Legionella Link Managing the health risks November 2003 • follow-up of 1159 Risk Management Plans Legionella Risk Management Plans that had reported non-compliance issues strategy update • over 1000 site inspections or Under the Building Act 1993, a Risk Management Plan (RMP) for a cooling Dr Robert Hall investigations by departmental officers tower system is a document that identifies Director Public Health • 150 improvement notices issued risks associated with the system and that and Chief Health Officer under the Building Act 1993 sets out steps to be taken to - Department of Human Services • survey and investigation of domestic • manage the risks; and cooling tower system risks • ensure compliance with any requirements • electronic mapping system linked to the relating the system imposed by or under Cooling Tower System Register. It is now the Building Act 1993, Health Act 1958 and much easier for investigating officers to regulations under both of these Acts. The government’s Legionella Reform identify cooling tower systems linked with The Building Act 1993 requires the owner Strategy, which took effect back in cases of Legionnaires’ disease. of any land on which there is a cooling March 2001, involves a working partnership Although implementation of the strategy tower system to take all reasonable steps between the Department of Human is now complete, the Legionella Program to ensure that an RMP is prepared, Services, Building Commission, Plumbing will continue its education, monitoring and in respect of each cooling tower system Industry Commission and industry groups. investigation work, to further reduce the on the land. In most cases, separate Each phase of the strategy’s incidence of Legionnaires’ disease. RMPs are necessary for each cooling implementation has seen a reduction tower system. One exception may be a This issue of Legionella Link aims to: in the number of Legionnaires’ disease system consisting of a number of identical notifications in Victoria. • provide feedback from the first round evaporative condensers, located in close of Risk Management Plan audits, Currently, about 5,500 cooling tower proximity to each other. including the most common reasons systems (6,531 cooling towers) are To meet the requirements of the Act, for non-compliance registered with the Building Commission. both for an RMP and an RMP audit, • offer examples of good and bad practice The past 12 months have seen the the document must address the risks following achievements: • encourage consideration of these specified in the Building (Legionella Risk issues during the coming annual plant Management) Regulations 2001. • an accredited independent auditor maintenance/shut down period. training program for cooling tower The Act does not specify whom may system Risk Management Plans For more details on Legionella risk prepare an RMP but, for high risk or management, please feel free to contact complex sites, or where large workforces • training and certification of the Legionella Program on 1800 248 898. are involved, the department recommends 125 independent auditors Dr Robert Hall that a risk management consultant is used. • the commencement of annual Director Public Health The department published A Guide auditing of Risk Management Plans and Chief Health Officer to Developing Risk Management Plans • 260 audits completed by Department Department of Human Services for Cooling Tower Systems to assist of Human Services (DHS) officers landowners, cooling tower system 2 Legionella Link owners and managers to provide a safe • operational programs will be commenced Important points are that: environment for their staff, contractors, from the commencement date of the RMP • the requirements refer to the entire cooling customers and the public, and to comply • proposed system improvements will be tower system, not just the cooling tower with Victorian legislation. completed by the end of the following • the person responsible for meeting the The Guide incorporates an RMP template, audit period. requirements is not the water treatment to be completed when a risk assessment service provider, but the “responsible has been carried out and decisions Legionella legislation person” (“the person who owns, made on appropriate risk management The Victorian Government is committed manages or controls the system”) measures. At least 90 per cent of current to minimising the risk of Legionnaires’ • the owner or manager of the system must RMPs use the template, or a modification disease in the community. Legislative ensure that the routine maintenance and of the template. requirements in the Building Act 1993 testing of the system, as well as any and various regulations, including the Remember: The RMP (plus required remedial action and record Health (Legionella) Regulations 2001, implementation plan or schedule) keeping, address the risks of the were introduced in 2001. must be a practical, easy-to-read system and meet the requirements The department administers this of the regulations. document, that has been dated legislation in partnership with the and reflects the owners’ intentions. More on sampling, remedial action Building Commission and the Plumbing and record keeping can be found Industry Commission. The Department’s When developing an RMP, it is later in this issue. website www.legionella.vic.gov.au/ important that recommendations be translated into statements of has links to all the relevant Acts RMP reviews and Regulations. the owners’ intent, together with The Building Act 1993 requires that all appropriate timelines. The department’s Health (Legionella) RMPs be reviewed, and if necessary view is that recommendations not yet updated, at least once annually prior Regulations 2001 accepted by the owner of the land or to renewal of registration. These Regulations specify: system are not part of the RMP. This may happen at any time, but an RMP • definitions for cooling tower, cooling review should be considered following: When a risk assessment or a draft tower system, biocide, clean, disinfect, RMP document has been prepared, • changes to the water system or its use HCC, Legionella, responsible person it is important that: and warm water system • changes to the use of the building in • all statements in the document referring which the system is installed • continuous treatment to control the to proposed system improvements and growth of microorganisms, including • the availability of new information the system’s operational program reflect Legionella, and to minimise scale or technology the owner’s intentions and include formation, corrosion and fouling; • results indicating that control measures timelines, or ongoing maintenance and testing of are no longer effective • it is accompanied by an implementation cooling tower systems; six-monthly plan or schedule, setting out the • a case of Legionnaires’ disease possibly cleaning and disinfection of systems; owner’s intentions, timelines for associated with the system HCC testing at least monthly system improvements and the • unusual factors, for example demolition • remedial action for high HCC readings system’s operational program. or construction of buildings on or near the or when Legionella is detected Schedules help document the locations, site, or road works or other construction • notification requirements when Legionella activities likely to generate dust risk classification, proposed actions is detected in 3 consecutive samples and timelines for removal/activation • a change in number, or level of of ‘dead legs’. • maintenance and testing of vulnerability, of people who may be warm water systems exposed to aerosols from the system. The department’s view is that, unless relevant timelines have been • record keeping requirements. specified in the RMP, the document should be read as though: Legionella Link 3 The process should include, Undertaking a review prior to an What the auditor needs as a minimum, a review of: RMP audit means: To assess whether the RMP addresses • risks and risk categories associated • maintenance and testing records can be the risks, the auditor requires a copy with the system assembled and checked by the owner of the RMP, to check that it contains • results of microbiological and chemical • the records are available for the audit references to the the risks specified in tests for the previous 12 months the regulations. The auditor is not required • an assessment can be made as to to determine the extent to which the • details of service records for the whether the plan is still relevant to risks are being managed. previous 12 months the risks, or requires an update To form a view that the RMP is being • the environment surrounding the • issues can be addressed by the owner, implemented, the auditor will require system and before the audit. repair, maintenance and testing records, • changed conditions, if any, under which The review should be documented and together with any other relevant records the system is operating attached to the RMP, which may or may for the interval between the previous not require re-drafting. registration renewal date and the audit. Risks specified in the The review can be conducted in-house, Building (Legionella with the assistance of the water treatment Choosing an auditor Risk Management) service provider, or by a consultant. The Building Act 1993 specifies that Regulations 2001 In more high risk or complex sites, audits may only be conducted by or where large workforces are involved, approved auditors. See the Legionella • stagnant water (including the the department recommends that an website for a list of approved auditors: lack of water recirculation in a independent consultant be engaged to www.legionella.vic.gov.au/ cooling tower system and presence conduct the review. of dead-end pipework and other Check with the auditor about the level of service provided; some may provide a fittings in a cooling tower system) RMP audits single contact-only service, which does • nutrient growth (including the Legal need not provide the opportunity to locate presence of biofilm, algae and missing documents. With this service, protozoa in a cooling tower system, Each cooling tower system RMP requires there is an increased risk of the auditor water temperature within a range an annual audit. forming the view that the RMP is not that will support rapid growth of Section 75FA of the Building Act 1993 being implemented. micro-organisms in a cooling tower states: “The owner of any land on system, and the exposure of the Note To avoid conflicts of interest, which there is a cooling tower system water of a cooling tower system the auditor cannot be the owner of the must take all reasonable steps to ensure to direct sunlight) land or the cooling tower system, or be that a risk management plan audit is associated with the water treatment • poor water quality (including the conducted in relation to the risk service for the system, the design of the presence of solids, Legionella and management plan prepared in respect of system, or the development of the RMP. high levels of micro-organisms in the system in the 3 months before the a cooling tower system) registration of the system is due to expire.” Timing • deficiencies in the cooling tower Purpose The RMP audit is best undertaken system (including deficiencies in early in the three months before the the physical design, condition and The audit determines two things: registration is due to expire. This helps maintenance of a system) • whether the RMP addresses the risks ensure that the audit is completed within • the location of and access to a specified in the regulations the registration period. cooling tower or cooling tower • whether the RMP is being implemented. system (including the potential for environmental contamination of the system and the potential for exposure of people to aerosols from the system) 4 Legionella Link Efficient audits Outcomes Testing also provides feedback on the effectiveness of the biocidal treatment To keep costs down and to assist The auditor will provide a certificate for program, which owners pay for as part with compliance: each RMP, stating whether it addresses of the water treatment service contract. • Make sure that the RMP is clearly set the critical risks and whether it is being out, addresses the the risks specified implemented. The auditor’s reasons for Water samples must be in the regulations, is dated and is signed a finding of non-compliance will be representative of the off by the responsible person for the stated on the certificate. circulating water system cooling tower system. If the RMP Where an RMP is non-compliant, a copy has been reviewed and changes made, of the certificate will be forwarded by the Sampling points a record of this should be kept and auditor to the department for follow-up. attached to the RMP. Inspectors are still seeing systems A non-compliant audit may have where the samples are taken immediately • Ensure that target dates or timelines are adverse effects on site industrial downstream of the biocide dosing point. shown for all proposed actions: relations, quality programs and In some other poor examples, the samples – If any action is undated in the RMP, it is site/business insurances. are taken from the cooling tower basin in expected that the action be completed which the biocide is added. The results of Audit feedback by the end of the following audit period. testing may have little meaning, as the To date, the department has received samples are not representative of the – If the RMP states that an action is notices of 1159 non-compliant audits. circulating system. required within a timeline – such as every fortnight, or monthly – ensure that Many were non-compliant because they Sampling should be taken from a point the timeline is complied with. lacked documentation (such as missing near the area of highest risk. For cooling service reports, test results, invoices or tower systems, the highest risk of release • Work towards showing the relevant proof of work) to show that the RMP had of aerosols containing Legionella is from registration (CTS) number on all been fully implemented. the drift or exhaust of a cooling tower. It is maintenance and testing records – avoid using local names for each Where management believes that an appropriate to sample near this release of cooling tower system, unless the auditor activity has occurred, but is not able aerosols to the atmosphere. A sampling is provided with a link between the CTS to locate the record for the audit, point on the return line close to the numbers and the local names. the service provider should be cooling tower would be best. contacted to obtain a copy. The Australian Standard AS 3666.3 • Where possible, keep all service records etc for a cooling tower system separate In some cases, photographs have Air-handling and water systems of buildings from other cooling tower systems on been included in the records showing - Microbial control Part 3: Performance- the site. specific actions taken - such as the based maintenance of cooling water removal of redundant pipework or systems and Code of Practice for Water • Keep these records on-site in installation of signage. Treatment Service Providers (Cooling Tower chronological order, and make sure Keeping better and more practical Systems) also support this approach. they are each dated and identify the CTS number. If records are sent off-site for records will ensure a higher success Until a sampling point is installed on audit, copies should be kept on-site with rate in future audits. the return line, it is better to sample each respective RMP. falling water from just below the fill – Microbiological rather than from the basin, if that is • Some complex sites with multiple systems have employed an auditor to conduct the sampling where the dosing occurs. first audit on-site. While not required under Identify and label this preferred the legislation, some companies have Purpose sampling point, as a cooling tower found advantages in this approach. Testing the microbiological quality of the system may have many potential water in a cooling tower system is an sampling sites. integral part of any RMP, as it measures the microbiological performance of the system. Legionella Link 5 HCC and the new It is expected that HCC results will HCC sampling fluctuate during the year, taking into Australian Standard method Heterotrophic Colony Count (HCC) account different patterns of use (AS/NZS 4276.3.2 (2003) of the cooling tower system and is a measurement of the number of bacteria that are able to grow in a A new standard method for the climatic variations. general-purpose growth medium at determination of HCC in waters Some concerned owners have contacted 37ºC. The department adopted the containing biocides has been published. the department after adverse HCC or limit of 100,000 cfu/mL in the new This method uses a different growth Legionella results have been obtained. legislation (down from 500,000 medium (R2A agar) for bacterial An adverse result presents an opportunity cfu/mL) to be consistent with enumeration. Biocide treatments of water for the owner to discuss the reasons for Australian Standards (AS/NZS injure or stress bacterial cells and R2A such a result with the water treatment 3666.3) and levels adopted or agar was introduced, as it is a better service provider. It may also be an to be adopted by other states. recovery medium for such cells. opportunity to review the RMP and The measurement of bacteria by The impact of the use of R2A agar on put improvements in place. the HCC method does not include the HCC levels of cooling tower water Owners and managers of systems Legionella, which has very specific is not known and the department should periodically assess the performance growth requirements for testing in has not moved to adopt this method. of their water sampling programs, a laboratory. There is no direct Most laboratories use Plate Count Agar including any remedial action required. correlation between HCC levels for cooling tower HCC tests. and Legionella concentrations. • For engineers or operators, HCC is a DHS test results There is potential for false sampling to mask sub-standard maintenance. measurement of the microbiological DHS is currently compiling a summary The department is monitoring for control in a cooling system; high of Departmental cooling tower system instances of improper practice, and HCCs can lead to bio-fouling and water sample test results for HCC and would consider legal action if poor heat transfer, particularly at the Legionella, with the view to providing examples came under notice. condenser tubes or heat exchangers, information for industry. resulting in system failure. Microbiological testing is an A summary of the results will shortly important measure in assessing • From the microbiological be available at the DHS website the performance of water treatment perspective, a rising or high HCC is www.legionella.vic.gov.au and these programs. These programs are a warning of a lack of system control will be periodically updated. vital in managing the risk of and provides an opportunity to Taking an interest in results Legionnaires’ disease. correct this. There are often simple reasons for this rise – a sudden There have been reports of samples being intake of dirt-laden air, a large piece taken immediately after disinfection or There are no penalties for a single of dirt/sludge/bio-film dislodged dosing with biocide – without waiting high test result. The penalties into the system, the biocide the legislatively prescribed 2-4 days. provided by the regulations are reservoir has been depleted, This practice reduces the meaning of the for failing to take the prescribed or the biocide pump has failed. results and is also not supported by the remedial action. • From the risk management Australian Standards (AS/NZS 3666.3). perspective, additional bacteria in the system shows a lack of microbiological control, the presence of nutrients and a possibility that Legionella could be developing in the system. 6 Legionella Link • have an agreement with the water • Details of any alternative maintenance Legionella testing treatment service provider (WTSP) or testing methods approved under The time taken for Legionella testing under which the WTSP would attend regulation 24. (up to 10 days) is considerably longer within 24 hours, including public holidays and weekends or WHERE must these records than for HCC. In the absence of a Legionella result, it is often appropriate • be able to self-treat the cooling tower be kept? to take action in the meantime on a system, (and know which biocide to use, These records must be kept on the site high HCC result. This action should where to locate it, how much to use, and where the cooling tower is located and also have an effect on any Legionella how and where to dose the system) or be available for inspection upon request present. It is hoped in the future that • have an agreement with the WTSP under by an authorised officer. there will be rapid tests developed for which the WTSP would provide telephone They may be stored in the site kit provided Legionella detection. advice on self-treatment. by the Building Commission at the time of In 2000, the Legionella Working Party Consider sampling at a time that takes the system’s initial registration. Records did not support mandatory routine into account: must be kept for at least seven years. Legionella testing for all cooling tower • the required delivery time to the laboratory WHY must these records systems, because of long delays (no longer than 24 hours from sampling) before test results become available, be kept? the costs involved and the potential • the required laboratory incubation period The auditor requires the above records, for negative results to give a false of 48 hours plus a copy of the RMP, to enable the sense of security. It was decided that • sufficient opportunity for the WTSP annual RMP audit. Presenting the auditor a risk management approach should to respond within normal work hours. with all of the required records in an be taken on maintenance of cooling orderly sequence will help achieve a tower systems and that discussions The who, what and compliant audit result and expedite regarding Legionella testing be made according to the risk classification of where of records for the auditor’s work. Requirements for record keeping are the system. cooling tower systems specified in the Health (Legionella) WHO keeps the records? Regulations 2001, Building (Legionella The legislation identifies disinfection Risk Management) Regulations 2001 actions if Legionella is detected in samples The owner, manager or operator of (as amended) and the Building Act 1993. taken. Given the time delay in obtaining the cooling tower system is responsible test results, the concentration in the for maintaining records and keeping REMEMBER: maintain complete system could have changed considerably them current. records and keep them on-site. in the meantime and rapid action is required to ensure the risk is reduced. WHAT records must be kept? • Microbiological test results of water Decommissioning or Remedial biocide samples (copies of laboratory reports recommissioning a dosing for high HCC for HCC and Legionella tests). To assist Under the Health (Legionella) Regulations with monitoring the process, identifying cooling tower system trends and assembling documentation for Disused cooling tower systems remain 2001, the responsible person must, reviews and audits, it is useful to maintain registered with the Building Commission within 24 hours of receiving a report that a a spreadsheet or summary, showing dates until they have been appropriately sample of cooling tower system water has of the samples and results of the tests. decommissioned. an HCC count exceeding 100,000 cfu/mL, manually treat the water of the system • Repair, maintenance and corrective The Building Act 1993 requires the with additional quantities of biocide or activities (monthly servicing, cleaning, land owner to notify the Commission with an alternative biocide. disinfection, installation or upgrading of within 30 days of the removal or drift eliminators or signage, removal of permanent decommissioning of To fully meet this requirement, the ‘dead legs’ and so on). a cooling tower system. responsible person would need to either: Legionella Link 7 When the land owner contacts the Under the Building Act 1993, the owner of The Australian Institute of Refrigeration Commission, they will be asked to the land is required to notify the Building Air Conditioning and Heating (AIRAH) confirm that the following steps have Commission within 30 days of any of the accreditation program for water treatment been undertaken, according to the following changes: technicians is now being implemented in Guide to Developing Risk Management • ownership of the land on which the Victoria, and the first participants have Plans for Cooling Tower Systems: cooling tower system is located recently been awarded their certification. • the cooling tower system has been • addition or removal of a cooling tower “The accreditation program gives added drained in accordance with any advice to or from the cooling tower system credibility to water treatment companies, from the local water authority by confirming that their technicians • removal or permanent decommissioning • the chemical dosing tanks (where fitted) are skilled. By accrediting technicians of the cooling tower system have been removed individually, the program gives confidence • relocation of the cooling tower system in the ability of each and every technician • both power and water supplies on the lot of land on which it stands. that is accredited,” says Jennifer Pelvin, have been disconnected A Cooling Tower Systems Change CEO of AIRAH. “It also confirms, • if the cooling tower has not been removed, Form may be downloaded from for customers, that a company’s a sign has been placed on the tower www.buildingcommission.com.au/ service forces as a whole have indicating that it must not be re-activated achieved that standard.” without first contacting the department Further information on As part of the technician-level program, or the Building Commission. registration of cooling tower participants are given a self-paced A Decommissioning a Cooling Tower systems may be obtained at workbook to complete, along with a System Form may be downloaded http://www.buildingcommission. copy of AIRAH’s DA18 - Water Treatment from the Commission’s website com.au/ manual. The workbook includes questions www.buildingcommission.com.au/ or by contacting the on state regulations and tests participants Before a decommissioned cooling tower Registrations Coordinator at on the Victorian Code of Practice for Water system is re-commissioned: (03) 9285 6498 Treatment Service Providers (Cooling Tower or email Systems) and the Guide to Developing • it must be registered/re-registered email@example.com Risk Management Plans for Cooling Tower with the Building Commission Systems. Once the workbook has been • it must have a chlorine compatible completed, the participants sit an exam to bio-dispersant added to the AIRAH accreditation demonstrate their understanding of the re-circulating water, and then be disinfected, cleaned and program for water content of the manual and workbook. “The advantage of having both the re-disinfected according to the treatment technicians workbook and exam is that it gives water Health (Legionella) Regulations 2001 Jennifer Pelvin treatment companies an independent • a Risk Management Plan must CEO AIRAH assessment of each technician - be developed and implemented a benchmark of their progress,” for the system. remarks Ms Pelvin. “The workbook ensures that new Cooling Tower technicians cover the important aspects Systems Register of water treatment in detail. The course The Building Commission maintains is also suitable for those who are tertiary a register to ensure that cooling tower qualified, as there is no tertiary course systems can be promptly identified and that assesses practical water treatment investigated in the event of a case or knowledge.” outbreak of Legionnaires’ disease. It is essential that this information is current. 8 Legionella Link The course content also includes: Legionella contact information • the need for water treatment • safety in water treatment Department of Human Services • characteristics and chemistry of water Website: www.legionella.vic.gov.au/ LRMP address: firstname.lastname@example.org • overview of cooling water systems Past issues of Legionella Link www.legionella.vic.gov.au/resources.htm • understanding control methods Telephone: 1800 248 898 • maintenance, sampling, testing and Facsimile: (03) 9637 4657 recording. “This is the first step of the accreditation Building Commission process” explains Ms Pelvin. “We are Website: www.buildingcommission.com.au/ looking forward to implementing the Telephone: (03) 9285 6498 program for supervisors and managers Facsimile : (03) 9285 6497 and the accreditation of water treatment companies, which will include independent Plumbing Industry Commission verification of each company’s Website: www.pic.vic.gov.au/ compliance with the Code of Practice”. Telephone: (03) 9889 2211 For further information or to register, Facsimile : (03) 9889 2244 phone Lea at AIRAH on 1300 308 838 or email email@example.com Plumbing Industry Commission The Plumbing Industry Commission is responsible for licensing and registering people who construct and maintain cooling towers and cooling tower components. The standard of work must comply with the Plumbing Regulations, which are made under the Building Act 1993, and place into regulation the AS/NZS 3666 series of specifications. Cooling tower work, as defined by the Plumbing Regulations, does not include water treatment. The Commission supports the continual DHS Legionella Team. Back row: Philip Montalto, Anthony (AJ) Simon, Stuart Adcock, Mark D'Agostino, Natalie Blyth and Stephen Waddington. Front row: Bernie Zwolak and Ray Goudey (A/Manager). improvement of knowledge and skills within the industry, through targeted training and information. This is critical if the safe construction and maintenance provisions for the cooling towers are to be met. It also recognises the importance of AIRAH, with the accreditation program for water treatment technicians as integral to the total approach towards safer cooling towers.
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