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4-STAGE CLEARANCE (4-SC) PROJECT – GUIDANCE FOR LABORATORIES

CARRYING OUT SITE CLEARANCE CERTIFICATION.

1. Introduction

1.1 The purpose of this document is to give guidance on the application of various clauses
of ISO/IEC 17025 (1) – General requirements for the competence of testing and
calibration laboratories and ISO/IEC 17020 (2) – General criteria for the operation of
various types of bodies performing inspection, in relation to the conduct of site
clearance certification. It will be used by UKAS assessors during the assessment of
laboratories carrying out the 4-stage clearance procedure, and will form the basis of
establishing conformity or otherwise with accreditation requirements.

1.2 This guidance has been produced following the introduction of revised procedures for
conducting site clearance activities, as specified in Health & Safety Executive (HSE)
Approved Code of Practice and Guidance, L28 (Fourth Edition) (3), and to respond to
a request from HSE to develop a credible assessment and accreditation regime to
cover the 4-stage site clearance certification process.

1.3 The guidance has been produced in consultation with the UKAS Asbestos Technical
Advisory Committee, containing representatives from the Health & Safety Executive,
local authorities, professional bodies, laboratories, inspection bodies, contractors,
training organisations and customers.

1.4 The revised site clearance certification process involves four stages : -

• Stage 1 – preliminary check of site condition and job completeness

• Stage 2 – a thorough visual inspection inside the enclosure/work area
• Stage 3 – clearance air monitoring
• Stage 4 – final assessment post-enclosure/work area dismantling

Laboratories that are currently accredited by UKAS for clearance air monitoring
already carry out Stage 2 and Stage 3 activities under their existing accreditation.
Disclaimers are currently required to be included in test certificates/reports for Stage 1
and Stage 4 of the revised site clearance procedure (see clause 2.9.1).

1.5 By following the guidance given in this document, laboratories will be able to
demonstrate at assessment that they meet the requirements. Alternative methods may
be adopted provided that they are shown to give an equivalent outcome. This
publication does not cover all of the requirements of ISO/IEC 17025 or ISO/IEC
17020, which remain as the authoritative documents on accreditation matters.

Following the ‘pilot assessment’ programme, this guidance will be further reviewed,
and will subsequently be published to enable accreditation for all 4-stages to be
available to those laboratories involved in clearance air monitoring activities.

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1.6 Laboratories will be required to demonstrate competence and effective application of

ISO/IEC 17025, and of the requirements of ISO/IEC 17020 identified in this guidance
document. Laboratories will not be required to comply with all of the requirements of
ISO/IEC 17020.

Accreditation will be granted for the 4-stage clearance certification activity

under the ISO/IEC 17025 standard.

Note : EA publication 5/01 (4) (Accreditation of inspection bodies: Guidelines on the

application of ISO/IEC 17020) also provides useful guidance on the application of
ISO/IEC 17020.

2 GUIDANCE ON ACCREDITATION.

The following paragraphs contain guidance on specific requirements of ISO/IEC

17025 and ISO/IEC 17020 that are considered to be of relevance to site clearance
certification activities.

2.1 Review of requests, tenders and contracts ISO/IEC 17025 clause 4.4
(ISO/IEC 17020 clause 10.5)

2.1.1 A copy of the method statement (plan of work) shall be made available to the analyst
carrying out the site clearance. The analyst shall check that the work method on-site is
in accordance with the job details notified on the method statement. If a copy of the
method statement is not available on-site, the analyst should fail Stage 1, indicating
the reason for failure on the Certificate of Reoccupation.

Note : Throughout this document reference is made to the “contractor”. This should
be taken to refer to the asbestos removal contractor who carried out the removal
works.

2.1.2 The laboratory’s procedure for ‘contract review’ should also include a requirement to
establish whether or not the testing of hygiene unit(s) is required to be carried out as
part of the laboratory’s scope of testing work.

2.1.3 Upon arrival at the site, the analyst shall ensure that the work carried out on-site is in
accordance with the scope of work. Any deviations shall be recorded by the analyst,
for reporting on the Certificate of Reoccupation.

2.1.4 Staff responsible fo r booking- in / logging jobs shall have appropriate competence in
implementing ‘contract review’ procedures.

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2.1.5 The conduct of reassurance testing following completion of Stage 4 of site clearance
certification is not included within The Analyst’s Guide (5). The laboratory’s
procedure for ‘contract review’ should consider whether or not such testing will be
required by the client. N.B. It is emphasised that the conduct of reassurance air
monitoring is NOT part of the 4-stage site clearance procedure.

2.1.6 During the contract review process, the laboratory should consider the possibility of
using more than one analyst during the clearance of “large” or complicated
enclosures. The effective planning and use of resources will be of importance in
ensuring that inspections (including Stage 2 visuals) are carried out thoroughly.
Analysts may need to take rest breaks during lengthy inspections to prevent fatigue.

2.2 Control of records ISO/IEC 17025 : clause 4.12

(ISO/IEC 17020 : clause 12)

2.2.1 Whilst carrying out the Stage 1 preliminary inspection of areas surrounding the
enclosure/work area, transit and waste routes etc. the analyst shall record the presence
of materials such as building rubble and debris etc. where this may give rise to any
doubt regarding the completeness of the Stage 1 inspection. The analyst shall initially
consult with the contractor, requesting that interfering materials be cleared. If this is
not possible or practicable, relevant details shall be recorded on the Certificate of
Reoccupation.

2.2.2 The analyst shall also record, and request the removal of, any obvious asbestos debris
arising from the removal work – particular attention should be paid in areas adjacent
to waste skips (and the contractor’s vehicle, if present during the inspection). In the
event that any asbestos debris remains within the area, then the analyst shall record
(and report) a clearance failure at Stage 1.

2.2.3 A copy of the contractor’s plan of work must be reviewed by the analyst when
carrying out the Stage 1 inspection. In the event that a copy of the diagram from the
contractor’s plan of work is not available, the analyst shall produce a site diagram
including approximate dimensions, detailing the location of the enclosure, air locks,
hygiene unit, transit and waste routes etc. This diagram shall form part of the
laboratory’s formal records system.

2.2.4 The use of photographic records may be desirable, subject to the granting of
permission by the client or building owner/manager.

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2.2.5 The analyst shall record the presence or absence of viewing panel(s), for the purpose
of inspection of enclosures from the outside. Other methods of viewing, such as
webcams or CCTV may also be useful during inspections. In the event that viewing
panels are not present, the analyst must record the absence of viewing panels within
the site records and proceed with the inspection. Additionally, the analyst
should discuss with the contractor’s representative whether smoke tests or leak testing
have been carried out on the enclosure and should record details of any discussions
held (and any documentation examined). The Licensed Contractor’s Guide(6) requires
daily visual checks of enclosure integrity to be carried out by the contractor. The
analyst can also check the contractor’s records for supporting evidence. Such
evidence will be of potential use to the analyst in assessing the integrity of the
enclosure, as part of the Stage 1 inspection. The analyst should, however, bear in
mind that such testing may have been carried out some time prior to the clearance.
The integrity of the enclosure must again be verified and recorded as part of Stage 1.

2.2.6 The presence of any known asbestos-containing materials (ACMs) that are to remain
in-situ following site clearance certification must be recorded by the analyst on the
Certificate of Reoccupation. A record shall be kept of any ACMs noted to remain in
the enclosure during the Stage 2 visual inspection.

2.2.7 The analyst must record the presence of leaking pipes, seepage of groundwater,
‘dusty’ surfaces (that may compromise the completeness of the dust disturbance
procedure), inaccessible asbestos etc. on the Certificate of Reoccupation.

2.2.8 The analyst must record whether any sealants or lock-down sprays have been used in
or around the work area. There should be no use of sealants prior to the 4-stage
clearance procedure (unless they are used as part of the control during the removal
process – e.g. removing AIB ceiling tiles, or as permanent sealing). If sealants (e.g.
PVA) have been used in a bid to obtain clearance, then this is a potential fail. The
analyst can direct that sealants be removed. The analyst can, of course, authorise the
use of sealants, but reasons and justification for their use (e.g. where non-asbestos
dust within the enclosure may cause an air test failure) must be recorded on the
Certificate of Reoccupation.

2.2.9 The analyst must discuss with the removal contractor whether testing is required in
the hygiene unit. It should be noted that separate clearance certification must be
issued for this purpose. The analyst must record the outcome of any relevant
discussions held with the contractor.

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2.3 Internal audits ISO/IEC 17025 clause 4.13

(ISO/IEC 17020 clause 7.7)

2.3.1 The laboratory’s programme for internal audits shall include auditing of all authorised
analysts carrying out site clearance certification on at least a 12- monthly basis. Such
auditing should normally be carried out by a designated “competent person” (i.e. that
possesses qualifications, training, experience and knowledge to meet the requirements
of HSE’s ACoP L28). Internal auditing procedures shall include witnessing of
authorised personnel carrying out on-site inspection and testing activities associated
with site clearance certification.

2.4 Personnel ISO/IEC 17025 clause 5.2

(ISO/IEC 17020 clause 8)

2.4.1 Analysts responsib le for conducting inspections as part of the site clearance
certification process are required (by both ISO/IEC 17025 and ISO/IEC 17020) to
have appropriate qualifications, training, experience and knowledge. Moreover, the
additional responsibilities that are now placed on laboratory analysts following the
introduction of the 4-stage site clearance process will undoubtedly result in more
stringent demands being placed on laboratories in areas such as initial training and the
ongoing monitoring of analyst performance on-site. Details of training requirements
are given below (see Table 1).

2.4.2 Analysts who have no demonstrable previous experience of carrying out site asbestos
clearance work will require at least three months relevant experience (whilst working
under the close supervision of a fully-authorised person), in order to gain sufficient
and detailed knowledge of the 4-stage site clearance process. At the end of the period
of supervision, competency must then be verified by conducting, for example, on-site
auditing of the trainee. Details of the competency assessment (including the date on
which the trainee is designated as ‘fully competent’) must be recorded as part of the
training records.

2.4.3 Currently (as per requirements of UKAS publication LAB 30, Edition 1 (7)), at least
one member of the laboratory who holds a senior position of responsibility (e.g the
quality manager, a member of the technical management team, or the training officer)
should hold a relevant formal qualification – which is supported by evidence of
appropriate experience and demonstrable competence.

2.4.4 The British Occupational Hygiene Society (BOHS) Certificate of Competence in

Asbestos (Module S301 plus a pass in the complementary ‘oral’ examination) is an
acceptable formal qualification.

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2.4 Personnel (continued) ISO/IEC 17025 clause 5.2

(ISO/IEC 17020 clause 8)

2.4.5 Other alternative qualifications include the BOHS proficiency modules in asbestos
(P series) Those that are relevant to the 4 stage clearance process are : -

• Proficiency Module P 403 Asbestos fibre counting

• Proficiency Module P 404 Air sampling and clearance testing of asbestos

2.4.6 The syllabus for module P 403 will be amended by BOHS to take into account the
anticipated changes in fibre counting rules, as required by the European Worker
Protection Directive 2003/18/EC (8)(The rules for fibre counting will be aligned with
those contained in the World Health Organisation ‘WHO’ method (9)). The
introduction by BOHS of the revised P 403 syllabus will coincide with the
implementation of the next revision to the Control of Asbestos at Work
Regulations (10). This is anticipated to be around the autumn of 2005.

2.4.7 The syllabus for module P 404 has been revised by BOHS to incorporate the
additional requirements of the 4-stage site clearance certification process.

2.4.8 It is anticipated that, following revision of the syllabi for the P 403 and
P 404 proficiency modules, all analysts carrying out site clearance testing will be
required to hold these minimum qualifications. Analysts who currently hold passes in
these modules must undergo suitable in-house competency assessment that
incorporates the new 4-stage site clearance procedures.

2.4.9 The following table gives details of requirements for qualifications, experience
and knowledge requirements for analysts carrying out 4-stage site clearance
certification.

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Table 1

Qualifications, experience and knowledge requirements for analysts carrying out 4-stage clearance
procedures .

Minimum qualification Minimum experience Knowledge

The British Occupational 3 months appropriate experience in Familiarity with the range, location,
Hygiene Society (BOHS) 4-stage clearance procedures, use and appearance of asbestos
Proficiency Certificate in followed by a competency products
‘Asbestos fibre counting’ assessment by a fully qualified
(P403) analyst Knowledge of appropriate sampling
strategies and inspection regimes for
and ‘Air sampling and 4-stage clearance work
clearance testing of asbestos’
(P404), or other more wide Knowledge of current regulations,
ranging qualifications ACoPs and guidance (in particular
approved by BOHS. the HSE Analyst’s Guide)

(See notes below) Knowledge of the fitting, wearing

and care of respiratory protective
equipment

Knowledge of decontamination
procedures, transiting procedures,
and the use of airlocks and hygiene
facilities

Notes :
1 BOHS Proficiency Certificate in ‘Asbestos fibre counting’ and ‘Air sampling and clearance testing of
asbestos’ can be gained by successfully completing the written examination and practical assessment of
BOHS P403 and P404 Modules.

The more wide ranging qualifications approved by BOHS and accepted by UKAS are :

• BOHS (formerly BIOH) Certificate of Competence in Asbestos (gained by passing BOHS Module
S301 ‘Asbestos & other fibres’ and the complementary oral examination).
• BOHS (formerly BIOH) Certificate of Operational Competence in comprehensive occupational
hygiene (Cert. Occ. Hyg.) which includes a study of asbestos within the course content.
• BOHS (formerly BIOH) Diploma of Professional Competence in comprehensive occupational hygiene
(Dip. Occ. Hyg.) which includes a study of asbestos within the course content.

2 Qualifications other than those specified above may be accepted but these must be reviewed and agreed
by UKAS.

3 Details of any proposed alternative qualifications should be submitted to UKAS for review and
agreement.

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Personnel (continued) ISO/IEC 17025 clause 5.2

(ISO/IEC 17020 clause 8)

2.4.10 Procedures for Stage 1, Stage 2 and Stage 4 inspections require analysts to be familiar
with the appearance and visual identification of various types of asbestos-containing
materials. Laboratories must ensure that analysts receive suitable training and
instruction in recognising these types of materials (including, in particular, their
appearance following wetting and stripping), and tha t training records contain
appropriate confirmatory evidence of competence.

2.4.11 Analysts must receive training in the use of airlocks and hygiene facilities, including
all entry and exit procedures. In addition, they shall be trained and competent to
effectively decontaminate themselves (and their equipment) upon exiting from
enclosures – in order to prevent the spread of asbestos fibres, and to minimise
exposure to others. Additional guidance is contained within ACoP L28 and in the
Analyst’s Guide.

2.4.12 Analysts must be given training in the fitting, wearing and care of respiratory
protective equipment. Training records must be maintained up-to-date, including
details of any refresher training given.

2.5 Test and inspection methods ISO/IEC 17025 clause 5.4

(ISO/IEC 17020 clause 10)

2.5.1 During Stage 2 of the procedure, analysts must visually inspect the airlocks, as well as
the enclosure/work area itself. The presence of any dust/debris must be notified to the
removal contractor, and remedial actions undertaken (by the contractor) prior to Stage
3 clearance air monitoring. The laboratory shall have documented in- house procedural
guidance on conducting thorough visual inspections. The analyst must ensure that fine
settled dust is located (and subsequently notified to the contractor) during the Stage 2
inspection, and a fingertip search must be carried out on all surfaces within the
enclosure – including floor areas, at all heights, behind items etc. Appropriate
equipment – e.g. ladders, torch, probes or screwdrivers etc. may be required.

2.5.2 The area where the enclosure was - and the surrounding area - must be carefully
inspected for asbestos debris. Transit and waste routes must also be re- inspected if
waste has been moved during the 4-stage clearance process. Re- inspection of these
areas must therefore be conducted during Stage 4.

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2.6 Equipment ISO/IEC 17025 clause 5.5

(ISO/IEC 17020 clause 9)

2.6.1 Setting of flow rates during Stage 3 (clearance air monitoring) should normally take
place either in the outer compartment of the airlock (i.e. the compartment furthest
from the enclosure), or in an area immediately outside (and adjacent to) the
enclosure/work area. (Calibrated) flow meters should not be taken inside the
enclosure, to prevent unnecessary contamination of the equipment.

2.6.2 The laboratory must ensure that respiratory protective equipment is maintained and
inspected in accordance with a defined programme. Suitable records must also be
maintained in order to meet legislative requirements in this area (ref. also the
Analyst’s Guide and Control of Asbestos at Work Regulations, 2002).

2.6.3 The laboratory shall have documented procedures in place for the regular inspection
and maintenance of equipment used during 4-stage clearance work - including, for
example, ladders and other access equipment. Relevant records shall also be
maintained.

2.6.4 The use of site equipment checklists is desirable, as they will minimise the likelihood
of wasted journeys by analysts, thus ensuring that additional time pressures are not
placed on analysts carrying out clearance work.

2.7 Sampling ISO/IEC 17025 clause 5.7

2.7.1 ACoP L28 now requires the use of brushes or brooms for the purpose of dust
disturbance. This may give rise to excessive amounts of particulate matter on filters,
and thus invalidate samples taken. Laboratories should therefore consider the use of
shorter sampling periods (and the pooling of measurements to give the required
minimum sampled volumes), in order to alleviate such problems. Details of
alternative sampling strategies adopted must be included in the laboratory’s records,
and in the air monitoring report accompanying the Certificate of Reoccupation.

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2.8 Assuring the quality of test results ISO/IEC 17025 clause 5.9

2.8.1 Laboratories are strongly advised to consider and prepare for necessary changes to
their internal quality control schemes for fibre counting, due to the anticipated
changes from existing European Reference Method (ERM) rules, as per HSE MDHS
39/4 (11) , to the World Health Organisation (WHO) fibre counting rules. Analysts and
laboratory staff involved in administering internal QC schemes for fibre counting will
need to receive suitable training and guidance, internal reference slides will need to be
re-evaluated using the new fibre counting rules, laboratory procedures will require
suitable amendment etc. An additional round of RICE slides will also be circulated in
the period leading- up to the changeover to the new rules.

2.9 Reporting the results of tests and inspections ISO/IEC 17025 clause 5.10
(ISO/IEC 17020 clause 13)

2.9.1 The laboratory shall ensure that the requirements of DTI publication
URN 98/887 (12) are complied with, and that UKAS accreditation is not claimed for
Stage 1 and Stage 4 of the site clearance certification process prior to the formal grant
of accreditation.

Currently, it is anticipated that the grant of accreditation to laboratories meeting the

relevant accreditation requirements will take place in December 2005 (following
completion of the UKAS Development Project).

The following paragraphs contain guidance on specific requirements of ISO/IEC 17020

(inspection activities).

2.10 Liability insurance cover ISO/IEC 17020 clause 3.4

2.10.1 The laboratory shall hold liability insurance cover that relates to the carrying out of
site clearance certification following asbestos removal.

2.10.2 Additional guidance on requirements for insurance liability cover is given in EA

publication EA-5/01, to which reference should be made.

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2.11 Independence, impartiality and integrity ISO/IEC 17020 clause 4

(See also ISO/IEC 17025 clause 4.1)

2.11.1 If a laboratory is employed for site clearance certification by the removal contractor
who is carrying out the removal work, then the laboratory should be independent from
that removal contractor.

This means if a laboratory has any ‘links’ with a removal contractor by common
ownership, common management, contractual arrangements, informal understanding,
or other means that may have an ability to influence the outcome of a site clearance
certification, then the laboratory should not perform site clearance certification for
that removal contractor which has links with the laboratory.

The laboratory should demonstrate that they have robust processes and systems to
prevent being employed for site clearance certification by a removal contractor, which
is linked to the laboratory.

If, due to exceptional circumstances, the laboratory has to perform site clearance
certification for a removal contractor that has links with the laboratory, then the
laboratory must demonstrate that the laboratory’s analysts have the necessary
independence to be completely impartial when conducting site clearance certification.
In such cases the assessment by UKAS of measures taken by the laboratory to assure
the impartiality of analysts may require additional assessment effort, depending on the
laboratory’s arrangements for assuring impartiality and therefore, such arrangements
should be discussed with UKAS at the planning stages of the assessment.

2.11.2 Any laboratory, whether it has links with removal contractors or not, shall identify the
circumstances in which analysts may encounter commercial, financial or other
pressures that may affect their impartiality and operational judgement in carrying out
on-site clearance work, and shall demonstrate the measures taken to assure
impartiality.

2.12 Guidance on staff conduct ISO/IEC 17020 clause 8.5

2.12.1 The laboratory shall provide guidance for the conduct of its staff whilst carrying out
4-stage clearance work. Such guidance may cover issues relating to work ethics,
impartiality, personal safety, relationship with clients/contractors, adherence to
Company rules, protection of clients’ proprietary rights, and any other issues needed
to assure the proper conduct of laboratory staff.

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2.13 Safety procedures and instructions ISO/IEC 17020 clause 10.8

2.13.1 Risk assessments shall be carried out for all jobs involving 4-stage site clearance
work. These must be fully documented, and must include consideration of all site-
specific hazards that are likely to be encountered. Laboratories must consider aspects
such as the possible need for working at heights, ‘lone working’, working in confined
spaces etc. - and also their obligation to take reasonable steps to ensure that the health
and safety of other persons are not affected.

2.13.2 Procedures for carrying out risk assessments must be documented, and analysts must
receive adequate training in the fitting, wearing and care of respiratory protective
equipment (including refresher training, where relevant). In addition, analysts must
receive training in decontamination procedures, transiting procedures, and the use of
airlocks and hygiene facilities.

2.13.3 Arrangements should be made for effective emergency procedures to be enacted in

the event of loss of services to the hygiene unit, failure of any appliance - including
negative pressure unit(s), accident or illness, fire etc. Emergency procedures should
include access to the emergency services (e.g. via the use of a mobile telephone), and
also knowledge of escape routes etc.

3 Literature references

1 ISO/IEC 17025 International Standard General requirements for the competence of

testing and calibration laboratories, ISO/IEC, 1999

2 ISO/IEC 17020 International Standard General criteria for the operation of various
types of bodies performing inspection, Published as BS EN 45004 : 1995, BSI

3 Work with asbestos insulation, asbestos coating and asbestos insulating board.
Control of Asbestos at Work Regulations 2002. Approved Code of Practice and
Guidance L28 (Fourth Edition). HSE Books, 2002

4 EA – 5/01 EA Guidance on the application of EN 45004 (ISO/IEC 17020). European

Co-operation for Accreditation, Revision 3, December 2003.

5 Health & Safety Executive – The Analyst’s Guide – INSERT CORRECT

VERSION - 4th draft – March 2004?).

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3 Literature references (continued)

6 Health & Safety Executive – The Licensed Contractors Guide – DRAFT 2 January
2004? – INSERT CORRECT VERSION.

7 Application of ISO/IEC 17025 for asbestos sampling and testing. UKAS Publication
LAB 30 (Edition 1), UKAS, March 2002.

8 Directive 2003/18/EC of 27 March 2003 amending Council Directive 83/477/EEC on

the protection of workers from the risks related to exposure to asbestos at work.
L97/48, OJEU, 15.4.2003.

9 Determination of airborne fibre number concentrations: A recommended method by

phase contrast optical microscopy (membrane filter method). World Health
Organisation, 1997. ISBN 92 4 154496 1

10 Control of Asbestos at Work Regulations, 2002. SI 2002/2675, The Stationery Office

11 Asbestos fibres in air: Light microscope methods for use with the Control of Asbestos
at Work Regulations. MDHS 39/4. HSE Books, 1995. ISBN 0 7176 0913 8

12 Conditions for the use of national accreditation marks by UKAS and UKAS
accredited organisations. URN 98/887 - Department of Trade and Industry, published
2003.

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