Rail safety issues and actions

Risk assessment for a rail-mounted equipment interaction incident

Issue number: RO-2018-018-SI-01
Issue owner: BHP Billiton Iron Ore - Train Operator
Transport function: Rail: Freight
Background: Investigation Report RO-2018-018
Issue release date: 17 March 2022
Current issue status: Closed – Adequately addressed
Issue status justification:

BHP has completed the review of the rail mounted equipment interaction risk assessment and implemented additional controls and control effectiveness tests in relation to the potential for a train rollaway event.

Safety issue description

Although BHP’s risk assessment for a rail-mounted equipment interaction incident identified numerous causes and critical controls for such an incident, it was broad in scope and had limited focus on the causes and critical controls for a train runaway event. In addition, the risk assessment did not include the procedure for responding to brake pipe emergencies and penalties as a critical control and BHP’s material risk control assessments (MRCAs) did not test the effectiveness of this procedural control for preventing an uncommanded movement of a train during main line operations.

Proactive action

Action number: RO-2018-018-PSA-01
Action organisation: BHP Billiton Iron Ore
Action status: Closed

Following the runaway and derailment accident involving M02712, and after collection of physical site evidence, BHP formed an independent team to investigate and analyse the accident. The following summarises the improvement actions identified relevant to this safety issue, the intent and the status of implementation, as advised by BHP on 20 January 2020 and updated 31 January 2022:


Undertake a review of the material risk (management framework) associated with rail mounted equipment interaction and update the material risk assessment to reflect any necessary changes.


To ensure that all exposure pathways are identified in relation to the material risks associated with Rail Mounted Equipment and subsequently included in the Risk Bowtie.

Progress (Complete)

BHP has conducted a thorough review of the Risk Bowtie for rail mounted equipment. Following that review, additional controls in relation to potential train rollaway events and associated control effective tests have been added. In addition, appropriate control designers and control owners have been appointed.


Implement a Systems Engineering Framework for the current BHP WA Rail system, in alignment with ISO 15288 including the creation and implementation of a fit for purpose CENELC compliant process of system assurance including the management of Safety Related Application Conditions (SRACs) and other safety related information presented by system vendors.


To provide an appropriate safety framework to manage the various systems utilised within the BHP Rail system and the related integration activities.

Progress (Complete)

BHP Rail engineering have developed a systems engineering and assurance framework based on industry best practice, EN50126 and ISO15288. This has taken the form of the rail systems engineering framework (RSEF). The framework has been integrated to existing processes and systems. The framework is live and resides in the BHP document control system.

Last update 17 March 2022