Rail safety issues and actions

Task design – brake pipe emergencies and penalties

Issue number: RO-2018-018-SI-02
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:

The ATSB is satisfied that the action being taken by BHP has reduced the risk of this safety issue.

Safety issue description

The task of responding to brake pipe emergencies or penalties relied extensively on a driver’s memory, with limited processes in place to facilitate or cross-check a driver’s performance to ensure all safety-critical actions were completed.

Proactive action

Action number: RO-2018-018-PSA-02
Action status: Closed

Following the runaway and derailment accident involving M02712, BHP rescinded OI 18-72 and issued OI 18-75 to address findings from the internal BHP investigation and other learnings.

The revised operating instruction introduced an added administrative control requiring the driver to complete a form confirming the actions undertaken in response to the emergency ECPB application. Completion of the form required the driver to acknowledge placing the automatic brake handle in the pneumatic emergency position, that the brake pipe pressure was exhausted (0 kPa) and the verbal validation of the actions by communicating with the rail operations supervisor/ co-ordinator, before leaving the locomotive cab. This process provided for the cross-checking of the driver’s actions in response to the emergency by another competent rail safety worker (Figure 15).

Figure 15: Extract from BHP Operating Instruction OI 18-75 – 120% emergency application form

Figure 15: Extract from BHP Operating Instruction OI 18-75 – 120% emergency application form

Last update 17 March 2022