Attachment C - Asbestos Management Plan.pdf

Department of Veterans Affairs VHA DIRECTIVE 2010-036 Veterans Health Administration Washington, DC 20420 August 12, 2010

ASBESTOS MANAGEMENT PROGRAM

1. PURPOSE: This Veterans Health Administration (VHA) Directive provides policy for the safe management of asbestos-containing materials.

2. BACKGROUND: Prolonged exposure to asbestos fibers increases the risk of associated diseases for workers and their families. The Occupational Safety and Health Administration (OSHA) and the Environmental Protection Agency (EPA) have issued recommendations and regulations for safe work practices and management of asbestos containing building materials (ACBM). Recently rescinded VA 7701.1 policy required all facilities to conduct comprehensive triennial EPA asbestos inspections under the Asbestos Hazard Emergency Response Act (AHERA). This VHA policy designates the AHERA inspection records as the baseline facility survey with no triennial survey requirement. VHA will continue to mandate the use of EPA AHERA certified inspectors and methodology to ensure program consistency across all Networks. VA facilities are public buildings and must comply with the Asbestos School Hazard Abatement Reauthorization Act (ASHARA), as well as the National Emission Standards for Hazardous Air Pollutants (NESHAP). Specifically, AHERA certification is required for ACBM inspection, project design and response, but not for development of ACBM management plans.

3. POLICY: This VHA policy requires compliance with OSHA, title 29 Code of Federal Regulations (CFR) 1910.1001, 29 CFR 1926.1101, EPA ASHARA (40 CFR 763.EPA Appendix E to Subpart E), and NESHAP (40 CFR 61) regulations, which establish minimum program elements for the safe management of asbestos containing materials.

4. ACTION

a. Director, Office of Construction and Facilities Management (CFM). The Director, CFM is responsible for:

(1) Providing construction procedures, design guides and specifications to address asbestos containing building materials that ensures asbestos is removed and managed in accordance with local, state and Federal requirements for projects under CFM management; and

(2) Ensuring lease contracts contain asbestos notification requirements.

b. Chief Consultant, Occupational Health, Safety, and Prevention Strategic Healthcare Group (13D). The Chief Consultant, Occupational Health, Safety, and Prevention Strategic Healthcare Group (13D), is responsible for providing policy and guidelines on occupational health issues related to asbestos hazards and medical surveillance criteria.

c. Deputy Under Secretary for Health for Operations and Management (10N). The Deputy Under Secretary for Health for Operations and Management (10N) is responsible for:

THIS VHA DIRECTIVE EXPIRES AUGUST 31, 2015

VHA DIRECTIVE 2010-036

August 12, 2010

(1) Developing and implementing VHA Occupational Safety and Health (OSH) Program and policies, and

(2) Establishing OSH performance standards for Veterans Integrated Service Network (VISN) Directors and the Director, Safety, Health, Environmental, and Emergency Management

(10NS).

d. Director, Safety, Health, Environmental, and Emergency Management (10NS). The Director, Safety, Health, Environmental, and Emergency Management (10NS), is responsible for:

(1) Providing administrative management and technical support to VISNs and VHA facilities in complying with Federal, state, and local regulations.

(2) Ensuring Operations and Maintenance (O&M) Plans are implemented at all facilities using industry standards and recommended practices.

e. VISN Director. Each VISN Director is responsible for providing adequate resources for the implementation of this Directive and ensuring:

(1) Asbestos programs, projects, and evaluations meet VHA policies, and Federal and state regulations.

(2) VHA employees, volunteers, patients and visitors are protected from asbestos exposure.

(3) An annual workplace review of facility asbestos management programs to evaluate safe working conditions, training, labeling, and posting accurate updates that reflect ACBM actions.

(4) A review of facility in-house asbestos removal programs.

(5) Review, suspension, or limiting any facility asbestos removal program upon report of OSHA or EPA regulatory non-compliance.

(6) If applicable, all VHA-managed child care programs comply with AHERA regulations (40CFR763) as required by these state authorized programs.

(a) Under these circumstances, VHA contracts issued for operation or leasing must contain AHERA notifications and requirements.

(b) Contracting officials are to ensure asbestos-free documentation is obtained and forwarded to facility coordinator or manager.

(c) Under these circumstances, VHA contracts issued for operation or leasing must contain AHERA notifications and requirements.

f. Facility Director. Each VHA Facility Director is responsible for:

(1) Identifying ACBM locations.

(2) Implementing safe ACBM work practices.

(3) Reducing or phasing out the use of asbestos-containing products.

(4) Providing adequate resources for the implementation of an asbestos management program for compliance with VA and VHA policy.

(5) Certifying to the VISN Director that the current ACBM inspection and risk assessment (ACBM Survey) of record is comprehensive for all VHA-owned properties and accurately represents all ACBM abatement and repair actions, or an additional AHERA inspection and risk assessment survey will be conducted by the end of Fiscal Year (FY) 2010.

(a) All ACBM inspections must be completed using an AHERA certified inspector.

(b) Subsequent AHERA inspection and risk assessment surveys must be conducted upon determination by the VISN Safety Office or Director (10NS) of inadequate ACBM survey, removal and repair recordkeeping, or ACBM surveillance.

(6) Ensuring the office(s) tasked with managing ACBM projects and contractor oversight fully records in the ACBM Survey (by appendix, computer aided design program, or equivalent) all abatement, enclosure, encapsulation, and repair actions within 45-days of project completion.

(7) Ensuring a list of the abatement and repair actions (site location and action) is provided to the VISN Safety Office and local Union Safety Representatives, upon request.

(8) Ensuring an ACBM abatement or repair plan and schedule is developed and implemented for all friable asbestos materials that are classified as “damaged” and “significantly damaged” in the current ACBM survey.

(9) Implementing a written O&M Plan and designating a program manager for ACBM types, locations, and compliance activities by the end of the 4th quarter of FY 2010.

(10) Ensuring the facility program manager is certified to meet individual state requirements to oversee:

(a) Comprehensive labeling of ACBM. All thermal insulation (pipeline, tank and boiler) is labeled. ACBM is identified using alternate locations when labeling is not feasible (e.g., spray-on, tile floors, liners, gaskets).

(b) Annual asbestos awareness training for VHA custodial and facility maintenance staff and supervisors. New employees must receive training within 60 days of assignment.

1. Employee information and training must include the requirements of 29 CFR 1910.1001(j).

2. Employee awareness training includes:

a. The facility system used for identification of ACBM.

b. The hazards of asbestos exposure.

c. Recognition of ACBM types and damage.

d. Procedure for reporting damaged ACBM and fiber release.

e. Access to ACBM location information for assigned work areas.

(11) Conducting on-going visual surveillance for ACBM damage. This includes:

(a) Listing in the O&M Plan the work areas requiring visual surveillance of friable ACBM every 6 months for the following classifications designated in the ACBM survey.

1. ACBM with the potential for damage.

2. ACBM with the potential for significant damage

(b) Documenting the method of this visual inspection in the O&M Plan (AWE, EOC Rounds, remote staff contact, etc.).

(c) Reporting any ACBM damage to the O&M Program Manager or supervisor.

(12) Identifying and listing in the O&M Plan the specific work tasks and locations that require engineering controls and personal protection procedures to address the potential for disturbance of ACBM or debris (e.g., entry into tile ceilings with potential for spray-on ACBM debris on tile, entry into chases or utility zones with potential ACBM debris, penetration of asbestos wall board or joint compound, etc.). This includes:

(a) Developing written standard operating procedures for these tasks which impact ACBM.

(b) Verifying that the controls and procedures are implemented by trained VHA employees with representative personal air monitoring for asbestos exposure.

(c) Ensuring contractors are informed of the requirements and verifying compliance. Under OSHA regulations, these O&M procedures may require compliance with Class III or IV operations.

(13) Designing and conducting all renovation and construction work to prevent ACBM damage and the release of airborne asbestos fibers.

(14) Ensuring any additional ACBM sampling and inspection is conducted by AHERA-certified inspectors.

(15) Ensuring all contracting officers (COs) and Contracting Officer Technical Representatives (COTRs) responsible for ACBM contracts complete initial O&M asbestos awareness training.

(16) Ensuring staff and contractors conducting ACBM project design are AHERA certified.

Under ASHARA regulation, some states may have adopted project monitor training requirements for the designated building owner representative (CO or COTRs).

(17) Ensuring a review of all facility projects is conducted by the asbestos program manager, CO or COTR, or facility management supervisor to determine impact to ACBM.

(18) Ensuring contractors and VA staff assigned to perform construction, renovation, building maintenance, or other services (custodial, canteen, etc.) are informed of ACBM locations in the assigned work area and O&M work practice requirements.

(19) Implementing separate asbestos abatement and industrial hygiene service contracts for asbestos site clearance. In-house resources may be developed using AHERA certification of safety office, CO or COTRs, and maintenance staff. NOTE: These requirements do not preclude the contractor’s right to collect duplicate samples. It is prohibited to sub-contract the following abatement site clearance and inspection tasks through the ACBM abatement contractor:

(a) Pre-abatement (ambient) air samples and analysis,

(b) Daily air monitoring samples exterior to containment,

(c) Final clearance visual inspection, and

(d) Final clearance air monitoring and analysis.

(20) Ensuring all asbestos emergency response, abatement, and repair programs supervised and conducted by VHA employees (in-house) are submitted to the VHA Facility Safety Office for approval.

(21) Ensuring a written program is published designating the staffing levels, certifications, standard work procedures, level of respiratory protection, waste disposal plans, training, medical evaluation procedures, and personal exposure monitoring plan.

(a) The in-house asbestos abatement program cannot employ individuals in VHA patient compensated work therapy or incentive therapy status.

(b) Local Union representatives are notified when in-house abatement programs are submitted for approval.

(22) Ensuring all VHA facility contracts (residential and commercial) for lease or rent of VHA property include identification of ACBM locations and recognition of additional requirements as required by state and local regulations. NOTE: VHA employees and residents occupying leased or rented space through VHA contract can have access to ACBM location information and asbestos program requirements.

(23) Ensuring all training (employee, contractor, and consultant) for asbestos inspectors and risk assessors, project designers, supervisors, and asbestos workers meet EPA Asbestos School Hazard Abatement Reauthorization Act (ASHARA) requirements. Unless required by state regulation, employee hazard awareness training and on-going visual surveillance does not require training by an EPA-certified individual. NOTE: VHA employees and contractors have access to ACBM location information and asbestos program requirements.

g. Occupational Health Providers. Occupational Health providers must offer medical surveillance to staff assigned medical examinations due to potential past or present exposure to

ACM.

h. Facility Management Supervisors. Facility management supervisors are responsible for ensuring:

(1) Custodial and maintenance staff complete annual asbestos awareness training.

(2) Reports of damaged or deteriorating ACBM are reported to the Engineering or Safety office.

(3) VHA staff complete assigned training and properly wear personal protective equipment.

(4) Staff conduct specific ACBM safe work practices.

5. REFERENCES

a. OSHA Asbestos Information http://www.osha.gov/SLTC/asbestos/

b. EPA Asbestos Information http://www.epa.gov/asbestos/pubs/asbreg.html

c. EPA ASHARA http://www.epa.gov/fedrgstr/EPA-TOX/pre1994/4170-1.pdf

d. EPA AHERA http://ecfr.gpoaccess.gov/cgi/t/text/ http://www.osha.gov/SLTC/asbestos/ http://www.epa.gov/asbestos/pubs/asbreg.html http://www.epa.gov/fedrgstr/EPA-TOX/pre1994/4170-1.pdf http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&sid=2b41cb0cff4310b466a585471eec366c&rgn=div5&view=text&node=40%3A30.0.1.1.18&idno=40#40%3A30.0.1.1.18.2.1.17.4

6. FOLLOW-UP RESPONSIBILITY: The Deputy Under Secretary for Health for Operations and Management (10N) is responsible for the contents of this Directive. Questions may be directed to the Director, Safety, Health, Environmental and Emergency Management (10NS) at

(202) 266-4547.

7. RESCISSIONS: None. This VHA Directive expires August 31, 2015.

Robert A. Petzel, M.D.

Under Secretary for Health

DISTRIBUTION: E-mailed to VHA Publications Distribution List 8/17/2010