Attachment 5 Asbestos Management SOP.pdf

Standard Operating Procedure

MAY 2018 130-19

ASBESTOS MANAGEMENT PROGRAM

1. PURPOSE:

A. To institute and maintain procedures and practices that are adequate to protect the safety and health of all employees, patients, and visitors while working near asbestos or occupying buildings containing asbestos.

B. To implement an Asbestos Program meeting the requirements of Occupational Safety and Health Administration (OSHA) regulations found in the General Industry Standards (29, CFR 1910.1001) and in the Construction Standards under 29 CFR 1926.1101 (Asbestos).

C. Asbestos has been used as a building material in many GLA facilities. The presence of this asbestos containing building material will not pose a potential hazard to GLA employees, patients, and visitors if it is managed correctly.

2. POLICY:

A. GLA will control all asbestos containing materials (ACMs) in accordance with accepted professional practice, OSHA, Environmental Protection Agency (EPA), and VA requirements. The Program is composed of four coordinated elements.

(1) All facilities will be surveyed for the presence of asbestos in all its forms.

This assessment will conform to the EPA requirements (49 CFR 763) established to implement the Asbestos Hazard Emergency Response Act (AHERA) that are appropriate for GLA facilities.

(2) Once assessed, all ACMs will be addressed in an Asbestos Management Plan detailing the controls needed to ensure the health and safety of all GLA employees, patients, and visitors.

(3) Asbestos Operations and Maintenance Procedures will be developed and documented for all activities that may impact ACM. All maintenance and environmental services personnel assigned asbestos related tasks will be trained in accordance with those portions of EPA regulations published to implement AHERA.

(4) Abatement project contracts will be prepared based on the latest version of the

VA Asbestos Specification. All air sampling activities will comply with all appropriate portions of EPA regulations designed to implement AHERA. Air sampling for final clearance of asbestos

130-19

MAY 2018

abatement projects will be accomplished and results reported by qualified VA personnel or consultants reporting directly to VAGLAHS health and safety professionals.

3. DEFINITIONS:

A. Aggressive Methods: Removal or disturbance of building material by sanding, abrading, grinding, or other methods that break, crumble, or disintegrate intact ACMs.

B. Amended Water: Adding surfactant to water to increase its ability to penetrate ACM.

C. American Conference of Governmental Industrial Hygienists (ACGIH): A professional organization that is known for developing and publishing recommended occupational exposure limits for chemical substances and physical agents.

D. Asbestos: A hydrated silicon oxide mineral. There are various types called chrysotile, amosite, crocidolite, tremolite, anthophyllite, and actinolite, and any of these materials that have been chemically treated or altered.

E. ACM: Any material containing more than 1% asbestos.

F. Asbestos Work Classes: Various levels of work activities that require different protective methods and training.

(1) Class I: Activities involving the removal of Thermal System Insulation (TSI) and surfacing ACM and Presumed Asbestos Containing Material (PACM).

(2) Class II: Activities involving the removal of ACM, which is not TSI or surfacing material. This includes, but is not limited to, the removal of asbestos containing wallboard, floor tile and sheeting, roofing and siding shingles, and construction mastics.

(3) Class III: Repair and maintenance operations where ACM, including TSI and surfacing ACM and PACM, is likely to be disturbed.

(4) Class IV: Maintenance and custodial activities during which employees contact but do not disturb ACM or PACM and activities to clean up dust, waste, and debris resulting from Class I, II, and III activities.

G. Authorized Person: Any individual authorized by an employer and required by work duties to be present in regulated areas.

H. Certified Industrial Hygienist (CIH): An individual certified in the practice of industrial hygiene by the American Board of Industrial Hygiene (ABIH).

I. Competent Person: Individual trained to identify existing asbestos hazards in the workplace and to select an appropriate control strategy for asbestos exposure and who has the authority to take prompt corrective action to eliminate hazards.

(1) Class I and II: Specifically trained in a course meeting the criteria of EPA’s Model Accreditation Plan (40 CFR, Part 763) for a supervisor or his/her equivalent.

(2) Class III and IV: Trained in a manner consistent with EPA requirements for training of local education agency maintenance and custodial staff, as set forth at 40 CFR 763.92(a)(2).

J. Critical Barrier: One or more layers of plastic sealed over all openings into a work area or any other similarly placed physical barrier sufficient to prevent airborne asbestos in a work area from migrating to an adjacent area.

K. Decontamination Area: An enclosed area, adjacent and connected to the regulated area, consisting of an equipment room, shower area, and clean room. This area is used for the decontamination of materials, equipment, and personnel.

L. Disturbance: Activities that disrupt the matrix of ACM or PACM, crumble or pulverize ACM or PACM, or generate visible debris from ACM or PACM. This includes cutting away small amounts of ACM or PACM, no greater than the amount that can be contained in one standard glove bag or waste bag 60 inches on the side, in order to access a building component.

M. Fiber: A particulate or aerosol form defined as at least 5 micrometers or longer with a length-to-diameter (aspect) ratio of at least 3 to 1.

N. Glove Bag: A “standard “ glove bag is defined as an impervious plastic bag-like enclosure not more than 60" X 60". This enclosure is fixed around the ACM, and it is equipped with glove-like appendages through which materials and tools can be handled to remove the ACM. The removed material remains in and is disposed of in the bag.

O. High-efficiency Particulate Air (HEPA) Filter: A filter capable of trapping and retaining at least 99.97% of mono-disperse particles.

P. Homogeneous Area: An area of surfacing material or thermal insulation that is uniform in color and texture.

Q. Industrial Hygiene: The science devoted to the anticipation, recognition, evaluation, and control of those environmental factors, stresses, or agents (i.e., physical, chemical, and biological) that may cause sickness, impaired health, or significant discomfort to employees or residents of the community.

R. OSHA: Agency under the Secretary of Labor tasked to promulgate as a federal standard any national consensus standard for the protection of the safety and health of employees. This agency is tasked to inspect most work areas to ensure every employee has a “safe and healthful” work environment. In California, as an “Agreement State”, Cal/OSHA promulgates the laws, standards, and regulations. Permissible Exposure Limit (PEL): The legally enforceable exposure limit for a substance established by Federal OSHA. The PEL indicates the permissible concentration of air contaminants to which nearly all workers may be repeatedly exposed eight (8) hours a day, forty (40) hours a week over a working lifetime of forty (40) years.

S. PCM: Phase Contrast Microscopy

T. PACM: “Presumed asbestos containing material”: Refers to thermal system insulation and surfacing materials found in buildings constructed no later than 1980.

U. Regulated Area: An area where airborne concentrations of asbestos exceed, or there is a reasonable possibility they may exceed, the PEL.

V. Removal: Operations where ACM and/or PACM is taken out or stripped from structures or substrates. This includes demolition operations.

W. Renovation: The modifying of any existing structure.

X. Repair: Overhauling, rebuilding, reconstructing, or reconditioning of structures or substrates. This includes encapsulation or other repair of ACM or PACM attached to existing structures or substrates.

Y. South Coast Air Quality Management District (SCAQMD): This is the local air quality regulatory agency with authority over West Los Angeles Healthcare Center, Sepulveda ACC and Nursing Home, and Los Angeles ACC.

Z. Surfacing ACM: Surfacing materials that contain more than 1% asbestos.

AA. Surfacing Material: Material that is sprayed, toweled on, or otherwise applied to surfaces such as acoustical plaster on ceilings, fireproof materials on structural members, or other materials on surfaces for acoustical, fireproofing, or other purposes.

BB. TSI Thermal System Insulation: TCI applied to ACM applied to pipes, fittings, boilers, breeching, tanks, ducts, or other structural components to prevent heat loss or gain.

CC. TSI Thermal System Insulation ACM: TSI that contains more than 1% asbestos.

DD. Threshold Limit Value (TLV): An exposure limit for a substance established by the ACGIH. The TLV indicates the permissible concentration of air contaminants to which nearly all workers may be repeatedly exposed eight (8) hours a day, forty -(40) hours a week over a working lifetime of forty-(40) years.

EE. Time Weighted Average (TWA): Refers to concentrations of airborne toxic materials that have been weighted or averaged over duration.

FF. TEM: Transmission Electron Microscopy

4. RESPONSIBILITIES:

A. Director is responsible for providing a health care environment free of hazards associated with ACM and PACM and has the authority to take any action necessary to control exposures to asbestos fibers in the event of a construction error or emergency. The Medical Center Director has delegated the authority and responsibility for the GLA Asbestos Program to the Chief, Facilities Management.

B. Environment of Care Committee is responsible for providing oversight, monitoring, and review of the effectiveness of the overall Environment of Care Management Program, including the management of ACM and PACM in all facilities.

C. Service Chiefs and Supervisors are responsible for:

(1) Reviewing this Asbestos Program policy with their Safety Coordinators and employees to address any potential asbestos issues as part of their department specific safety and health plans.

(2) Inspecting all areas with ACM or PACM to ensure the areas are well managed and the materials have not been disturbed.

(3) Ensuring their department personnel participate in required asbestos training especially if they are involved in activities that may result in contact with ACM and PACM.

(4) Ensuring all ACM and PACM in their facilities and/or areas of responsibility are properly labeled in accordance with existing standards and this policy.

(5) Coordinating the initial and annual department specific and job specific training employees require covering the risks associated with asbestos materials that may be present their work areas as part of the Hazard Communication Program.

(6) Supporting Industrial Hygiene with asbestos assessments and management with evaluations, establishment of control measures, and formal employee training.

(7) Reporting any incident where ACM/PACM is damaged to Environment of

Care immediately. If significant damage has occurred, ensure the immediate area near the damaged asbestos has been evacuated.

D. Chief, Engineering is responsible for:

(1) Ensuring that the Engineering Department is aware of the location and amount of ACM and PACM in all facilities so that proper specifications to deal with the ACM and/or PACM are incorporated in all planned facility modifications.

(2) Actively supporting the Asbestos Management Program, this will include supporting the identification of ACM and/or PACM areas.

(3) Based on updates to the GLA Facility Asbestos Assessment received from IH, maintaining accurate labeling of asbestos locations on engineering building drawings and updating these drawings after abatement.

(4) Ensuring that all personnel understand that they may not participate in any

Class III activities, defined as repair and maintenance operations, where ACM (including TSI and surfacing ACM and PACM) is likely to be disturbed.

(5) Ensuring that all personnel understand that they may not participate in those

Class IV activities defined as repair and maintenance activities to clean up dust, waste, and debris resulting from Class I, II, and III activities.

(6) Ensuring that all personnel understand that they may participate in those Class

IV activities defined as repair and maintenance operations during which employees contact but do not disturb ACM or PACM, as long as AHERA training requirements are met.

(7) Ensuring all personnel are trained to report damaged or disturbed ACM and/or

PACM immediately to their supervisors and those facility occupants affected by the damaged material.

E. Chief, Environmental Management Services is responsible for:

(1) Actively supporting the Asbestos Management Program, this includes supporting the identification of ACM and/or PACM areas.

(2) Based on updates to the GLA Facility Asbestos Assessment received from IH, maintaining accurate labeling of both ACM and PACM areas.

(3) Ensuring that all personnel understand that they may not participate in those

Class IV activities defined as janitorial duties to clean up dust, waste, and debris resulting from Class I, II, and III activities.

(4) Ensuring that all personnel understand that they may participate in those Class

IV activities defined as janitorial duties during which employees contact but do not disturb ACM or PACM, as long as AHERA training requirements are met.

(5) Ensuring all personnel are trained to report damaged or disturbed ACM and/or

PACM immediately to their supervisors and those facility occupants affected by the damaged material.

F. Chief, Occupational Safety and Health is responsible for:

(1) Managing the GLA Asbestos Program, including its development, implementation, documentation, and annual review.

(2) Complying with all OSHA, EPA, South Coast Air Quality Management

District (SCAQMD), Los Angeles Fire Department (LAFD), and Department of Veterans Affairs

(DVA) regulations and procedures concerning the notification, management, handling, and disposal of ACM and/or PACM.

(3) Appointing an Asbestos Program Manager (APM) to oversee the program and ensuring that the individual receives training necessary to certify him/her for that position, as required by AHERA.

(4) Maintaining the GLA Asbestos Assessment and making changes to the assessment as necessary. Updating the GLA Facility Asbestos Assessment after abatement.

Coordinating these efforts with the Chief, Engineering Department.

(5) Coordinating the program needs of all facilities and departments by providing

Certified Asbestos professional expertise and technical resources.

(6) Ensuring that the SCAQMD and Cal/OSHA are notified at least 10 working days before asbestos abatement activity, other than emergency projects, in which more than 100 square feet of surface ACM is removed.

(7) Assisting all facilities and departments with the evaluation of those areas containing ACM and/or PACM. This will include assessing the condition of the material and, based on that assessment, prioritizing the areas presenting the greatest risk for encapsulation or removal.

(8) Providing all necessary training required by AHERA, either in-house or by contract, for those individuals involved in Class IV work activities.

(9) Contracting with a competent, licensed asbestos abatement company to perform asbestos abatement as part of building renovation and maintenance projects. This includes contracting with an AHERA certified inspector for a written "Comprehensive Asbestos Exposure Abatement Survey Report" every three (3) years.

(10) Notifying employees adjacent to proposed asbestos abatement projects of the work schedule prior to abatement.

(11) Notifying employees for re-occupancy of work areas based upon

Industrial Hygiene guidance and direction.

(12) Notifying outside contractors of asbestos locations and specifying the preventive measures that must be followed while working around ACM.

(13) Ensuring friable ACMs identified in the "Comprehensive Asbestos

Exposure Abatement Survey Report" are identified with the appropriate caution labels.

G. Industrial Hygiene is responsible for:

(1) Conducting building surveys and collecting bulk samples to identify ACM locations, quantities, condition, and exposure potential. This may include air sampling to determine airborne fiber levels where there is a potential inhalation exposure.

(2) Working with an AHERA certified inspector in the preparation of a written

"Comprehensive Asbestos Exposure Abatement Survey Report" every three (3) years.

(a) Prioritizing all ACM and/or PACM areas for abatement based on the exposure risk assessment documented in the "Comprehensive Asbestos Exposure Abatement Survey Report.”

(b) Assessing the condition of ACM in those areas identified as potentially high and medium exposure and recommending prioritized abatement projects to an APM.

(3) Taking prompt and appropriate action to reduce any asbestos exposure hazards.

(a) These actions will be based on inhalation exposure assessments involving a comprehensive personal breathing zone air sampling study.

(b) Ensuring that all employee exposures remain at or below the airborne fiber OSHA PEL standard 8-hour TWA of 0.10 fiber/cc and 30-minute short-term exposure limit (STEL) of 1.0 fiber/cc.

(4) Reviewing asbestos abatement specifications and information submitted by asbestos abatement contractors.

(5) Monitoring outside contractors performing services that could disturb asbestos materials to assure compliance with Asbestos Program requirements.

(a) Inspect the quality of work, credentials, and regulatory compliance of asbestos abatement contractors at GLA.

(b) Perform perimeter air sampling to determine fiber levels in order to verify the adequacy of the enclosure.

(c) Perform all clearance sampling either in-house or by contract. Release the work area for re-occupancy if fiber levels are equal to or less than the VA clearance standard of 0.005 fiber/cc and there is no visible asbestos dust or debris. Crawl spaces can be re-occupied with a clearance of 0.01 fiber/cc.

(6) Maintaining records on asbestos bulk and air sampling and asbestos awareness training provided to employees. Asbestos exposure records will be kept for at least 30 years.

(a) Referring asbestos exposed or potentially exposed employees and patients to Administrative Medicine for medical evaluation.

H. Administrative Medicine is responsible for:

(1) Performing mandatory OSHA medical examinations for those employees who are currently or may have been exposed to airborne asbestos at or above the PEL of 0.10 fiber/cc for 30 days or more per year. Asbestos examinations will be performed every five (5) years and at the termination of employment for employees who have been exposed.

(2) Maintaining medical records of asbestos exposed employees for the duration of employment plus 30 years.

I. Supervisors and employees are responsible for:

(1) Attending mandatory AHERA asbestos awareness if they work in areas containing asbestos.

(2) Reporting any damaged ACM and/or PACM in their work areas, centers, or facilities to their supervisors immediately.

(3) Reporting any possible asbestos exposure hazard immediately to the

Industrial Hygiene Office.

(4) Staying clear of all asbestos abatement activities.

5. PROCEDURES:

A. Asbestos abatement priorities:

(1) Projects, renovations, and repairs:

(a) The APM will conduct asbestos abatement required of major projects in accordance with the VA Asbestos Abatement Specifications.

(b) Industrial Hygiene will conduct building surveys in those areas being renovated or repaired where ACM may be disturbed or removed. This includes asbestos-containing pipe insulation, ducts, floor tiles, stucco, and roofing materials. The surveys will determine quantities, friability, location, and exposure potential of ACM. Industrial Hygiene will prioritize the areas of proposed asbestos abatement in consultation with the Asbestos Program Manager.

(2) ACM facility survey prioritization:

(a) Industrial Hygiene will prepare a list of potentially high to low risk asbestos containing areas based on the most recent "Comprehensive Asbestos Exposure Abatement Survey Report."

(b) The highest priority will be given to abating asbestos containing materials in those areas where there is a high potential for exposure.

B. Asbestos abatement and quality assurance procedures:

(1) All asbestos abatement procedures will be done in accordance with the OSHA Asbestos in Construction Standard, 29 CFR 1926.1101.

(2) The use of any chemical mastic adhesive remover is prohibited at this facility.

Bead blasting,shot blasting,water blasting and grinding is allowed.

(3) Industrial Hygiene will perform pre-abatement, abatement, and clearance asbestos air monitoring and quality assurance.

(4) All abatement work affecting employees inside of buildings will be evaluated by a Safety Specialist to ensure all elements of the NFPA Life Safety Code are adhered to. The APM will coordinate a fire safety inspection prior to any work starting with the safety specialist, project monitoring contractor and the abatement contractor.

(5) Notification of pending abatement operations will be provided to all employees in adjacent areas as soon as possible.

(6) Employees will be cleared from the area surrounding the abatement area.

(7) The APM will provide a re-occupancy notice to all Service Chiefs and

Supervisors based upon the OSHA PCM Clearance Standard of 0.01 f/cc or TEM Standard of 70 Structures/mm2 with no visible asbestos dust or debris.

C. Identification:

(1) Caution signs:

(a) All locations where airborne concentrations of asbestos fibers have been found to exceed the PEL (O.1 fiber/cc), as determined by air sampling, will be posted at each location.

(b) The signs will be posted at locations in order to be readily visible, such as approaches to areas containing airborne asbestos fibers.

(c) These warning signs will display the following wording:

DANGER

ASBESTOS

CANCER AND LUNG DISEASE HAZARD

AUTHORIZED PERSONNEL ONLY

RESPIRATORS AND PROTECTION CLOTHING

ARE REQUIRED IN THIS AREA

(2) Caution labels:

(a) Caution labels will be attached to entrances to areas that contain friable ACM such as crawl spaces, mechanical rooms, pipe closets, attics, and penthouses until the asbestos is completely abated. All friable asbestos containing material will be labeled at approximately every 100 square feet or every 20 linear feet.

(b) Caution labels will also be attached to all friable materials, waste, and debris-containing asbestos or their containers. The caution labels will be printed in letters of sufficient size and contrast to be readily visible and legible.

(c) The labels will contain the following information:

DANGER

CONTAINS ASBESTOS FIBERS

AVOID CREATING DUST

CANCER AND LUNG DISEASE HAZARD

(3) Pipe/duct labels: Asbestos containing thermal insulation will be labeled with a red letter "A" approximately every 20 linear feet along pipes and ducts.

(4) Drawing denotation: Engineering Department and the Industrial Hygiene

Office will maintain a set of drawings and loose-leaf binders noting those buildings that have asbestos containing materials. The notations will include:

(a) All ACMs such as pipe and duct insulation, vinyl asbestos floor tiles, ACM ceiling tiles, elbows, etc.

(b) Locations of bulk samples.

(c) These drawings will be continually updated indicating any ACM removal.

D. Air sampling methods and analysis records:

(1) Air monitoring measurements will be taken in buildings containing asbestos materials in accordance with these guidelines. Exposed employees or their representatives will be given an opportunity to observe any air monitoring. Copies of all air monitoring records will be made available to the exposed employees or their representatives upon request.

(a) The membrane filter method, using phase-contrast microscopy (PCM) and The National Institute for Occupational Safety and Health (NIOSH) 7400 analysis will be used to determine the airborne fiber levels in the workplace.

(b) The pumps will be calibrated before and after air sampling with a calibrated rotameter or primary standard.

(2) Area or environmental samples:

(a) These samples will be taken during the removal or encapsulation of asbestos materials. Their purpose is to ensure the integrity of the asbestos control measures such as wet methods, enclosures, etc.

(b) The pumps will be located immediately beyond all major openings to the sealed abatement area, such as adjacent to the Decontamination Unit, and at the exhaust of negative air HEPA filtration devices.

(3) Clearance sampling:

(a) After the asbestos work area has been wet wiped and/or HEPA vacuumed, clearance air samples will be taken in the work area.

(b) Transmission Electron Microscopy (TEM), using the AHERA protocol if the abatement area is more than 160 square feet or 260 linear feet, will be used to analyze these samples. If the work area is less than or equal to 160 square feet or 260 linear feet, the samples will be analyzed using PCM. The AHERA clearance criteria are 70-structures/square millimeter for TEM.

(c) The AHERA clearance standard for PCM is 0.01-fiber/cc.

(d) Minimum sample volumes are 1,000 liters for PCM and 1,200 liters for TEM. If air monitoring after clean-up results in fiber counts above the clearance standard, the project area must be cleaned again and the sampling process repeated until the clearance level is attained.

(e) Critical barriers are removed only after the clearance standard is achieved.

(4) Work area samples:

(a) At least one air sample will be taken per day in the asbestos abatement work area during gross removal, bagging, and cleanup to validate the effectiveness of engineering controls. Analysis of the sample shall be by PCM.

(b) Personal samples will be taken in the breathing zone of employees who are performing maintenance tasks where ACM is disturbed. Asbestos abatement contractors are responsible for performing this personal air sampling for their employees in accordance with OSHA regulations. Eight-hour TWA and 30-minute STELs will be taken during each work shift.

(5) Bulk sampling:

(a) Industrial Hygiene will review the “Comprehensive Asbestos Exposure Abatement Survey”, and if necessary, collect bulk samples to determine the scope of recommended asbestos abatement throughout the GLA.

(b) Bulk samples will be placed in sealable plastic bags or containers and the sample type, friability, sample number, and locations will be noted on the bulk sample log.

(6) Laboratory analysis and records:

(a) A laboratory accredited by the AIHA and a successful participant in the Proficiency Analytical Testing (PAT) Program must analyze all air samples. The asbestos analysts should also be listed in the Asbestos Registry. The standard analytical method for air samples will be PCM, except for clearance air samples.

(b) TEM will be used for clearance air sampling if the asbestos abatement is at least 160 square feet or 260 linear feet. The TEM sample volume will be at least 1,200 liters.

If PCM is used for clearance air sampling, the volume should be at least 1,000 liters.

(c) Polarized Light Microscopy will be used to analyze bulk samples for asbestos content and type of asbestos. The analysis laboratory will be a successful participant in the National Voluntary Laboratory Accreditation Program (NVLAP).

6. REFERENCES:

A. Department of Veterans Affairs Handbook 7700, Occupational Safety and Health, Washington, DC, February 11, 2009.

B. Title 29, Code of Federal Regulations, Part 1910, Subpart Z, 1910.1001, and Part

1926, Subpart Z, 1926.1101-Asbestos, current register.

C. Title 49, Code of Federal Regulations, Part 763-Asbestos, Subpart E-Asbestos

Containing Materials in Schools, current register.

D. KEY WORDS:

(1) OSHA

(2) Asbestos Management

(3) The National Institute for Occupational Safety and Health (NIOSH)

(4) Industrial Hygiene

(5) Asbestos Containing Materials (ACMs)

(6) VA Asbestos Specification

(7) NFPA Life Safety Code

7. COLLABORATED WITH: Chief of Occupational Safety and Health, Industrial Hygiene, Engineering, EMS.

8. RESCISSION:

A. Asbestos Management Program. Occupational Safety and Health SOP #130-19.

Veterans Administration of Greater Los Angeles. March 2016.

B.

C. Asbestos Management Program. Occupational Safety and Health SOP #130-19.

Veterans Administration of Greater Los Angeles. March 2013.

D. Asbestos Management Program. GLA Environment of Care Manual, 2009.

9. REVIEW DATE: Review annually and reissue every three years.

Benjamin K. Spivey Date Chief, Occupational Safety & Health