertaking works should review the information and if deemed not suitable, liaise with the commissioning person to determine additional information or actions required, e.g. refurbishment survey/visual inspected (as referenced above). Asbestos abatement/control works may also be required to allow for the works to progress safely. The commissioning person is to liaise with the Asbestos Compliance Team and follow the planning process within sections 6.7 and 7.3 of this AMP with suitable scope of works required. If there is doubt as to whether the asbestos information is suitable and sufficient then the Asbestos Compliance Team should be consulted. All external contractors shall follow the University s Site Access Permit procedures prior to attending site and commencing works. Guidance on the Site Access Permit can be found in Appendix 17 of this AMP. Works cannot proceed until suitable asbestos information has been supplied and any asbestos abatement works or controls have been undertaken or introduced. Commissioning persons are responsible for reviewing contractors Risk Assessments and Method Statements in regards to asbestos prior to works commencing and issuing the relevant permits. The commissioning person is also responsible for checking that contractors undertaking works are suitably trained to allow them to undertake the task safely. Asbestos awareness training from an accredited organisation is a requirement as a minimum when working on the University s premises. Should any queries be raised then the Asbestos Compliance Team should be consulted. All maintenance and project works undertaken by external contractors will follow the Site Access Permit process detailed within Appendix 17. Further detail on Asbestos abatement works can be located within section 7.3 of this AMP. Page 35 of 132

36 9.0 Exposure to Unidentified Materials or Accidental Damage to Known ACMs Including Out of Hours Emergencies 9.1 Emergency Situations and Suspected Exposure to Asbestos Containing Materials Emergency procedures in regards to exposure to asbestos fibre, damage to known asbestos containing materials or damage on an unknown suspect material can be found within Appendix 3. Incident reporting forms are contained with Appendix 6. Further guidance can be found within HSE Guidance document EM1, which can be found at the below weblink: Within the emergency procedure flowchart is the requirement for the use, if required, of Decon Packs. These will be held by the Asbestos Compliance Team and will contain the following: Four pairs Category 3 Type 5/6 Coveralls and overboots Disposable underwear Two P3 Disposable Mask Wet Wipes Disposable Towels Shower Gel Asbestos Disposal Bag These kits will be brought to the location of any suspected exposure to asbestos containing materials where debris is present to the persons. The procedure described within Appendix 3 should be followed. The Asbestos Compliance Team will, in the first instance, be the person who maintain and manage the decon kits. They will also be the persons to commence procedures on site. All members of the Asbestos Compliance Team will be audited correctly utilizing the equipment by the Authorising Engineer prior to being authorised to undertake actions on site. It is imperative that the kits are well managed and maintained so that should the use in the field be required they can be dispatched without the delay. The Asbestos Compliance Team will be responsible for maintenance spare stock of all items. It is imperative that all incidents or near misses in regards to asbestos exposure or damage to known or suspected materials is reported to the Asbestos Compliance Team as soon as reasonably practicable. All incidences of damage to asbestos containing materials or potential exposure instances are to be investigated by the Asbestos Compliance Team and the report issued to the Health and Safety Manager, the assistant Estate Director and also the manager(s) of the persons affected. Investigations should be undertaken using Form ASB003 As part of the investigation all aspects of the project which may have led to the exposure should be investigated and where possible an assessment of the level of release and should be undertaken. In exceptional circumstances it may be required that the incident should be reported under the requirements of RIDDOR where the exposure to fibre is, in the opinion of the consultant, presumed to have been significant. The final decision of reporting of incidents will lie with the University health and safety director after consultation with other parties. The HSE state that: Exposure to asbestos is reportable under RIDDOR when a work activity causes the accidental release or escape of asbestos fibres into the air in a quantity sufficient to cause damage to the health of any person. Such situations are likely to arise when work is carried out without suitable controls, or where those controls fail they often involve: use of power tools (to drill, cut etc) on most ACMs Page 36 of 132

37 work that leads to physical disturbance (knocking, breaking, smashing) of an ACM that should only be handled by a licensed contractor eg sprayed coating, lagging, asbestos insulating board (AIB) manually cutting or drilling AIB work involving aggressive physical disturbance of asbestos cement eg breaking or smashing If these activities are carried out without suitable controls, or the precautions fail to control exposure, these would be classed as a 'dangerous occurrence' under RIDDOR and should be reported. In instances of potential exposure to asbestos a record of exposure should be held on the personnel file for all who may have been affected by Human Resources. These records must be kept for a minimum of 40 years. This information must be captured on Form ASB Out of Hours Emergencies or Incidents Should there be damage to a material, which is suspected to be asbestos containing outside of normal working hours the area should be sealed off wherever possible until such time as an assessment can be made by the Asbestos Compliance Team. Where this is not possible then the on call surveyor should be contacted and University s approved LARC also contacted to attend site in an emergency capacity in order to make the area safe prior to sealing off. It should be noted that it will not be possible to undertake all asbestos removal/remediation works at this time and works will be only to make the area safe. A member of the Asbestos Compliance Team is to be required to be contacted as soon as reasonably practicable also. Following on for emergency works further investigations will be required and suitable abatement works undertaken where required. The Asbestos Compliance Team will be required to create a full report on any such incident using Form ASB003. The University has a number of its DLO and contractors on Call Out, should there be any maintenance be required to be undertaken out of normal working hours. In such circumstances the University s Security department will be the first point of contact to record any defect information. A flowchart of the process for asbestos management as detailed below. Page 37 of 132

38 Page 38 of 132

39 10.0 Training Requirements and Communication The University recognises the importance of communicating the content of the Asbestos Management Plan including the requirements of current legislation so that those who may encounter asbestos are aware of their obligations and the obligations of others Training Regulation 10 of CAR 2012 require that the employer provides training to all employees whose jobs require them to work on or near asbestos-containing materials or may have occasion to respond to instances of damaged asbestos. In the case of the University this will extend to all directly employed employees or those seconded through other organisations. At present all directly employed staff will hold up to date general asbestos awareness training although a training needs analysis has identified the need for further training to be supplied by the University to its employees. The University currently has a large number of consultants seconded within its Estates Directorate. These staff will be treated as University employees for the purposes of this AMP. The Authorising Engineer will work alongside the Asbestos Compliance Team to develop a range of bespoke asbestos awareness and procedural training to varying levels to meet the requirements of various roles within the University. The scope of the course content must be relevant and meet the specific needs of the group being trained and must be based on current site conditions. Attendance at all asbestos related training is mandatory and will be contain a written assessment, with a minimum pass mark required to be met by all operatives. A training needs analysis is currently being developed which will identified the training requirements for the Dutyholder and responsible persons. Once this has been completed a Skills Matrix of requirements will be added to this AMP. At the present time the following training needs have been identified: Interpretation of survey data This course should be all employees that may encountered asbestos during their day to day activities and should be undertaken as an addition to the General Awareness Course described below. In coming years this course will be incorporated into the General Awareness Course but will still offered as a standalone should it be required. The course aims to give an overview of interpreting data within asbestos Management, Refurbishment and Demolition surveys, including the caveats and limitations and also interpreting information within areas adjacent to works areas which may require access or be disturbed and also an understanding of ACMs on the route to the workplace. General Awareness Training This course is aimed at those people who may encounter asbestos during their day to day activities. The course will be bespoke and contain specific section on the University Asbestos Management Plan, procedures and asbestos management database. The course will cover: Introduction to asbestos regulation, Health effects, uses and locations, Survey types, Manchester Metropolitan University Procedures, Asbestos Management Database A full General Awareness course is to be sat every three years. In the interim years the requirement for annual refresher training will be undertaken in the form of updates on asbestos regulation, University procedure and strategy and tool box talks on asbestos related topics. Toolbox talks and information on changes to regulation and guidance will also be cascaded to employees in addition to annual training. Page 39 of 132

40 Dutyholder/ Senior Responsible Persons Duty to Manage This course is in aimed at the main Dutyholder, their deputy and senior responsible person and highlights the more specific requirements for persons with more senior responsibilities with regard to asbestos management and the requirements of CAR 2012 such as commissioning persons. As with the General Awareness the course will be bespoke to the University s requirements. The course will cover: Responsibilities under CAR 2012 and the roles and responsibilities of the Main Duty Holder and deputies. Delegating responsibilities to others. Understanding the Asbestos Management Plan, Processes etc. and administering. Management of the Asbestos Management Plan of requirements for sign off Understanding the need for an Asbestos Management Plan and its use. As with the general awareness training, annual refresher training will be undertaken in the form of updates, asbestos related topics and also updates to the AMP and Family Investment Office management procedures. Commissioning Person Duty to Manage This course is in addition to the general awareness course and highlights the more specific requirements for persons with more senior responsibilities with regard to asbestos management and the requirements of Regulations 4 and 5 of CAR 2012 such as commissioning persons. As with the General Awareness the course will be bespoke to the University s requirements. The course will cover: Responsibilities under CAR Understanding requirements for surveys and different types of survey. Familiarity with asbestos surveys (and limitations), plans of work and technical specifications. Understanding the need for an Asbestos Management Plan and its use. Overview of varying asbestos work categories. University procedure and asbestos Management Database for Management. As with the general awareness training, annual refresher training will be undertaken in the form of updates, asbestos related topics and also updates to the AMP and Family Investment Office management procedures. BOHS P405 Management of Asbestos in Buildings Aimed at the Senior Responsible Persons identified in the AMP and those with an in depth role in the asbestos management across the University campuses. The course will require in depth study and require completion of examination in order to complete the course. The course will cover the following aspects: Legislation and legal requirements The management of asbestos in buildings Asbestos Remediation The role of laboratories and analysts Asbestos removal controls and decontamination (incl. Plans of Work) BOHS P407 Managing Asbestos in Premises the Duty Holder Requirements Aimed at the Senior Responsible Persons and the Appointed Person, Asbestos Control Officers identified within the AMP and those with an in depth role in the asbestos management across the University campuses. This course requires either the successful completion of either the BOHS P405 module (referenced above) or the completion of the Certificate of Competence (COC) in asbestos. The course will require the completion of an examination and subsequent submission of evidence of understanding (in report format, either a produced AMP or the critical review of an existing document). The course will cover the following aspects: Page 40 of 132

41 Requirements to enable management of asbestos within premises Development and requirement for Asbestos Management Plans Development and requirements for Asbestos Policies Implementation of AMPs and Policy Implementation of procedures surrounding AMP Checks on effectiveness and review of the AMP In addition to the training requirements identified above, the Asbestos Compliance Team will deliver bespoke training in regards to sections of the Asbestos Management Plan and the associated processes and systems as and when it is deemed to be required. This training should also be supplemented by suitable Health and Safety and other training requirements for the roles and responsibilities of the persons identified. As part of this AMP, audits on training requirements will be assessed on a periodic basis and will be addressed should the need arise, this may be down to additional training requirements being identified, changes to policy and procedure or other factors. Project specific training requirements should be discussed between the commission manager, the Asbestos Compliance Team and the Authorising Engineer. This applies to both University employees and approved contractors/suppliers External Contractors and Consultants All contractors undertaking works within the University s buildings or on its behalf will be required to prove they have undertaken suitable and sufficient asbestos awareness training as a minimum prior to undertaking any works. Copies of asbestos awareness training certificates must be supplied if required Communication of Changes The Asbestos Compliance Team will communicate to all parties who have responsibilities under this AMP whenever there are changes to procedures and processes surrounding asbestos management to the University s property portfolio. This will be undertaken via a number of means and will dependent on the requirement of the change. Updates on the AMP and amendments to it will also be given as part of annual Asbestos Awareness Trainings Communication of Incidents Should an incident in regards to Asbestos Management or potential exposure be encountered then the procedures within section 9 should be followed. Following on from the incident the Asbestos Compliance Team or the Authorising Engineer will undertake an investigation into the incident and produce a report of findings, outcomes, lessons learned and changes to process due to incident. Communication of the incident will be communicated to all relevant parties for review. Where it is deemed relevant a Safety Express will be issued to all staff informing them. The incident will also be reported using the University s accident and near miss reporting system, managed by the University Health and Safety Team;. Should additional ACMs be identified within an area which presents a risk to persons undertaking works within the vicinity where it has previously been reported as safe to access then a communication will be sent out to all project managers and supervisors informing them of the additional items identified and the additional controls required to be able to access the area Asbestos Management Steering Group The Asbestos Management Steering Group is to be established in the early part of 2017 and is designed to act as liaison between the asbestos compliance team, other key stakeholders within the Estates Directorate, other departments/persons within the University. The aim of the steering group is to discuss all aspects of the management plan and asbestos management throughout the University. The steering group will be chaired by the Authorising Engineer and all parties invited will be requested to fully engage in the process, including liaising with others within their departments prior to the meeting to highlight matters and also to cascade the findings of the group to staff. The following persons sit on the Steering Group: Duty Holder Director of Estates Authorising Engineer Assistant Director of Estates Management Appointed Persons (Asbestos Operational and Strategic) Estates Directorate Projects Team Representative ISDS Services Representative Facilities Management Representative Page 41 of 132

42 Maintenance Representative Health and Safety Manager The group has responsibility for reviewing practices and procedures appertaining to asbestos management including the review of the Asbestos Management Plan, associated procedures and any associated documentation. It is anticipated the group will sit on a quarterly basis, although this will be reviewed on a periodic basis. Feedback from the meetings and subsequent actions taken will be communicated to all concerned parties. The manner in which this information is communicated will be confirmed at the first sitting of the group and the AMP will be updated accordingly. Page 42 of 132

43 11.0 Performance Monitoring, Auditing, Performance Reviews and Management Reviews 11.1 On site Auditing and Compliance Checks Audits are to undertaken to monitor the effectiveness and awareness of asbestos procedures. The Authorising Engineer will undertake regular audits on approved consultant and LARC providers and also other personnel undertaking tasks within University premises. These audits are tailored to the auditee and assess the knowledge of the individual and their understanding of the University s policies and procedures and management plan relating to asbestos. All audit findings are recorded within an agreed audit Forms ASB005, 010 and 011 which is to be stored within the specific folder on the asbestos folder on the Estates Directorate server. Any further actions or noncompliances which are highlighted during the course of the auditing process will be raised to the relevant persons and, where necessary the commissioning persons or line manager. It will be a requirement that all findings are suitably followed up and actioned satisfactorily. Any actions taken following the audit must be documented and saved as evidence alongside the original audit. The auditing documentation is currently in development and these will be detailed within this AMP when developed. A tracking spreadsheet on non-compliances will also held so that it can be easily observed which stage each non-compliance is currently at. Detailed of non-compliances or follow on actions highlighted within audits will be compiled in the quarterly performance review, which is detailed below. Non-compliances, actions and close outs will also be detailed within a non-compliances spreadsheet, held on the asbestos server Performance Reviews In order to enable the University to monitor Asbestos Management, the Asbestos Compliance Team or the Authorising Engineer will co-ordinate production of a quarterly report to the Assistant Director of Estates Management. This report will highlight the following matters and also issues which have been identified: Awareness Training of the Manchester Metropolitan University management and operational staff; Progress of management and reinspection surveys; Asbestos removal programme during the previous quarter; Asbestos related incidents during the previous quarter; Progress against the annual asbestos Action plan; and Any other compliance issues or initiatives, including audit report findings Document Control It is recognised that the need for all Forms and Documents related to this AMP to be controlled is paramount to enable traceability of requests, works undertaken and documents received in order to keep the Asbestos Register up to date. As processes and procedures evolve there may be the requirement to amend Forms and Documents to reflect these changes. To ensure that the latest version of the Forms or Documents are used all latest versions will be available from the icred Sharepoint site. For each instance of use the documents should be retrieved from this location only and copies should not be stored on desktops or personal drives as this may mean that superseded versions are used. Each Form or Document is to be given a unique identifier and also and issue number, along with date of issue which will be located within the footer of the document. A log of all forms will be held within the asbestos folders of the R Drive. A front tab will have all The Identifiers and name of all Forms and Document along with the current issue number and also the date of issue and the person who issued the document. Each Form or Document will also have an individual tab where details regarding amendments for each issue can be detailed along with who has undertaken the amendments. Whenever information is received, for example survey reports, abatement completion packs, sampling documents or specifications or contractor information then this should be filed within the correct sections of the Asbestos folders and also, where required, onto the Sharepoint site. A log of all received documents is to be held within the asbestos folders and all documents are to be logged when received. The log will include the Name of the document received, the date received, whom received from and where the document has been filed (using Hyperlinks). Where multiple documents are received within one or by other means then each document will be required to be documented individually. Page 43 of 132

44 11.4 Asbestos Management Plan Agreement and Management Reviews The main Dutyholder and the Assistant Director of Estates Management will, in conjunction with the Appointed Persons Asbestos Control Officers and other identified persons (to be agreed) will undertake a review of the initial Asbestos Management Plan and Asbestos Policy. Once all are happy, the Main Dutyholder will initiate final sign off of the document and issue for publication. All reviews are to be documented using Form ASB, which is currently in development. This will require filing within the Asbestos Management Plan files of the R (Staff2Staff Drive). The main Dutyholder and relevant persons, as identified within section 3 will monitor this policy and management plan and review it annually or more frequently if appropriate (it is anticipated that more frequent reviews will be required in 2017 due to the number of changes in policy, procedure and process), in discussion with the Authorising Engineer, and recommend approval to the appropriate board. The main Dutyholder is responsible for sign off of the Asbestos Management Plan and must be in agreement to all amendments made during review or at any other stage. Prior to main Dutyholder sign off the Authorising Engineer must review the review undertaken and any amendments made to the Management Plan and must give initial authorisation to proceed to sign off stage. The Asbestos Management Plan review will: Address the need for any changes to the Policy, objectives or other elements; Reflect on management results and asbestos incidents during the period covered; Assess any changes to circumstances of the business; and Provide an opportunity for continual improvement of asbestos management. All changes made the AMP or Policy will be recorded within the amendments table within Appendix 1 of this document. Evidence of review and audit of the AMP must be recorded using the correct documentation, which is currently in development Page 44 of 132

45 APPENDIX 1 - Reviews and Amendments to Asbestos Management Plan Activity with regards to the management review and any changes to the Asbestos Management Plan are captured in the table below Type of Change (Version, any change as a result of Audit, change in personnel or process) Addition of New appendices and coding By Whom Reason Approved by Date Dr John Hindley New Forms developed by WSP Parsons Brinckerhoff WSP Page 45 of 132

46 APPENDIX 2 - Current Persons Appointed To Key Roles Identified Person or Authority Ian McManus Director of Estates Role Duty Holder Wik Cookney Building Services Manager (Mechanical) Appointed Person (Strategic) Michael Young Building Maintenance Manager Appointed Person (Operations) WSP Parsons Brinkerhoff Consultant External Authorising Engineer (Asbestos) Page 46 of 132

47 APPENDIX 3 - Emergency Procedures Flowcharts Emergency Flow Chart Asbestos discovered in Works Page 47 of 132

48 Emergency Flow Chart Investigation Workflow Page 48 of 132