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.
The ATSB is satisfied that the action being taken by BHP has reduced the risk of this safety issue.
Following the runaway and derailment accident involving M02712, BHP rescinded OI 18-72 and issued OI 18-75 to address findings from the internal BHP investigation and other learnings.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.
On 31 January 2022, BHP updated the above proactive action, advising the content of OI 18-75 has been imbedded into work instruction 0155275. BHP also advised it developed a process flow chart requiring that all completed forms are reviewed at a supervisor level and then sent to the specialist safe work for auditing and confirmation against the automatic train protection logs.
