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Health and Safety - Asbestos Management Procedure

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Section 1 - Summary

(1) This Procedure aims to prevent asbestos-related disease resulting from exposure to airborne asbestos in the workplace and to ensure asbestos containing materials are managed and controlled according to Victorian and Australian legislative requirements.

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Section 2 - HESF/ASQA/ESOS Alignment

(2) HESF – Standard 2.3 Wellbeing and Safety; 7.3 Information Management.

(3) Standards for Registered Training Organizations (RTOs) 2015 (Cth): Standard 8.

(4) This Procedure also aligns with ISO 45001:2018 – 6.1, 8.1.2, 7.  

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Section 3 - Scope

(5) This Procedure applies to:

  1. Victoria University (VU) buildings erected before 2005, VU grounds, surface coverings, portable equipment, plant and devices.
  2. VU staff completing campus services activities and Contractors performing work for the University, Occupational Health and Safety Advisors, Victoria University Staff and Asbestos Consultants.
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Section 4 - Definitions

(6) Asbestos Containing Material (ACM)- ACM include materials such as cement sheeting, vinyl floor tiles, ceiling tiles, insulation of old furnaces, boilers and water heaters, bar heaters, heating mantles, pump gaskets, pipe gaskets, switchboard linings, heat resistant mats and asbestos gloves.

(7) Asbestos - Naturally occurring fibrous mineral. Asbestos was commonly used in a wide variety of industrial, manufacturing, building and construction applications in Australia between the 1940s and late 1980s. The presence of asbestos does not pose health risks unless it is broken, in poor or deteriorated condition, or disturbed during activities that produce dust containing asbestos fibers. Inhalation of asbestos fibers is a serious health risk and can lead to diseases such as mesothelioma, lung cancer and asbestosis. 

(8) Asbestos Consultant - Audit - A qualified Occupational Hygienist with specialist knowledge appointed to identify all ACM in Victoria University buildings and major building equipment items and update the Asbestos Registers (Division 5 Audit, and report on any ACM identified prior to demolition Division 6 Audit). This may include testing of Asbestos Containing Materials.

(9) Asbestos Consultant - Removal - A qualified Occupational Hygienist, who is an independent party, with specialist knowledge to oversee the requirements for asbestos removal to ensure that all aspects of the removal specification are strictly followed.  This includes review of proposed removal operations, determination of airborne asbestos, visual inspection for residue and provision of clearance certificates.

(10) Asbestos Disturbance - Where actions to asbestos containing materials occur causing release of airborne asbestos fibers. For example where asbestos containing materials are removed, cut, damaged or drilled or where enclosed areas which contain ACM are opened and/or entered.

(11) Asbestos Exposure - Where airborne asbestos fibers are inhaled. The asbestos concentration which could impact on health is above 0.1 fibers per milliliter measured as a time weighted average over an 8 hour working day in a person's breathing zone according to the required standards.

(12) Asbestos Register - A register identifying all the locations where asbestos is present within the University. The Register details the location of asbestos containing materials in all buildings erected prior to 2005, the ACM condition and priority classification.

(13) Contractor – Maintenance person or company or builder engaged by the University to undertake maintenance, construction or upgrade works.

(14) Digital and Campus Services Project Manager - The Victoria University Digital & Campus Services staff member responsible for managing the works. Any Staff who plan and oversee building maintenance or works for a given building demolition, excavation or renovation job. 

(15) Division 5 Risk Assessment - Assessment of the health risks associated with the presence of ACM in University buildings constructed before 2005.  Division 5 Assessments to include all buildings erected or renovated prior to 2005 that have not yet been assessed.

(16) Division 6 Risk Assessment - An audit of all buildings erected or renovated prior to 2005 which ensures identification of all hazardous material before demolition or refurbishment.  Division 6 assessments shall include sample testing following removal of tiles, carpet, floor coverings and sampling of walls and insulation.  Where destructive testing is required, the area shall be sealed off to minimise risk of exposures between testing and refurbishment work. NOTE: Most Division 6 assessments require demolition of small areas of rooms or equipment for sampling to assess if ACM or other hazardous materials are present.

(17) Friable Asbestos - Asbestos-containing materials which, when dry, can be crumbled or pulverized to a powder by hand or, as a result of a work process, becomes such that it may be crumbled, pulverised or reduced to powder by hand pressure.

(18) Hazardous materials – Term for materials such as asbestos, paint containing lead, polychlorinated biphenyls, synthetic mineral fibers etc. which may be present in older buildings.

(19) HEPA - High efficiency particulate arrestance (or air) filter.

(20) NATA - National Australian Testing Authority - approves the methods and accredits the providers of asbestos content determinations and sampling for airborne asbestos fibers.

(21) Nominated Builder - Where capital works exceed $350,000 the Nominated Builder will be responsible for all aspects of work related to asbestos management. 

(22) Non-friable Asbestos - Asbestos containing materials that when dry, cannot be crumbled by hand pressure.

(23) Priority Risk Ratings – Risk levels following Hazardous Materials audits:

  1. P1: Hazards with High Risk Potential - These areas are isolated, labelled and addressed as soon as is practicable.
  2. P2: Hazards with Elevated Risk Potential.
  3. P3: Do not currently pose a significant risk to health and safety.
  4. P4: No access during survey.

(24) Worksafe - Victoria's workplace health and safety regulator.

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Section 5 - Policy/Regulation

(25) Health and Safety Policy

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Section 6 - Procedures

Part A - Summary of Roles and Responsibilities

Roles Responsibility
Director, Campus Services Safe management of asbestos in pre 2005 buildings, equipment and grounds within the University.
Associate Director, Services Consult with University Management and Health and Safety Representatives regarding current asbestos risk assessments and any planned asbestos removal activities.

Ensure any identified asbestos containing materials, where it is not practicable for removal, are contained, sealed and labelled. This may be delegated to a Contracted Suitably Qualified Provider.

Work with the OH&S Team to ensure regular Asbestos Awareness Training is available and completed by the required staff.

Provide training/information to a worker if that worker may reasonably be involved in asbestos related work. Training must include the identification, safe handling and suitable control measures for asbestos and ACM.
Manager, Facilities Support the Technical Services and Trades staff in identifying any portable equipment or plant which may contain asbestos. Arrange any testing if required.

Ensure any asbestos removal is carried out in compliance with legislative requirements. 

Retain all past versions of the Asbestos Register and Asbestos Removal documentation. Arrange for immediate remediation for any sites or locations identified during asbestos audits where the asbestos is friable or in poor condition. (P1 sites)

Ensure the required arrangements for Asbestos identification and removal during demolitions, renovations and refurbishments are carried out.

Communicate results of any asbestos testing or environmental monitoring to equipment owners and OH&S team to enable update of the Asbestos Register.
Asbestos Consultant - Audit Conduct the asbestos register audit review and update as required.

Immediately communicate P1 (see definitions) Level hazard to Associate Director, Services for remediation.

Forward all required documentation to the Associate Director, Services.

Placement of labels on asbestos containing materials as they are identified.
Asbestos Consultant – Removal
Advise on most appropriate method and workflow to minimise risk of airborne asbestos fibres being generated or escaping from a removal work area.
Determine placement of samples and conduct environmental and personal monitoring of fibres during removal works. Organise analysis of samples.
Ensure asbestos removal work is conducted according to the documented plan.
Inspect removal area on completion of works and provide a clearance certificate.
Forward all documentation to the Campus Services Project Officer and the Associate Director, Services.
OH&S Team
Management of the University's Asbestos Register (Division 5 Risk Assessment) for all campuses and buildings.

Maintain the accuracy of the Asbestos Register by arranging audits by an Asbestos Competent person at least every 5 years and after new finds of ACM and ACM removals.

Ensure access to Asbestos register for all VU staff with special emphasis on contractors and staff members carrying out maintenance activities.

Keep VU Staff informed of the availability and location of the Asbestos Registers and the risk and measures in place to control risks associated with asbestos.

Assist the Associate Director, Services in delivery and management of Asbestos Awareness Training.

Support and advise the Associate Director, Services, including consultation with staff enquiries with respect to Asbestos health risks.

Audit of compliance with this Procedure.
Digital and Campus Services Staff
Consult the relevant asbestos register prior to carrying out any maintenance work which could pose risks of asbestos exposure. E.g. drilling holes, cutting pipework, electrical refurbishment.
Ensure a Division 6 risk assessment which includes ACM identification is conducted prior to commencing work.
Communicate results of any asbestos testing or environmental monitoring to equipment owners and OH&S team to enable update of the Asbestos Register.
Digital and Campus Services Project Manager
For any buildings erected or renovated prior to 2005:
Review the specific location Asbestos Register (Division 5 Risk Assessment) prior to any minor projects, demolition or refurbishment work.
Recognise that excavation may include asbestos contaminated soil.
Ensure a Division 6 risk assessment is conducted prior to work including determining the likelihood of asbestos or other hazardous materials.
Where asbestos is identified liaise with the Associate Director, Services; engage the correct people to mitigate the risks.
Forward all documentation relating to asbestos removal, environmental test results and refurbishment to the Associate Director, Services and relevant area Health and Safety representatives.
Victoria University Staff or Contractors
Ensure that no Asbestos containing material is purchased, brought onto University sites, acquired or transported except for approved remediation works.
Ensure that any enquiries, concerns or faults relating to asbestos are referred to the Manager,Facilities in the Digital and Campus Services team.
Ensure no interference with ACM, ACM labels or ACM sealing measures on University property.
Ensure that any equipment purchased or acquired has been checked to determine asbestos content.
Ensure all portable equipment which may contain asbestos is identified, checked by OH&S and labelled as required.
Review any demonstration or teaching items brought into class for potential asbestos containing materials.
Recognise that purchased or acquired equipment from overseas may contain asbestos, making the transaction illegal in Australia.
Prior to the commencement of any works, the VU Staff member organising the work must determine whether asbestos or any other hazardous materials are present.  Where demolition is involved a Division 6 Risk Assessment must be carried out for buildings erected prior to 2005.
NOTE:  Old equipment or new items imported from India, China or other countries may contain asbestos.
Executive Deans, Directors and Managers
Ensure that no asbestos containing materials are purchased, made, or brought onto nor stored in any Victoria University Location.
Ensure that within their locations of responsibility, buildings erected or renovated prior to 2005 have current building Asbestos Registers.
Recognise that acquired portable equipment may contain asbestos and ensure checks are made prior to acquisition or use.
Ensure that labelling of any asbestos containing materials has taken place within their area of responsibility.
Report any issues with respect to Asbestos to the Associate Director, Services and the OH&S Team.

Part B - Procedures

General Requirements

(26) As far as is reasonably practicable, any risk associated with the presence of asbestos must be eliminated by removing the asbestos. The person managing the workplace must ensure that all persons at the workplace are not exposed to an atmospheric concentration of asbestos fibres in excess of the asbestos exposure standard.

  1. If the ACM can't be removed and any risk remains, it must be enclosed.
  2. If the ACM has been enclosed but there is still a health risk, the material must be sealed.
  3. If the ACM is present it must be labelled.
  4. If there is any doubt about whether airborne asbestos is present, then determination of an employee’s exposure to airborne asbestos fibres must be carried out.

(27) Where asbestos is fully encased and sealed it presents no risk, this material shall be labelled as containing asbestos and listed on the Asbestos Register. Asbestos identification labels shall be selected and placed according to the Asbestos Labelling Guidelines.

Prohibited activity

(28) Due to the hazard that it poses, the manufacture, supply, storage, transport, sale, use, re-use, installation and replacement of asbestos is banned across Australia. Care should be exercised when purchasing or acquiring items from other countries as the same legislation may not apply in jurisdictions other than Australia.

Identify Asbestos Containing Materials

(29) The Associate Director, Services will ensure that asbestos containing materials at each Victoria University Workplace and building (erected prior to 2005) are clearly identified and labelled as far as is reasonably practicable.

(30) This includes identifying when buildings were constructed and what materials were in construction and any ACM in plant under the control of Victoria University.

(31) ACM are identified using an Asbestos Consultant - Audit. The Asbestos Consultant - Audit must inspect locations, and revise and update the Asbestos Register.

(32) Where there is uncertainty (based on reasonable grounds) as to whether any material is likely to contain asbestos then assume asbestos is present and manage, contain and label accordingly or arrange for analysis of samples.

Asbestos Register (Division 5 Review)

(33) The locations of asbestos containing materials in buildings erected prior to 2005 will be recorded in a register, which must be current, with all relevant information about the identified ACM. The register must include a record of:

  1. the location of the asbestos;
  2. the type of ACM;
  3. the nature of the ACM (friable or non-friable);
  4. the condition of the ACM;
  5. any work activities that may affect or cause damage or deterioration to the ACM;
  6. Level of access;
  7. Risk priority rating for the material. P1 to P4 (Refer to priority risk ratings in definitions).

(34) It is also beneficial to include floor plans and photographs of asbestos locations and records of any material testing conducted in the Asbestos Register.

(35) The Asbestos Register shall be updated whenever there is a change to the condition of any asbestos or if it is removed, enclosed or sealed. Regardless of any changes, the register must be reviewed and updated at least every five years.

Asbestos Containing Materials Labels

(36) All materials and locations where asbestos containing materials are identified shall be labelled as far as is practicable.

(37) Labels shall be placed according to the Asbestos Labelling Guidelines.

Asbestos Register Access

(38) Asbestos Registers must be readily available to any staff member and the following groups who may be engaged by the University to carry out work in buildings erected prior to 2005:

  1. External contractors who may be engaged to carry out drilling or cutting work on floors or walls. 
  2. An asbestos licence holder who has been engaged to do asbestos removal work.
  3. Those who perform the following asbestos-related activities:
    1. Sample or analyse suspected asbestos;
    2. Enclose or seal ACM;
    3. Hand-drill or cut ACM;
    4. Conduct research involving asbestos.
  4. Persons who perform any other work activity likely to produce asbestos airborne fibres in excess of one half of the asbestos exposure standard;
  5. Anyone who takes over management or control of the workplace.

(39) Before they start, any contractors who are engaged to perform work that involves the risk of exposure to asbestos must be given a copy of the asbestos register. The register must include the location of the asbestos.

Planning and Quoting Demolition, Excavation and Refurbishment work

(40) The Digital and Campus Services Project Manager must ensure that a copy of the Asbestos Risk Assessment is provided to Contractors/Asbestos Consultants who are planning or quoting for any works involving the disturbance of asbestos containing materials in buildings erected prior to 2005.

(41) A Division 6 Asbestos Risk Assessment must be organised by the Digital and Campus Services Project Manager and the Contractor before undertaking any demolition or refurbishment work in buildings erected or refurbished prior to 2005. This applies to any work involving the potential disturbance of walls, floors ceilings, etc. and including scraping, screwing, cutting or painting which includes sanding.

(42) Architects, Contractors or staff must consult with the Digital and Campus Services Project Manager and the Associate Director, Services during the planning stage so that if asbestos is present, the ACM is removed or alternative methods are used to avoid disturbing the sealed asbestos.

Works Where Asbestos Containing Materials are Identified and/or may be Disturbed

(43) Activities where there is potential ACM disturbance, including entry into crawl spaces under buildings or rooms which have been sealed off, require the person organizing the work and/or the Digital and Campus Services Project Manager to ensure correct training and PPE are used and the procedure is compliant with the Asbestos Removal and Renovation Plan.

Accidental Damage to Asbestos-containing Materials during Works or Usual University Operations

(44) If accidental damage occurs to any ACM during the course of a works project or during the usual course of University operations:

  1. The contractor must stop work immediately, and students and staff shall immediately vacate the immediate area.
  2. The contractor or the student supervisor will advise the Digital and Campus Services Project Manager/Contractor/Maintenance Provider who will contact:
    1. The Associate Director, Services and the Occupational Health and Safety team and take appropriate steps to prevent access to the affected area or ensure that the area is made safe. For example: Where a small dent or hole is made (less than hand size), covering and sealing a broken edge and ensuring appropriate ventilation before allowing re-entry to the area.

(45) For larger damage or disturbance, the Digital and Campus Services Project Manager will make arrangements according to the Asbestos Removal and Renovation Plan.

(46) In the case of a large area (greater than hand size) of ACM disturbance, Contractors, Staff and students will not reoccupy the room or location until they have been advised it is safe to do so after a clearance has been issued by an Asbestos Consultant - Removal in writing.

Training

(47) The Facility team and individuals dealing with any aspect of work related to asbestos should complete General Asbestos Awareness Training via VUDevelop. 

(48) The University must maintain any records relating to training.

Record Keeping

(49) The Associate Director, Services must ensure that all current documents regarding asbestos matters are maintained in a centralised file and archived documents are retained in accordance with the Records Management Policy. Records should include:

  1. Asbestos Management Procedure - intranet document reviewed and updated by the OH&S Team in conjunction with the Associate Director, Services;
  2. Asbestos Register which includes regular audit and risk assessment reports (Division 5 Reports).  Retained by Campus Services and OH&S with access via the Digital and Campus Services Intranet site and hardcopies of registers may be located at Campus Security desks;
  3. Any Division 6 Asbestos Audits, Hazardous Building Materials Audit. Retained within the Digital and Campus Services document management system with access provided to Contractors on request or when quoting for refurbishment or demolition work. 

(50) The OH&S Incident Management System shall retain records of incidents involving asbestos.  These include any incidents of accidental damage or unforeseen asbestos identification.

Limited Removal Work

(51) Where limited asbestos removal work is considered and/or planned the Associate Director, Services must be consulted.

(52) Small amounts of unlicensed asbestos work can be carried out but must comply with strict safety requirements. The material must be non-friable, area less than 10m2 and the work of cumulative duration is 1 hour or less in any period of seven days. Small asbestos removal jobs shall be managed by a trained VU Campus Services staff member.

(53) Prior to commencement of the work, a documented asbestos control plan must be developed in conjunction with an Asbestos Consultant and the Associate Director, Campus Services.

(54) All staff involved in the work must have current Asbestos Awareness Training where records are retained.

(55) The proposed work area must be isolated, barricaded and labelled.

(56) Communication and consultation will occur with staff working in the area and relevant Health and Safety Representative/s.

(57) The work must be carried out in such a way to minimise the generation of airborne dust. This may include spraying the surface with water or PVA glue/water mixture prior to the work.

(58) Only hand tools can be used. No mechanically operated tools.

(59) Staff must wear Australian Standard compliant respiratory protection, safety eyewear, and asbestos fibre resistant disposable overalls. (Refer to PPE Section below.)

(60) All disposable overalls and respirator filters shall be disposed of at the barrier of the work area into the double wrapped and labelled plastic bags for asbestos removal.

(61) Clean up shall involve damp rags or vacuuming where the unit has a HEPA filter. No dry broom sweeping or compressed air. All clean up materials will be double wrapped and disposed of as per asbestos removal.

(62) Any asbestos waste must be double wrapped in labelled plastic bags.

(63) Asbestos Containing materials are classified as prescribed waste and as such must be disposed of according to the Environment Protection (Industrial Waste Resource) Regulations 2009 (Vic).

Major Removal and Renovation Work

(64) See Asbestos Removal and Renovation Plan

Testing of Asbestos Containing Materials

(65) All testing of suspected asbestos containing materials shall be conducted by a NATA accredited laboratory which must be independent of the University.

Asbestos in Portable Equipment

(66) The Asbestos Register also contains a short listing of portable equipment identified as possibly containing asbestos.

Mandatory PPE during Asbestos Removal

(67) The mandatory PPE during Asbestos removal is:

  1. AS/NZS 1719: Selection, Use and Maintenance of Respiratory Protection - Compliant P2 respirator.
  2. Disposable coveralls of a suitable standard to prevent penetration of asbestos fibres.
  3. Disposable coveralls rated type 5, category 3 (pr EN ISO 13982-1) or equivalent meet this standard and are suitable for use during asbestos removal.