S06-VASDHS Asbestos Operations and Mainteneance Plan (Edited Final Draft).docx

Environment Health & Service VASDHS Asbestos Operations and Maintenance Plan

Kim, Chae 1-17-2018

Table of Contents

1.0 Veterans Administration San Diego Healthcare System (VASDHS) Policy

Asbestos has been determined to be a naturally occurring carcinogen once used in a wide variety of building products. Asbestos-containing materials (ACM), asbestos-containing construction materials (ACCM), and Presumed asbestos-containing materials (PACM); hereafter referred to as ACM and PACM, currently present in the Veterans Administration San Diego Medical Center (VASDMC)), owned and operated by the Veterans Administration San Diego Health Care System, referred to hereinafter as (VASDHS).

The presence of ACM and PACM within the buildings does not, in and of itself, pose a hazard to human health. For asbestos to be a health hazard, it must be disturbed in a way that causes the fibers to become airborne where it can be either inhaled or swallowed.

ACM and PACM can be distinguished as friable or non-friable. Friable, refers to materials that can be crumbled or crushed to a powder when dry with ordinary hand pressure. Friable materials, therefore, are considered potentially more hazardous because of their ability to easily release airborne asbestos fibers causing exposure to building occupants. Examples of friable ACMs include: Thermal Systems Insulation (TSI), surfacing materials (e.g., pipe, fitting, duct, and tank insulation, spray-applied ceilings, lay- in ceiling panels, and spray-applied fireproofing). Non-friable materials (materials that cannot be crumbled or crushed to a powder with ordinary hand pressure) are not hazardous unless cut, ground, sanded, or disturbed in a way that fibers can be released into the air. Examples of non-friable ACMs include: packings, gaskets, vinyl floor tiles, roofing materials, and Transite™ cement products.

This policy is designed to protect VASDHS employees, medical staff, contractors, and sub- contractors, patients, and guests from quantifiable exposure to occupational asbestos respiratory hazards. Protection of VASDHS occupants from asbestos shall be achieved through a combination of measures including, but not limited to: education (training) of said parties, periodic inspections of known ACM and PACM, implementation of appropriate response actions such as removal, enclosure, encapsulation, cleaning and operations and maintenance, adherence to certain policies and procedures, and compliance with all applicable Federal, state, local laws and regulations that are described in the Operations & Maintenance Plan (O & M). The O & M provides policies, procedures, and guidance to all levels of VASMDC staff and management.

2.0 Training Requirements

All VASDHS employees, contractors, and sub-contractors who perform duties in areas that contain ACM or PACM, or may come in contact with or disturb ACM or PACM shall receive Initial Asbestos Training and subsequent annual Asbestos Refresher Training commensurate to their level of contact or disturbance of ACM OR PACM as determined by the VASDHS and the Asbestos Program Manager (APM). Identification of training requirements based off of position and duties can be found in Appendix A.

2.1 Class IV Operations- Two (2) site specific asbestos awareness/hazard communication training/two (2) hour annual refresher

A. VASDHS employees and contractors, who perform their regular duties in areas which contain ACM or PACM, and/or may come in contact with ACM or PACM. At a minimum, the following entities shall receive training:

i. Environmental Management Service- Housekeeping staff and supervisors

ii. Personnel performing housekeeping activities within Building 1 and 2 of VASDHS

iii. Personnel entering regulated asbestos containing areas to survey or inspect and will not be disturbing ACM (asbestos abatement activities; going off the interstitial catwalk)

B. Minimum Training Topics

i. The health effects associated with asbestos exposure;

ii. The relationship between smoking and exposure to asbestos producing lung cancer.

iii. The quantity, location, manner of use, release, and storage of asbestos, and the specific nature of operations which could result in exposure to asbestos;

iv. The engineering controls and work practices associated with the employee's job assignment;

v. The specific procedures implemented to protect employees from exposure to asbestos, such as appropriate work practices, emergency and clean-up procedures, and personal protective equipment to be used;

vi. The purpose, proper use, and limitations of respirators and protective clothing, if appropriate;

vii. The purpose and a description of the medical surveillance program

viii. The content of 29 CFR 1910.1001, including appendices.

ix. The names, addresses and phone numbers of public health organizations which provide information, materials, and/or conduct programs concerning smoking cessation. The employer may distribute the list of such organizations contained in Appendix I to this section, to comply with this requirement.

x. The requirements for posting signs and affixing labels and the meaning of the required legends for such signs and labels

2.2 Class III Operations- Sixteen (16) Hour Site-Specific Operations, Maintenance, and Repair Training/ Four (4) Hour Annual Refresher

A. VASDHS staff, General Contractors, Sub-Contractors, Vendors, and Tenants who perform maintenance and repair or other activities in areas where ACM or PACM is likely to be disturbed (i.e. in close proximity to ACM, going off the interstitial catwalk, disturbing ceiling tiles). At a minimum, the following entities shall receive training:

i. Office of Information Technology (OI&T) Staff

ii. Building 2 - Plant Operations Staff

iii. Operations and Maintenance Staff

iv. Electrical/Electronic Staff

v. Equipment Repair/Pipefitting Staff

vi. General Contractors, Sub-Contractors

B. Disturbance activities expected under this category would include:

i. Response to fiber release episodes (Minor and Major)

ii. Clean up of minor fiber release episodes (e.g., less than 6 linear feet (<6 LF) or less than ten square feet (<10 SF) of ACM (e.g., fallen ceiling tile/spray-applied fireproofing debris from the Interstitial Space above into occupied areas);

iii. Operations and Maintenance removal and repair (e.g., removal of insulation to repair a pipe leak) that generates no more than one (1) 60” x 60” bag of asbestos waste; and

iv. Performing construction and maintenance activities in posted regulated areas that does not include asbestos abatement.

v. Access to Interstitial Space and other posted regulated areas where the personnel will be getting off the catwalk or has a likelihood of disturbing ACM during the performance of their work.

C. Training Topics

i. History, Physical Characteristics

ii. Uses for Asbestos

iii. Health Effects and Medical Surveillance Requirements

iv. Personal Protection

v. Regulations

vi. Asbestos Abatement Options and Removal Methods

vii. Engineering and Dust Control Measures

viii. Work Area Preparation

ix. Work Practices for Class III, and Class IV Asbestos Related Work

x. Clean Up and Disposal of Asbestos Containing Material

2.3 Class I and II Operations – Four (4) Day Worker and Five (5) Day Supervisor Training/Eight (8) Hour Annual Refresher

A. VASDHS contracts class (e.g., removal of Thermal Systems Pipe Insulation (TSI) and Surfacing ACM) and Class II (e.g., removal of vinyl floor tiles/mastic) ACM removal to licensed asbestos abatement contractors using negative pressure enclosures for planned demolition and renovation projects.

B. Class I and II activities under this category would include:

i. VASDHS General Contractors (asbestos abatement Sub-Contractors) and asbestos abatement contractors, who perform their regular duties in areas which contain ACM or PACM, and may engage in activities to remove or perform other abatement activities on TSI, surfacing, miscellaneous, and another ACM or PACM

ii. Clean up of major fiber release episodes (e.g., >6 LF or >10 square feet of ACM (e.g., fallen ceiling tile, spray-applied fireproofing debris from Interstitial Space into occupied areas).

iii. Operations and Maintenance removal and repair (e.g., removal of insulation to repair a pipe leak) that will generate more than one (1) 60” x 60” bag of asbestos waste.

2.4 Three (3) Day Project Designer/Eight (8) Hour Annual Refresher

A. Construction/Real Property Management and Engineering Office Staff will receive a three (3) day Project Designer training and annual Refresher Training. This course will enhance Construction and Real Property Management Staff with the ability to understand asbestos abatement project safety, engineering controls, abatement methods, and cost estimating techniques.

B. Training Topics

i. Background and Uses of Asbestos

ii. Health Effects/Medical Surveillance Requirements for Workers

iii. Roles of the Abatement Team Members

iv. Regulations (Federal, State, and local)

v. Legal Considerations for Specification Preparation

vi. Insurance Requirements for Team Members

vii. Designing the Asbestos Abatement Project

viii. Overview of Abatement Construction

ix. Safety System Designs

x. Additional Safety Hazards

xi. Budgeting and Cost Estimation

xii. Writing Abatement Specifications

xiii. Preparing Abatement Drawings

xiv. Replacement Materials

xv. Contract Preparation and Administration

2.5 Three (3) Day Building Inspector/Four (4) Hour Annual Refresher (AND) Two (2) Day Management Planner/Four (4) Hour Annual Refresher

A. Designated EH&S and Engineering staff will receive two (2) hour site specific asbestos awareness and three (3) day Building Inspector and two (2) day Management Planner training and annual Refresher Trainings. This course is designed to give additional instruction to asbestos bulk sampling, hazard assessment, legal responsibilities, asbestos control options, cost estimating and developing and implementing an O&M program.

B. Training Topics

i. Physical Characteristics

ii. Uses and Applications of Asbestos Containing Building Materials

iii. Health Effects/Medical Surveillance

iv. Sampling Protocols and Analytical Methodologies

v. Regulations (Federal, State and local)

vi. Specification Review

vii. Legal Considerations

viii. Insurance for the Building Inspector

ix. Safety Considerations

x. Personal Protection

xi. Identification of Suspect ACM

xii. Assessing Suspect ACM

xiii. Documentation/Record Keeping

xiv. Interpretation of Building Survey Results

xv. Evaluation of Building Survey Results

xvi. Response Actions

xvii. Legal Considerations for the Management Planner

xviii. Abatement Options

xix. Assembling and Submitting the Management Plan

xx. Financing

3.0 Responsibilities

Implementation of this O&M Plan will require involvement from all levels of VASDHS staff and management. The Asbestos Program Manager (APM) with assistance from Environment, Health & Safety (EH & S) Office, shall be responsible for carrying out day-to-day functions of site activities. VASDHS staff and management shall rely upon the services of the designated Asbestos Consultant and designated Hazardous Materials Contractor to fulfill certain requirements.

3.1 Environment of Care Committee (Director)

A. This Committee is responsible for establishing asbestos O&M policies that shall be adhered to at VASDHS.

3.2 Environment, Health & Safety Officer (EH&S)

A. EH&S Safety Office and staff are responsible for the implementation of VASDHS O&M policies and assisting the Asbestos Program Manager (APM) with periodic and semi-annual asbestos inspections, responding to employee reports of alleged unsafe or unhealthful working conditions , and responding to asbestos fiber release episodes (Major and Minor).

3.3 Asbestos Program Manager

A. The Asbestos Program Manager (APM) will be the located in VASDHS and be the on-site contact person and coordinator for all asbestos related activities in the buildings. His/her responsibilities include:

i. Manage the VASDHS Asbestos Management Plan (written plan), conducting tri-annual review/update; or as needed, whichever occurs first;

ii. Ensures completion of VASDHS AHERA semi-annual inspection and assessment of asbestos‐containing materials (ACM);

iii. Review and make recommendations to update VASDHS Asbestos abatement construction specification as needed;

iv. In coordination with Engineering Service Projects Safety Team, audit Engineering Department asbestos abatement projects to include attendance at project kickoff meetings and progress meetings;

v. Authorization to stop the unsafe act in the event of non‐compliance with Federal/State/Local Regulations, VA directives or contractual agreement specific to asbestos or safety hazard at project site;

vi. In coordination with Engineering Service Projects Safety Team, insure that vendors, General Contractors, and Sub-Contractors working in the building participate in, or comply with VASDHS asbestos training, respiratory protection program, and air monitoring requirements;

vii. APM to be included as a Medical Surveillance team member to communicate between VASDHS EH&S Office and Employee Health department issues specific to asbestos including respirators and employee exposure to asbestos;

viii. OSHA air monitoring compliance, including compliance with Permissible Exposure Limit (PEL) eight‐hour time‐weighted average (TWA) of 0.1 fibers per cubic centimeter (f/cc) and Short Term Exposure Limit (STEL) monitoring of 1.0 f/cc, as averaged over a 30-minute sampling period. (VASDHS personnel working in the Interstitial Spaces should have their exposures periodically assessed for OSHA Asbestos PEL/STEL compliance);

ix. Respiratory protection program compliance specific to asbestos, to include written respiratory protection plan, training, recordkeeping, and fit testing;

x. Respiratory protective equipment and PPE compliance auditing (e.g. interstitial space);

xi. In coordination with Hazardous Waste Manager, ensure asbestos waste management oversight and recordkeeping (manifests);

xii. Asbestos training program development, on‐site training of VASDHS staff, and training documentation recordkeeping;

xiii. Coordination of all emergency response to asbestos fiber release episodes (major and minor), (e.g., air monitoring for asbestos fibers, bulk sampling of suspect asbestos‐containing debris, and report preparation to affected staff, patients and/or visitors);

xiv. Ensures compliance with appropriate local, state, and federal agency requirements;

xv. Ensures appropriate local, state, and federal agencies are notified of asbestos work;

xvi. Acquires and maintains required level of asbestos training and certifications.

3.4 Engineering Service - Projects Safety Team

A. The Engineering Service Projects Safety Team is responsible for adhering to the policies and procedures described in this policy. Furthermore, the team shall conduct inspections and collect asbestos air samples of Projects’ construction sites when it is deemed as a regulated asbestos containing site. The Projects Safety Team, in collaboration with the APM, will be the on-site contact person for Projects related asbestos construction activities. The Engineering Service Projects Safety Team’s responsibilities include:

i. Review and approve asbestos abatement plans prior to stat of construction activity;

ii. Reviews training compliance of all project contractors entering regulated asbestos containing areas;

iii. Conduct inspections and collect asbestos samples of project sites

iv. Review Projects’ contractors’ exposure monitoring and negative exposure assessments to ensure no exposure above the PEL;

v. Authorization to stop the unsafe act in the event of non‐compliance with Federal/State/Local Regulations, VA directives or contractual agreement specific to asbestos or safety hazard at project site;

vi. Conduct inspection and collect clearance samples of Project sites upon completion of asbestos related work and/or prior to opening the area for occupancy;

vii. Ensures compliance with appropriate local, state, and federal agency requirements;

viii. Ensures appropriate local, state, and federal agencies are notified of asbestos work;

ix. Acquires and maintains required level of asbestos training and certifications.

x. Review Construction Specifications and project submittals to ensure requirements pertinent to construction activities involving ACM are addressed.

3.5 Engineering Service - Projects

A. The Engineering Service – Projects Staff, under the guidance of the Engineering Service Projects Safety Team, are responsible for adhering to the policies and procedures described in this policy. The Engineering Service Projects section responsibilities include:

i. Conduct and Infection Control Risk Assessment (ICRA) for all projects;

ii. In coordination with Engineering Service Projects Safety Team, review and approve asbestos abatement plans prior to start of construction activity;

iii. Conduct Project site inspections to ensure compliance with local, state, and federal regulatory requirements;

iv. Report asbestos violations to Engineering Service Projects Safety Team and Asbestos Program Manager;

v. Include Engineering Service Projects Safety Team to meetings related to projects dealing with asbestos.

vi. Provide Contractors with the facility’s Asbestos Operations and Maintenance Plan and ensure full understanding and compliance with requirements.

vii. At minimum, completing initial asbestos awareness training and familiarization with the Facility Asbestos O&M Plans. Completing additional training as recommended by the APC.

viii. Asbestos site clearance contracts require separate asbestos abatement and industrial hygiene service activities.

ix. Contracting officials will ensure any building materials asbestos-free documentation is obtained and forwarded to the facility coordinator or manager.

x. Holding pre-construction meetings with contractors to communicate contractor requirements described in the facility’s O&M Plans. These meetings will include:

a. Disclosure, including description and location, of known or suspected ACM located within the assigned work area.

b. Process to follow if contractor encounters unexpected ACM (presumed or suspected).

xi. Coordinating with Contracting Officer (CO) to obtain locations of any asbestos containing building materials in VA leased facilities.

xii. Ensuring appropriate awareness information related to asbestos is communicated to the contractor.

xiii. Consulting the plans and specifications prepared by the in-house or contract architects or engineers for all renovation or demolition projects to determine the need for and scope of a Pre-Construction Asbestos Survey (NESHAP Survey).

xiv. Ensuring a thorough Pre-Construction Asbestos Survey is performed by a licensed inspector and includes all spaces within the limits of the construction project, as well as adjacent areas where ACM may be disturbed by construction activities.

xv. Communicating the specific locations of ACM identified during the Pre-Construction Asbestos Survey that will be impacted by the renovation or demolition requirements and detailing the ACM within those areas that will be disturbed by the work to the APC so that the Management Plan can be updated.

xvi. Overseeing contractor and coordinating with the APC, GEMS Program Manager, or Facility Industrial Hygienist regarding notification of demolition or renovation activities that meet notification requirements of the state or local regulatory agency. Notification records will be sent to the APC.

xvii. Overseeing the asbestos abatement project, with the support of the APC.

xviii. Overseeing contractor and coordinating with the APC and GEMS Program Manager to ensure proper temporary storage, labeling, transportation, and disposal of ACM waste. Transportation and disposal records will be forwarded to the APC.

3.6 Engineering Service - Maintenance and Operations

A. The Maintenance and Operations staff responsible for adhering to the policies and procedures described in this policy. Furthermore, the Maintenance and Operations staff’s responsibilities include:

i. Conduct and Infection Control Risk Assessment (ICRA) for work that may pose infectious hazards to occupants;

ii. Report any visible disturbance or deterioration of known ACM to their Supervisor, EH&S, or APM;

iii. Notify the APM and EH&S of any demolition and renovation projects and other construction activities in the building that may impact ACM or PACM;

iv. Notify vendors of VASDHS asbestos O&M plan requirements;

v. Coordinate with APM and EH&S for inspections and sampling requirements

vi. Reviewing recommended training by the APC and assigning training for employees assigned to perform asbestos work;

vii. Maintaining training records for assigned employees and forwarding copies to the APC. Training will be recorded in the TMS.

viii. Carrying out the responsibilities defined in the Facility Asbestos O&M Plans.

ix. Ensuring employees are following proper asbestos practices and wearing appropriate PPE as defined in the Facility Asbestos O&M Plans.

x. Overseeing maintenance activities that are known or have the potential to impact ACM as defined in the Facility Asbestos O&M Plan.

xi. Reporting upcoming/planned abatement projects to the APC.

xii. Coordinating with the APC to initiate a Pre-Construction survey during minor construction or repairs which may impact existing ACM in accordance with the Facility Asbestos O&M Plan. All in-house renovation projects, beyond O&M activities defined in the Facility Asbestos O&M Plan, must be reviewed and approved by the APC to determine impact on ACM (e.g., NESHAP Survey thorough inspection).

xiii. Considering complete removal of ACM in budgets and when planning facility operations, maintenance, and construction projects whenever safety and budgetary considerations permit.

xiv. Ensure that employees are following specific ACM safe work practices determined by the APC, as required by the local Facility Asbestos O&M Plan and all regulatory agencies having jurisdiction over ACM work where the facility is located.

xv. Notifying APC or other competent persons responsible for facility asbestos-related activities when ACM is damaged, deteriorated or otherwise released into the environment.

xvi. Ensuring contractors are informed of VA medical facility ACM procedures and that their work activities are done to program requirements.

3.7 Environmental Management Service - Custodial/Housekeeping Staff

A. The Custodial (Housekeeping) Staff is responsible for adhering to the policies and procedures described in this policy. Furthermore, the Custodial (Housekeeping) staff’s responsibilities include:

i. Perform duties to identify asbestos containing materials that have the possibility of releasing airborne fibers within non-regulates asbestos areas (i.e. floor tiles, ceiling tiles, walls).

ii. Contain possible asbestos containing materials from further damage or disruption and notify their supervisor, EH&S, and/or APM

iii. Ensure care of asbestos containing flooring materials by ensuring no mechanical means (i.e. floor buffer) are used on flooring unless protective layers such as wax or sealants are present on the tiles

3.8 Engineering Service – Biomedical Engineering Staff

A. The Biomedical Engineering staff is responsible for adhering to the policies and procedures described in this policy. Furthermore, the Biomedical Engineering staff’s responsibilities include:

i. Report any visible disturbance or deterioration of known ACM to their Supervisor, EH&S, or APM;

ii. Performing their regular duties with increased caution in areas which contain ACM or PACM by performing limited disturbance activities, such as accessing above-ceiling plenums and the Interstitial Spaces to perform maintenance activities on biomedical equipment.

3.9 Office of Information and Technologies (OI&T) Staff

A. Office of Information and Technologies (OI&T) staff are responsible for adhering to the policies and procedures described in this policy. Furthermore, IT staff’s responsibilities include:

i. Report any visible disturbance or deterioration of known ACM to their Supervisor, EH&S, or APM;

ii. Performing their regular duties with increased caution in areas which contain ACM or PACM by performing limited disturbance activities, such as accessing above-ceiling plenums and the Interstitial Spaces to pull data cables and wires.

3.10 Engineering Service - Plant Operations Staff

A. Plant Operations staff are responsible for adhering to the policies and procedures described in this policy. Furthermore, Plant Operations staff’s responsibilities include:

i. Report any visible disturbance or deterioration of known ACM to their Supervisor, EH&S, or APM;

ii. Performing their regular duties with increased caution in areas which contain ACM or PACM by performing limited disturbance activities, such as performing maintenance on asbestos thermal insulation and fireproofing.

3.11 Physician/Licensed Occupational Health Care Provider

A. The Medical Surveillance Program is administered by the VASDHS Employee Health Department. The VASDHS Medical Surveillance Program is presented in Appendix B.

4.0 Areas of Known Asbestos-Containing Materials

4.1 ACMs are located in select areas throughout the building within materials such as:

A. 9”x9” vinyl floor tiles 12” x 12” vinyl floor tiles and associated mastics, B. Vinyl sheet floorings and associated mastics, C. Spray-applied fireproofing in the above-ceiling plenum/Interstitial Spaces, D. Pipe/fitting insulation in the above-ceiling plenum, mechanical spaces, and Interstitial Spaces, E. Wall joint compound associated with wall sheetrock (drywall) wall systems, F. Laboratory countertops, G. Fume hood liners, and H. Roofing materials.

4.2 Additional information can be found in the Comprehensive Asbestos Management Survey Report, Veterans Administration San Diego Healthcare System, Buildings #1 and #2, San Diego, California, Located in the Environment Health and Safety SharePoint Site.

5.0 General Requirements

5.1 The general requirements for managing ACM in the building

A. Engineering Controls B. Removal/Abatement C. Encapsulation D. Encasement E. Repair

5.2 Administrative Controls

A. Create and manage an asbestos O&M Plan B. Establish policies and protocols C. Establish clearly identified regulated and/or restricted areas D. Surveillance, monitoring, and inspections E. PPE Requirements

6.0 Emergency Response Procedures for Major and Minor Fiber Release Episodes

6.1 Fiber release episodes, which are defined as “the uncontrolled or unintentional disturbance of ACM or PACM which results in a visible emission,” are divided into two (2) categories:

A. Minor Fiber Release Episodes: Disturbance and release of less than 6 linear feet (<6 LF) or less than ten square feet (<10 SF) of ACM or PACM (e.g., fallen ceiling tile/spray-applied fireproofing debris from the Interstitial Spaces above, into occupied areas, or debris generated as the result of a pipe leak) that will generate no more than one (1) 60” x 60” bag of asbestos waste; and B. Major Fiber Release Episodes: Disturbance and release of >6 LF or >10 SF of ACM or PACM (e.g., fallen ceiling tile, spray-applied fireproofing debris from the Interstitial Space into occupied areas, or debris generated as the result of a pipe leak) that will generate more than one (1) 60” x 60” bag of asbestos waste.

C. The disturbance area is determined by measuring the damage on the substrate from where the ACM or PACM was released from, not the area of debris on the floor or other receiving surface.

D. VASDHS employees, medical staff, and contractors, should immediately report to their Supervisors, Service Chiefs, or EH&S of the presence of suspect asbestos-containing debris on the floor, water or physical damage to the ACM or PACMS, or any other evidence of a fiber release.

E. VASDHS Engineering Staff, IT Staff, EMS, contractors, and sub-contractors should immediately report to the APM or EH&S the presence of suspected asbestos-containing debris on the floor, water or physical damage to the ACM or PACMS, or any other evidence of a fiber release. The APM must notify EH&S of fiber release episodes.

F. Trained EH&S, Engineering and Maintenance Staff, or the designated Hazardous Materials Contractor may then take the following steps, with assistance from EH &S and the APM:

G. Remove personnel from the fiber release episode (spill) area;

H. Evaluate the extent of ACM or PACM damage;

I. Barricade contaminated areas against entry by unauthorized personnel;

J. Isolate the contaminated area by sealing doors and vents with polyethylene sheeting and duct tape and shutting off or modifying air handling system(s), or any other notification appropriate to restrict access or prevent exposure in other areas of the facility;

K. Post a warning sign outside the contaminated area.

6.2 Minor Fiber Release Episodes

A. The area should be isolated (full containment is not required) and cleared of unnecessary personnel;

B. Workers should wear respirators with HEPA filters, for which they have been trained and medically cleared to wear;

C. The debris should be thoroughly wetted with amended water, using a fine spray. The area affected should be kept as small as possible, and care must be taken to prevent water runoff which may spread asbestos contamination;

D. Area should be cleaned with wet cloths or a mop. Alternately, the debris may be collected with a HEPA vacuum;

E. Debris should be placed in labeled, 6-mil. plastic bags, ultimately double bagged and “goose-necked” for proper disposal;

F. The damaged area should be repaired with an asbestos-free material (e.g., install a new ceiling tile), or sealed with an encapsulant; and G. Workers should then follow proper personal decontamination procedures

6.3 Major Fiber Release Episodes

A. The areas should be isolated as soon as possible after the ACM debris is discovered. Where the area may be sealed by doors, they should be locked from the inside, but fire exit corridors must remain in operation. Signs must be posted to prevent unauthorized personnel from entering the work area.

B. The air handling system should be shut off or temporarily modified to prevent the distribution of fibers from the work area into other areas of the building. If possible, doors, windows, and HVAC registers should be sealed with 6-mil plastic sheeting and duct tape.

C. The cleanup should be treated as a Class I or Class II removal project, performed by a DOSH registered asbestos abatement contractor. This includes construction of negative pressure enclosure, decontamination facilities, and air monitoring.

D. If significant damage or delamination of ACM has occurred, consider total removal of the ACM by a DOSH registered asbestos abatement contractor in the affected areas and replacement with a non-asbestos-containing substitute.

E. To respond to fiber release episodes, the following materials will be available at each facility and accessible to Trained Engineering Staff for the purpose of isolating areas of damaged ACM.

FIBER RELEASE EPISODE SUPPLIES

Item

Recommended Quantity

F. Any additional response actions for fiber release episodes will be determined by the APM, EH&S, the designated Asbestos Consultant and conducted by the designated Hazardous Materials Contractor.

7.0 General Procedures

7.1 Accessing Above Ceiling Plenums

A. Accessing above ceiling plenums by trained Engineering Staff to perform routine maintenance activities is limited to that which will not disturb and release >6 LF or >10 SF (approximately two (2) ceiling tiles) of ACM or PACM.

B. Detailed procedures can be found in Appendix C

7.2 Operations and Maintenance Removal and Repair

A. Procedures can be found in Appendix G

7.3 Accessing Interstitial Spaces and any other Posted Regulated Areas

A. To prevent the migration of asbestos fibers from one area to another it is important to adhere to comprehensive decontamination procedures. The following general procedures will help minimize the potential of spreading asbestos contamination:

B. Detailed procedures can be found in Appendix D

8.0 Respiratory Protection

8.1 The VASDHS Respiratory Protection Program is presented in Appendix H.

9.0 Medical Surveillance

9.1 The VASDHS Medical Surveillance Program is presented in Appendix B.

10.0 Background Information

10.1 Background information is presented in Appendix F to help users understand the historical uses of ACM, health effects associated with exposure, and applicable laws and regulations.

11.0 Definitions

11.1 Asbestos. Asbestos is a generic term for a number of asbestiform hydrated silicates that, when crushed or processed, separate into flexible fibers made up of fibrils. Asbestos means chrysotile, cummingtonite-grunerite asbestos (amosite), crocidolite, anthophylite asbestos, tremolite asbestos, and actinolite asbestos.

11.2 Asbestos Containing Material. Any material containing more than 1 percent asbestos. ACM can be divided into three major categories - thermal system insulation, surfacing and miscellaneous.

11.3 Baseline Asbestos Hazard Emergency Response Act Survey (Asbestos Baseline Survey). An Asbestos Hazard Emergency Response Act (AHERA) Survey is a building-wide or facility-wide inspection that provides the general location, type, quantity, and condition of ACM present. It is thorough in that most accessible functional spaces are inspected and bulk samples taken of suspect materials observed. The baseline survey provides information for long-term management of ACM and prioritization of response actions. The presence of asbestos in suspect materials may be assumed or presumed in some cases without bulk samples being taken or analyzed. The Baseline AHERA Survey is unobtrusive in that samples are not taken where doing so would result in objectionable damage to surfaces or where institutional barriers preclude access. Destructive testing is avoided in a Baseline AHERA Survey.

11.4 Competent Person. A person capable of identifying asbestos hazards in the workplace and selecting appropriate control strategies for exposure and who has the authority to take corrective measures to eliminate such hazards. Further, for Class I and Class II asbestos work, one who has met the EPA Model Accreditation Plan training requirements for supervisors. For Class III and Class IV asbestos work, one who meets EPA training requirements for local education agency maintenance and custodial staff.

11.5 Facility Asbestos Operations and Maintenance Program. The principal objective of a Facility Asbestos O&M program is to minimize exposure of all building occupants to asbestos fibers. To accomplish this objective, an O&M program includes work practices to (1) maintain ACM in good condition, (2) ensure proper cleanup of asbestos fibers previously released, (3) prevent further release of asbestos fibers, and (4) monitor the condition of ACM. Successful O&M programs include the following elements:

A. Notification. A program to tell workers, tenants, and building occupants where ACM is located, and how and why to avoid disturbing the ACM. All persons affected should be properly informed.

B. Surveillance. Regular ACM Surveillance to note, assess, and document any changes in the ACM’s condition.

C. Controls. Work control/permit systems to control activities which might disturb ACM.

D. Work Practices. O&M work practices to avoid or minimize fiber release during the activities affecting ACM.

E. Recordkeeping. Recordkeeping will be used to document O&M activities.

F. Worker Protection. Worker protection will be used for medical and respiratory protection programs, as applicable.

G. Training. Training will be conducted for custodial and maintenance staff.

11.6 Facility Asbestos O&M Plans.

A. (1) Facility Asbestos O&M Plans are required for the ongoing management of ACM and shall include provisions for comprehensive building asbestos surveys, asbestos removal and other response actions associated with renovations involving ACM. They are the written permanent record of the current status and condition of all ACM in a facility’s inventory. The Facility Asbestos O&M Plan provides the documentation for all asbestos management efforts, and procedures for overseeing the entire facility asbestos management program, including procedures to ensure compliance with applicable OSHA, EPA, and state and local regulations.

B. The Facility Asbestos O&M Plans must communicate how the VA medical facility will manage three types of projects:

11.6.B.1 (a) Those that are unlikely to involve any direct contact or disturbance with ACM;

11.6.B.2 Those that may cause accidental disturbance of ACM; and 11.6.B.3 Those that will involve small-scale, short-duration disturbances of ACM.

C. Facility Asbestos O&M Plans must be site-specific and tailored for all buildings. The plans should take into account use, function, and design characteristics of a particular building. At a minimum the plan must address: (a) Organizational structure and assigned responsibilities for carrying out asbestos-related work.

11.6.C.1 Response action capabilities and procedures.

11.6.C.2 Worker protection and supply requirements.

11.6.C.3 Project coordination and communication necessary for minor projects, construction and renovation work involving facilities containing asbestos.

11.6.C.4 Procedures for interim control measures and extraordinary precautions.

11.6.C.5 Explanation of applicable OSHA and EPA rules.

11.7 Pre-Construction Asbestos Surveys (Pre-Construction Survey). A pre-construction asbestos survey is performed in anticipation of renovation or demolition where a Baseline AHERA Survey has not been conducted and there is no information, or insufficient information, as to the existence of ACM within the planned limits of construction. The Pre-Construction Survey requires destructive testing if concealed spaces are to be breached during construction. If ACM are found, a Project Design Asbestos Survey is conducted to provide information for preparing the plans and specifications. The Pre-Construction Asbestos Survey satisfies the EPA NESHAP requirements for renovation or demolition to “thoroughly inspect the affected facility” or the requirements of governmental agencies for issuance of a building permit. NOTE: ASTM has published detailed guidance on how to conduct a comprehensive building asbestos survey; contact ASTM for more information.

11.8 Abatement Project Design. If project meets definition of abatement project, the person doing abatement design must be accredited by the state as a project designer. The project designer must conduct a site evaluation and review the Pre-Construction asbestos survey to develop the abatement plans and specifications.

11.9 Similar Exposure Group (SEG). A group of persons exposed to similar agents. You can use a similar exposure group (SEG) to identify the people who are exposed to similar agents in your organization and have a common exposure profile.

Intentionally Left Blank

Appendix A (Training)

1.1 Asbestos Program Manager

A. AHERA Contractor Supervisor Initial – 40 Hour B. AHERA Contractor Supervisor Annual Refresher – 8 Hour C. AHERA Project Designer Initial – 24 Hour D. AHERA Project Designer Refresher – 8 Hour E. AHERA Building Inspector Initial – 16 Hour F. AHERA Building Inspector Refresher – 4 Hour G. AHERA Management Planner Initial – 8 Hour H. AHERA Management Planner Refresher – 4 Hour

1.2 Engineering Service- Projects Safety Team

A. AHERA Contractor Supervisor Initial – 40 Hour B. AHERA Contractor Supervisor Annual Refresher – 8 Hour C. AHERA Project Designer Initial – 24 Hour D. AHERA Project Designer Refresher – 8 Hour E. AHERA Building Inspector Initial – 16 Hour F. AHERA Building Inspector Refresher – 4 Hour G. AHERA Management Planner Initial – 8 Hour H. AHERA Management Planner Refresher – 4 Hour

1.3 Engineering Service – Projects Section

A. AHERA Project Designer Initial – 24 Hour B. AHERA Project Designer Refresher – 8 Hour C. Site Specific Asbestos Awareness – 2 Hour

1.4 Engineering Service – Maintenance and Repair, Structural Section

A. AHERA Contractor Supervisor Initial – 40 Hour B. AHERA Contractor Supervisor Annual Refresher – 8 Hour C. Site Specific Asbestos Awareness – 2 Hour

1.5 Engineering Service – Maintenance and Repair Section, Plumbing; Electrical; HVAC; Refrigeration; Equipment Repair; Boiler Plant Sections

A. Operations and Maintenance Initial – 16 Hour B. Operations and Maintenance Annual Refresher – 4 Hour C. Site Specific Asbestos Awareness – 2 Hour

1.6 Engineering Service – Maintenance and Repair, Locksmith Section

A. Site Specific Asbestos Awareness – 2 Hour

1.7 Custodial (Housekeeping) Staff and Supervisors

A. Site Specific Asbestos Awareness – 2 Hour

1.8 Biomedical Engineering Staff – That perform tasks off the catwalk (class III activities)

A. Operations and Maintenance Initial – 16 Hour B. Operations and Maintenance Annual Refresher – 4 Hour C. Site Specific Asbestos Awareness – 2 Hour

1.9 Biomedical Engineering Staff – That perform tasks within regulated asbestos containing areas (Class IV)

A. Site Specific Asbestos Awareness – 2 Hour

1.10 General Contractors/Sub-Contractors-Supervising Class I, II, or III activities

A. AHERA Contractor Supervisor Initial – 40 Hour B. AHERA Contractor Supervisor Annual Refresher – 8 Hour C. Site Specific Asbestos Awareness – 2 Hour

1.11 General Contractors/Sub-Contractors- Supervising Class IV activities

A. Site Specific Asbestos Awareness – 2 Hour

1.12 General Contractors/Sub-Contractors- Performing Class I or II activities

A. AHERA Asbestos Worker Initial – 32 Hour B. AHERA Asbestos Worker Annual Refresher – 8 Hour C. Site Specific Asbestos Awareness – 2 Hour

1.13 General Contractors/Sub-Contractors- Performing Class III activities

A. Operations and Maintenance Initial – 16 Hour B. Operations and Maintenance Annual Refresher – 4 Hour C. Site Specific Asbestos Awareness – 2 Hour

1.14 General Contractors/Sub-Contractors-Supervising or Performing Class IV activities

A. Site Specific Asbestos Awareness – 2 Hour

1.15 Office of Information Technology (OI&T) Staff and Supervisors – Performing Class III activities

A. Operations and Maintenance Initial – 16 Hour B. Operations and Maintenance Annual Refresher – 4 Hour C. Site Specific Asbestos Awareness – 2 Hour

1.16 Office of Information Technology (OI&T) Staff and Supervisors – That perform tasks within regulated asbestos containing areas (Class IV)

A. Site Specific Asbestos Awareness – 2 Hour

1.17 All Staff or contractors working at the facility

A. Initial Hazard Communication Training, which notifies the staff or contractor of the presence of asbestos in the facility.

1.18 All other staff that have any training or questions or concerns, please contact Asbestos Program Manager or EH&S.

END OF APPENDIX

Appendix B (Medical Surveillance)

1.1 Employee Health Department

A. In compliance with 29 CFR 1910.1001(l) – Provide pre-placement medical examinations to asbestos workers and respiratory protective equipment users, at the beginning of employment by a physician or licensed health care provider. To include but not limited to:

i. Evaluation

ii. Work and Medical History

iii. Chest x-ray (as needed)

iv. Pulmonary function test (PFT) (as needed)

B. In compliance with 29 CFR 1910.1001(l) – Provide annual medical examinations to asbestos workers and respiratory protective equipment users, at the beginning of employment by a physician or licensed health care provider.

1.2 Asbestos Program Manager

A. The APM shall be notified of any restriction requirements as the result of the medical examination provided to asbestos workers and respiratory protective equipment users, at the beginning of employment by a physician or licensed health care provider.

B. Every year thereafter, the APM receives a follow-up restriction requirement as the result of a medical examination for asbestos workers and respiratory protective equipment users, by a physician or licensed health care provider.

1.3 Environment, Health, & Safety Office

A. The EH&S office is notified by Employee Health Department if there are any restrictions stemming from the medical examination provided to asbestos workers and respiratory protective equipment users, at the beginning of employment by a physician or licensed health care provider.

B. Every year thereafter, the EH&S office is notified by Employee Health Department if there are any restrictions stemming from the follow-up medical examination for asbestos workers and respiratory protective equipment users, by a physician or licensed health care provider.

1.4 Asbestos Program Manager

A. Receive a medical examination provided to asbestos workers and respiratory protective equipment users, at the beginning of employment by a physician or licensed health care provider.

B. Every year thereafter, receive a follow-up medical examination for asbestos workers and respiratory protective equipment users, by a physician or licensed health care provider.

1.5 Engineering Service – Projects Safety Team

A. Receive a medical examination provided to asbestos workers and respiratory protective equipment users, at the beginning of employment by a physician or licensed health care provider.

B. Every year thereafter, receive a follow-up medical examination for asbestos workers and respiratory protective equipment users, by a physician or licensed health care provider.

1.6 Engineering Service – Projects Section

A. Receive a medical examination provided to asbestos workers and respiratory protective equipment users, at the beginning of employment by a physician or licensed health care provider.

B. Every year thereafter, receive a follow-up medical examination for asbestos workers and respiratory protective equipment users, by a physician or licensed health care provider.

1.7 Engineering Service – Maintenance and Repair, Structural Section

A. Receive a medical examination provided to asbestos workers and respiratory protective equipment users, at the beginning of employment by a physician or licensed health care provider.

B. Every year thereafter, receive a follow-up medical examination for asbestos workers and respiratory protective equipment users, by a physician or licensed health care provider.

1.8 Engineering Service – Maintenance and Repair Section, Plumbing; Electrical; HVAC; Refrigeration; Equipment Repair; Boiler Plant Sections

A. Receive a medical examination provided to asbestos workers and respiratory protective equipment users, at the beginning of employment by a physician or licensed health care provider.

B. Every year thereafter, receive a follow-up medical examination for asbestos workers and respiratory protective equipment users, by a physician or licensed health care provider.

1.9 Engineering Service – Maintenance and Repair, Locksmith Section

A. Receive a medical examination provided to asbestos workers and respiratory protective equipment users, at the beginning of employment by a physician or licensed health care provider.

B. Every year thereafter, receive a follow-up medical examination for asbestos workers and respiratory protective equipment users, by a physician or licensed health care provider.

1.10 Custodial (Housekeeping) Staff and Supervisors

A. No asbestos specific medical examination needed

1.11 Biomedical Engineering Staff – That perform tasks off the catwalk (Class III activities)

A. Receive a medical examination provided to asbestos workers and respiratory protective equipment users, at the beginning of employment by a physician or licensed health care provider.

B. Every year thereafter, receive a follow-up medical examination for asbestos workers and respiratory protective equipment users, by a physician or licensed health care provider.

1.12 Biomedical Engineering Staff – That perform tasks within regulated asbestos containing areas (Class IV)

A. Receive a medical examination provided to asbestos workers and respiratory protective equipment users, at the beginning of employment by a physician or licensed health care provider.

B. Every year thereafter, receive a follow-up medical examination for asbestos workers and respiratory protective equipment users, by a physician or licensed health care provider.

1.13 General Contractors/Sub-Contractors – Supervising Class I, II, or III activities

A. Receive a medical examination provided to asbestos workers and respiratory protective equipment users, at the beginning of employment by a physician or licensed health care provider. Records shall be kept maintained by General Contractor and provided to VASDHS as requested.

B. Every year thereafter, receive a follow-up medical examination for asbestos workers and respiratory protective equipment users, by a physician or licensed health care provider. Records shall be kept maintained by General Contractor and provided to VASDHS as requested.

1.14 General Contractors/Sub-Contractors – Supervising Class IV activities

A. Receive a medical examination provided to asbestos workers and respiratory protective equipment users, at the beginning of employment by a physician or licensed health care provider.