Asbestos Management Procedure (OBU-HAS-PROC-09.00)

1.1 This management procedure, aims to advise and guide on expected best practice for preventing any risk from exposure to asbestos containing materials (ACMs). It sets out clear responsibilities for the duty to manage elements of the Control of Asbestos Regulations 2012, as well as direction on compliance with the rest of the regulations. This document and the Asbestos Management Plan replaces OBUHSN05.

3.1 Managing the risks from asbestos in Oxford Brookes premises requires certain responsibilities being placed on a number of duty-holders shown below:

3.2 The Vice-Chancellor is responsible for ensuring that

• There are adequate and appropriate resources made available to ensure that the asbestos management plan (AMP) is effective and implemented.
• There is a ‘Duty Holder’ and ‘Responsible Person appointed to facilitate the AMP and that their duties and responsibilities have been communicated to them fully.
• Any breaches of compliance with the AMP are fully investigated.

3.3 Registrar and Chief Operating Officer is responsible for ensuring that:

• Adequate resources are provided and allocated to carry out the AMP.
• The necessary requirements for the safe management of asbestos are fully identified and incorporated into any design or specification.
• Adequate information regarding asbestos is sought for all potential purchases.
• Any building purchased on behalf of the Oxford Brookes is free of asbestos, so far as is reasonably practicable.

3.4 The Pro Vice Chancellor Deans of Schools and Directors of Service are also responsible for:

• Reporting to the Responsible Person (through the ECS Service Desk) any concerns from staff and or students related to asbestos.
• Ensuring all relevant staff have undergone appropriate training and/or awareness on the risks of asbestos.

3.5 Director of Estates and Campus Services is accountable for the statutory duties of the ‘Duty Holder’ and as such is responsible for ensuring that all aspects of the legislation are complied with in full. The Director of Estates and Campus Services has responsibility to:

• Ensure that an asbestos management plan (AMP) is in place, is implemented and reviewed at regular intervals.
• Appoint a person responsible for the day-to-day management of asbestos on site ("The Responsible Person").
• Ensure that all asbestos-related information is issued to all organisations and persons who may potentially disturb asbestos containing materials during their activities on site.
• Ensure that adequate resources are provided for the execution of the AMP.

3.6 The Health and Safety Department is responsible for:

• Where reporting is not a requirement of a Main Contractor or similar, reporting incidents where exposure limits exceed those laid down in the Control of Asbestos Regulations, to the Health and Safety Executive under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR,) and collating Dangerous Occurrence Forms.
• Providing health and safety advice (including relating to training) to staff, students and contractors and liaising with the Responsible person as required.
• Arranging for internal audits (conducted by H&S Dept) of the AMP to be undertaken and results fed back to the Duty Holder(s).

3.7 Head of Maintenance (The Responsible Person) is responsible for the management of asbestos within all academic buildings and residential buildings other than head lease properties.  In addition, they are responsible for ensuring that:

• Information on asbestos is appropriately stored and is made available to all interested parties.
• Appropriate records of asbestos works are properly retained.
• The Asbestos Register is maintained within the electronic asbestos portal to ensure all records remain current, and regular audits of the Asbestos Register are undertaken.
• Following risk assessment, asbestos locations are assigned appropriate management options and priority actions are timetabled.
• ECS employees and contractors have the necessary facilities, training and allied competencies to discharge the duties assigned to them under the action plan within the AMP arrangements are made so that all relevant personnel and organisations receive appropriate information, instruction and training related to the existence and use of the Asbestos Register.
• Regular meetings are held with relevant parties, e.g. the programmed Asbestos Progress Meetings.
• The performance of the AMP is annually reviewed and amended as necessary.
• Emergency procedures are established and reviewed regularly and in the event of any relevant incident.
• Bring to the attention of Director of ECS any situation where the current resources allocated for the management of asbestos may not be sufficient.
• Reviewing with the Competent Asbestos Consultant relevant regulatory requirements and best practice.

3.8 Buildings Team Manager (Deputy Responsible Person) is responsible for ensuring:

• They support the Responsible Person in the discharge of their responsibilities as listed above,
• A regular review of the costed remedial plan (provided by the Competent Asbestos Consultant) to develop a prioritised schedule of asbestos remedial work. The prioritisation criteria will include the material and priority risk ratings as well as a review of the operational context of each area.
• Raise with the Responsible Person, any concerns they have with the way in which asbestos is being managed within the University estate,
• Liaise with stakeholders such as the H&S Department regarding the day to day management of asbestos.
• Ensure asbestos related contractors undertake activities under an appropriate permit to work and relevant stakeholders are kept informed.

3.9 Contracts and Compliance Manager – Building is responsible for:

• Supporting the Responsible Person and Deputy Responsible Person in the operational delivery of their responsibilities including the planning of asbestos related works.
• Ensuring contractors under their control are appropriately aware of asbestos issues relevant to the work being undertaken.
• Ensuring the appropriate prioritisation of the delivery of all planned and reactive maintenance activities using contract resources for building services relating to the management of asbestos.
• Liaising as required with a range of stakeholders including the H&S team over activities that may impact on asbestos management.
• The monitoring of the quality and progression of all maintenance and minor adaptation work undertaken by outside contractors, including those involved in asbestos remediation works.
• Arranging annual asbestos awareness training for ECS staff.

3.10 Project Team Responsibilities Project managers within the ECS team are responsible for

• In consultation with the Responsible Person, areas are appropriately assessed for asbestos at the feasibility stage of a project.
• All appropriate actions within the AMP are implemented.
• Project changes are promptly reviewed with respect to asbestos information, for example where extension of project area, or changes to M&E installations occur. Actual reviews may fall within the remit of other project team members, such as the Principal Designer.
• Any necessary works use the management service provided by either the University’s preferred Asbestos Consultant or are managed to at least the same level by the contractor.
• The Principal Contractor for a project may be required to undertake asbestos surveys of a site as well as be responsible for the associated removal of asbestos. The Project Manager for the development is responsible for ensuring all necessary information and certificates are made available to the University’s Responsible Person in a timely fashion for these to be included within the university’s Asbestos Register.
• The results of any surveys, inspections, remedial work or removal of asbestos undertaken by a contractor in relation to project works, must be notified to the Responsible Person and Competent Asbestos Contractor so it can be placed on the Asbestos Register.
• All project personnel are informed of the location of any known asbestos affecting the project.
• Works are halted if suspected asbestos are discovered during the course of work and further advice is sought from the Responsible Person.
• All project management personnel are fully aware of emergency procedures in the event of an asbestos-related incident.

3.11 Network Team (IT Services) have the following responsibilities:

• Ensuring, where any works they commission or are responsible for, the contractor is provided with information from the Asbestos Register regarding the presence or otherwise of asbestos within the scope of the defined works.
• All work that involves or could involve a change to the building fabric or could disturb known asbestos, is brought to the attention of the Responsible Person and/or Deputy Responsible Person.
• Where asbestos containing material is identified (even where the Asbestos Register indicates no asbestos), suspend the work immediately and seek advice from the Responsible Person/Deputy Responsible Person.

3.12 Lettings Manager (Residential Services) is responsible for:

• Ensuring that for Oxford Brookes owned properties appropriate records are retained and available for contractors that the Residential Services team engage.
• Head lease properties - owners of the properties are classed as the duty holders with respect to the CAR 2012, For these property types the Lettings manager is responsible for:
  • ensuring owners are aware of the need for them to undertake and share an asbestos survey for properties built before 2000
  • where the surveys indicate the presence of ACMs, this is recorded on the Brookes Lettings H&S management system database and Oxford Brookes Contractor electronic portal.
  • Where asbestos remedial works are required, engage with the relevant landlord and advise they can use their own approved asbestos consultants or Brookes Lettings can make arrangements through the University’s approved asbestos consultants. Where landlords make their own arrangements, Brookes Letting will require certification to confirm the work has been undertaken satisfactorily. This information will be recorded on the Brookes Letting H&S management database.
  • Coordinating and recording condition inspections.
  • Undertaking annual condition surveys, recording these and where remedial actions are required refer these to the relevant landlord.

3.13 Competent Asbestos Consultant

Oxford Brookes has appointed a competent asbestos contractor who are responsible for:

• Undertaking inspections of existing asbestos surveys and carrying out asbestos surveys as requested.
• Provision of advice and guidance in relation to the management of asbestos.
• Provision of awareness training.
• Management of asbestos removal (including non-licensed. notifiable non-licensed and licensed removal) in conjunction with the Responsible (or Deputy) Person, including provision of site clearance certificates, disposal of waste and any notifications to the Health and Safety Executive.
• Provision and maintenance of an electronic asbestos register.
• Undertake an annual audit of the Asbestos Management Plan in conjunction with the Building Team Manager, Contract and Compliance Manager (Buildings) and Health and Safety Department.
• Providing the Responsible/Deputy Responsible Person with a schedule of remedial measures (including costs) following scheduled asbestos inspections.

3.14 Contractors are responsible for:

• Compliance with the AMP and relevant procedures, and where acting as sole, main or principal contractor to have a thorough understanding of these procedures.
• Subject to Project Team procedures contractors may be required to arrange for asbestos surveys and remediation of any asbestos discovered.  Where this is the case, the contractor must do this to at least the same standard as required by the AMP.
• Ensuring that all their subcontractors are informed of the AMP and relevant procedures, and are aware of the location of asbestos within the project area.
• Co-operating with any Licensed Asbestos Removal Contractors or associated contractors working within or adjacent to the known or intended project area.

• Ensuring that emergency measures are in place for any suspected or known exposure to asbestos and that these are in line with Oxford Brookes University procedures.

3.15 Staff are responsible for:

• Reporting any damage to the fabric of a building. Staff can do this through either their line manager or directly with the Campus Services Manager for that area or via ServiceNow
• Contacting their Campus Service Manager/ECS when they are looking to alter the fabric of the building or services. This also includes the fixing of any structure to the walls, floors or ceilings
• Attending the Oxford Brookes Asbestos Awareness training course when required
• Not undertaking any work on equipment that is likely to contain asbestos such as, kilns, safes, gaskets, heat resistant pads
• Seeking up to date information from the Responsible Person on any suspect equipment.
• Recognising that asbestos legislation does not apply in every country, therefore imported or inherited equipment may still be constructed with asbestos.

4.1 Oxford Brookes has a duty to provide Asbestos Awareness to all staff likely to be involved in works that have a risk of discovering asbestos materials

4.2 Training includes the following topics:

• health hazards
• types of asbestos and where they may have been used within premises
• risks associated with the materials
• overview of requirements of management plan
• dealing with emergencies
• relevant legislation and guidance
• responsibilities of various staff
• control of contractors
• risk assessments and method statements
• safe working practices.

4.3 Copies of training certificates are maintained locally and certificates issued to individuals.

4.4 The training is provided for the following:

• Duty Holder
• Responsible Person
• Health & Safety Advisors
• Oxford Brookes Maintenance Staff
• Campus Services Managers
• Technical staff (as appropriate)
• Specific IT personnel
• Contractors and subcontractors (as deemed appropriate).

5.1 Where Oxford Brookes is deemed to be the duty holder:

• All reasonable steps shall be taken to find materials in premises likely to contain asbestos and to check their condition.
• It shall be presumed that materials contain asbestos unless there is strong evidence available to confirm they do not.
• A written and electronic record (Register) of the location and condition of asbestos and presumed asbestos shall be compiled and the Register kept up-to-date.
• An assessment of the risk of anyone being exposed to identified and presumed asbestos shall be made and the management plan implemented.

This management plan seeks to ensure that:

1. Any material known or presumed to contain asbestos shall be maintained in a good state of repair.
2. Any material that contains or is presumed to contain asbestos shall, because of the risks associated with its location or condition, be repaired or if necessary removed.
3.  Information on the location and condition of asbestos shall be provided to anyone potentially at risk.

• shall ensure that any licensed works undertaken on asbestos within premises under their control shall only be undertaken by a competent asbestos contractor licensed by the Health and Safety Executive.
• For any work on asbestos based materials for both notifiable and non-notifiable works, an Oxford Brookes Permit to Work is required.
• Any non-licensed work undertaken on asbestos, such as asbestos cement, shall only be undertaken by contractors with the appropriate training and insurance to ensure high standards of work and safety. Where non-licensed asbestos is damaged or friable, the contractor will comply with CAR 2012 and notify the local enforcing authority. The contractor will keep a written record of the work undertaken. In addition, the works, where required, shall be managed and monitored by a suitably accredited asbestos consultant.
• Where Oxford Brookes is deemed not to be the Duty Holder or share the Duty Holder’s responsibilities with others, full cooperation shall be given and suitable investigations conducted to ensure compliance with the requirements of CAR 2012 Regulation 4 “Duty to manage Asbestos in Non-Domestic Premises”.

5.2 Management Procedure Flowchart (where Oxford Brookes are deemed to be the Duty Holder) can be obtained by contacting healthandsafety@brookes.ac.uk.

Planned Survey Protocols

5.3 Oxford Brookes is committed to ensuring a safe working environment for all contractors, employees and persons likely to be exposed to asbestos.  This includes achieving compliance with Regulation 4 of the CAR 2012.

5.4 To achieve this commitment a programme of management asbestos surveys has been undertaken and all corporate sites and residential premises completed. Surveys of housing stock and void properties were also instigated. 

5.5 Prior to February 2010, all relevant properties were surveyed in accordance with the Health and Safety guidance document MDHS100 ‘Methods for determination of Hazardous Substances’. All subsequent surveys were carried out in accordance with HSE guidance document HSG 264: Asbestos: The Survey Guide’.

5.6 The surveys consisted of three types - planned, reactive and project specific. These surveys consisted of mainly Management surveys with intrusive elements in specific areas if any refurbishment or demolition work has been planned.

5.7 The asbestos survey provides a material risk assessment as part of the survey report.  The use of the material risk assessment allows each ACM or presumed ACM to be scored and ranked in order of their ability to release fibres.

5.8 Periodically, the condition of materials identified in the survey should be visually inspected by a suitable nominee or company to determine whether its risk rating has changed.

5.9 There is also the need to consider the future likelihood of any ACMs to become damaged or disturbed by staff, visitors, maintenance, contractors etc.  

5.10 Periodically, the condition of materials identified in the survey should be visually inspected by a suitable nominee or company to determine whether its risk rating has changed.

Management of Asbestos

5.11 Following surveys of Oxford Brookes properties, there will be regular re inspections to ensure the asbestos material is kept in a safe and manageable condition. Summarised below are the protocols based upon the findings of the on-going survey programme, as detailed in section four.

Leave In-Situ and Manage 

5.12 If the material is in sound condition and presents no risks to health, undertake a survey, complete risk assessment and log information in the Asbestos Register, with periodic inspections to ensure condition has not deteriorated. Inspections will be visual to avoid unnecessary disturbance of fibre release and will not involve removal of covering material, i.e. duct panels or ceiling tiles (or overlaid carpet).

Signage and Labelling

5.13 It is not University policy to mark the location of all asbestos due to its widespread use in older buildings and the potential to undermine the effectiveness of hazard warning signs, further details are in the AMP.  

Repair, Seal, Encapsulate and Manage

5.14 If the material is slightly damaged but otherwise in sound condition or in a position where it may not cause a risk to health if left undisturbed, it may be repaired or sealed by an approved method. Risk Assessment will be carried out and information logged in the asbestos register database. Periodic inspections will take place at intervals to ensure the condition does not deteriorate further. Inspections will be visual to avoid unnecessary disturbance or fibre release and will not involve removal of covering material, i.e. duct panels or ceiling tiles or overlaid carpet.

Remove

5.14 If the material is in such a condition or location that it may present a future risk to health or is likely to be significantly disturbed by maintenance work, it should be removed by an approved method.

5.15 If the material is in such a condition or location that it may present a future risk to health or is likely to be significantly disturbed by maintenance work, it should be removed by an approved method.

5.16 The Asbestos Register will be maintained by the Competent Asbestos Consultant in consultation with the Responsible/Deputy Responsible Person to ensure all asbestos identified is logged and information retained for management purposes as defined within this Policy and Asbestos Regulations.  The register will be audited on an annual basis by the asbestos consultants to ensure it is being kept up-to-date.

5.17 Information and/or an Asbestos Survey Report will be included in specifications for all maintenance work, requiring information to be provided for contractors, and for contractors to consult the asbestos register for the presence of asbestos, together with a warning that not all asbestos may have been identified.

5.18 All Contractors and consultants will be required to provide evidence of asbestos awareness training given to their staff that may come into contact with asbestos containing materials.

5.19 If, on inspection, prior to any work being carried out or during works, material containing asbestos is found to be damaged or has deteriorated, it will be re assessed and re classified via a new `Risk Assessment` and an amended `Plan of Work` where appropriate.  When work is being undertaken and asbestos is suspected or identified, work must stop and the emergency procedure put in place.

5.20 Where the risk assessment and/or the test results of the asbestos containing material confirm asbestos is present and the outcome concludes there is a high risk, then Oxford Brookes Duty Holders, should consider, where appropriate, arrangements to vacate the area whilst effective remedial works are carried out, to ensure that health & safety has been fully considered.

5.21 In accordance with CAR 2012, even some non-licensed work where asbestos may be damaged or friable should be notified to the local enforcing authority.  The following are examples of Notifiable Non-Licensed Work (assuming in all cases exposure is sporadic and of low intensity and will not exceed the control limit):

• Minor, short duration, maintenance work involving asbestos insulation, e.g. repairing minor damage to a small section of pipe insulation where the exterior coating has been broken or damaged.
• Minor removal work involving AIB, when short duration and as part of other maintenance work, e.g. removing AIB panels fixed with screws to access pipe work.
• Entry into the roof space above an AIB tiled ceiling, when no decontamination or cleaning has taken place.
• Removal work involving textured decorative coatings where the method of removal requires deterioration of the material, e.g. where the material is treated by steam, hydrating gel etc. and scraped off the underlying surface or where it is very badly flood-damaged.
• Removal of asbestos paper and cardboard products if not firmly bonded in a matrix.
• Removal of asbestos cement (AC) which is substantially degraded e.g. badly fire-damaged or de-laminated material or where substantial breakage is unavoidable to achieve removal.

5.22 There is no time limit for the notification however the Responsible Person must notify the enforcing authority before the work starts via the online notification form and as soon as possible.

5.23 Any removal work must be notified to the Competent Asbestos Consultant through the Responsible/Deputy Responsible Person so that the Asbestos Register can be updated.

New acquisitions and contracts

5.24 Prior to acquiring any new freehold or leasehold property or entering into any contract the following enquiries and procedures must be conducted to ensure that Oxford Brookes University does not incur any liability due to the presence of asbestos. Appropriate information must be added to the Asbestos Register.

5.25 All Oxford Brookes agents and relevant staff should be made aware of the revised CAR 2012 and receive asbestos awareness/recognition training.  Oxford Brookes agents can then make suitable initial enquiries/investigations when researching potential new acquisitions/contracts. 

The process is outlined below:

Investigation into existing asbestos information 

• date of construction
• date of any alternations
• copies of any register/surveys
• details of any asbestos removal/remedial works
• copies of 4 stage clearance certificates
• copy of CDM Health and Safety files.

Management or refurbishment/demolition survey may be required. 

Information sent to:

• Legal advisors 
• Property team
• Asbestos Consultants.

Decision on acquisition to go ahead based on appropriate advice. 

Protocols prior to any maintenance/building project

5.26 The following procedures shall be implemented at the earliest opportunity when considering any project:

• Was any part of the building constructed before 1999? 
  • Yes. Check the asbestos register.  Does it cover all the areas where works are to take place, including voids, concealed areas and sandwich construction?
  • ACM’s are not expected op be present/Include a statement on the specification and pre-tender health and safety plan if CDM applies, if not project documentation proceed with work but cease immediately if suspected ACM’s are encountered and contact the relevant officer for further advice.
• Check the asbestos register. Does it cover all the areas where works are to take place, including voids, concealed areas and sandwich construction?
  • No. Request a Management Asbestos Survey for the entire premises (if appropriate) and a Refurbishment and Demolition Survey for the proposed works area.
  • Yes. Will the proposed works disturb ACM’s?
• Will the proposed works disturb ACM’s?
  • No. Include a statement in the specification and pre-tender health and safety plan if CDM applies. If no project documentation proceeds with work but cease immediately if suspected ACM’s are encountered and contact the relevant officer for further advice
  • Yes. Is it possible to re-design or carry out the work to avoid disturbing the ACM’s?
• Is it possible to re-design or carry out the work to avoid disturbing the ACM’s?
  • No. Consider the most cost-effective way of undertaking the work to ACM’s as part of the overall project and seek advice from the Duty Holder
  • Yes. Include a statement in the specification and pre-tender health and safety plan if CDM applies. If no project documentation proceeds with work but cease immediately if suspected ACM’s are encountered and contact the relevant officer for further advice

Key consideration shall include:

• does the work come under the Asbestos Licensing Regulations?
• is the work NNLW and require notification
• can the work be undertaken as prefatory work?
• will consideration need to be given to special programming?
• has relevant information been provided to the Contractor?
• contractors undertaking the work must develop a Risk Assessment and Plan of Work in accordance with Control of Asbestos Regulations.

Accidental disturbance or unexpected discovery protocols

5.27 The following procedure is to be implemented should asbestos be discovered on site, during any works, which due to their condition and/or location pose an immediate or imminent risk to health:

Suspect Material/Abestos

• Raise alarm, advising the relevant CSM, with control of the project/premises, isolate area if considered necessary
• Ensure any operatives who have come into contact with asbestos are decontaminated and equipment is left in situ
• CSM to seek specialist advice from Responsible Person
• ECS to refer to asbestos register and seek advice from Consultant where appropriate

Register confirmed no asbestos present

• Re-occupy area
• No asbestos present

No records or confirmation that the product contains asbestos

• Do not re-occupy area. Facilities to arrange security of area and provide signage: “No unauthorised access Potential asbestos incident”.
• Asbestos Consultant completes is survey and risk assessment.
• Asbestos Consultants arrange analysis of material suspected of containing asbestos.

Removal

• Responsible Person or Asbestos consultants to allow work to proceed only after ensuring all necessary risk assessment/plans of work and other precautions are taken and satisfactory.
• Work to be carried out in accordance with policy safe systems of work and all current legislative requirements for clean-up exercise/removal works.
• Responsible Person and Asbestos Consultant to arrange air sampling and competent supervision of contractor and final 4 stage clearance rest of affected area.
• Re-occupancy may only occur after clearance certificate has been issued by independent consultant/contractor.
• An investigation may be necessary by the Health and Safety Advisor and reporting under RIDDOR may be necessary.

Encapsulate

• Ensure contractors Risk Assessment and Plan of Work and precautions are satisfactory.
• Carry out work in strict accordance with current and relevant guidelines and legislation.
• Responsible Person of Asbestos Consultant to update register.
• Re-occupancy may only occur after clearance certificate has been issues by independent consultant/contractor.
• ECS arrange periodic re-inspection by referring to the asbestos register to ensure condition has not deteriorated.
• An investigation may be necessary by the Health and Safety Advisor and reporting under RIDDOR may be necessary.

• Asbestos: for the purpose of this procedure asbestos also includes asbestos containing material (ACM) and asbestos insulation board (AIB), unless these are referred to separately.
• HSE: Health & Safety Executive.
• CAR 12: Control of Asbestos Regulations 2012.
• CDM: The Construction (Design and Management) Regulations 2007 as amended.

• A Comprehensive Guide to Managing Asbestos in Premises. HSG227 (2002) 
• Asbestos Essentials Task Manual: Task Guidance Sheets for the Building Maintenance and Allied Trades. HSG210 (2010)
• Asbestos: The Analysts’ Guide for Sampling, Analysis and Clearance Procedures. HSG248 (2005)
• Asbestos: The Licensed Contractors Guide. HSG247 (2006)
• Asbestos: The Survey Guide. HSG264 (2012)
• The Management of Asbestos in non-domestic premises. Regulation 4 of the Control of Asbestos Regulations 2006. Approved Code of Practice and Guidance, L127
• Work with materials containing asbestos. Control of Asbestos Regulations 2013. (latest regs April 2012) Approved Code of Practice and guidance. L143 (2013)
• HSE Website