BHP's fatigue management processes required its train drivers to be rostered on 7 12-hour shifts, followed by a 24-hour break and then 7 12-hour shifts, with the roster pattern commencing at a wide variety of times of day. Such roster patterns were conducive to result in cumulative sleep restriction and levels of fatigue likely to adversely influence performance on a significant proportion of occasions, and BHP had limited processes in place to ensure that drivers actually obtained sufficient sleep when working these roster patterns.
The ATSB notes that BHP has recognised that its roster design (at the time of the accident) was not conducive to minimising fatigue. The ATSB also notes the significant amount of action that BHP has undertaken since 2018 and continues to undertake to evaluate and improve its fatigue management processes, and that due to the COVID situation there has been some constraints on progress. Overall, the ATSB is satisfied that the risk of this safety issue is reducing, and the ATSB will monitor further developments in addressing this safety issue.
In August 2018, at the request of BHP, an independent organisation completed a review of WAIO train driver rosters, including residential drivers and fly-in fly-out (FIFO) drivers. The review outlined several recommendations. These included ensuring that BHP provided recent and comprehensive education to drivers and supervisors, ensuring employees are aware they have access to support for fatigue-related problems through the employee assistance program (EAP), and ensuring any individual who shows fatigue-related problems undergoes a specialised individual assessment.
In June 2021, BHP advised the ATSB that it had reviewed the fitness for work training provided to employees and also engaged a specialist to undertake one-on-one discussions with employees (on a voluntary basis). It had also provided dedicated communications regarding the EAP to employees.
The August 2018 review also recommended reviewing whether the additional risks posed by working night shifts prior to day shifts was adequately mitigated by the stated control measures. In response to this recommendation, BHP engaged in a process to conduct further reviews of its rosters. During this process, it identified that most employees strongly preferred starting roll-over roster patterns with night shifts followed by day shifts (the reverse of that recommended by the August 2018 report).
In order to further address this issue, BHP requested the same review organisation to conduct a more detailed review of fatigue management at BHP WAIO rail operations, resulting in a more detailed report provided in February 2020. The February 2020 report included a number of additional recommendations on a range of topics. These included multiple recommendations relating to fatigue management training for employees, managers and rostering personnel. In response, BHP introduced a new on-line fatigue management training program, which many staff completed in August–September 2020, and also commenced developing a program of additional face-to-face training.
The February 2020 report also made further recommendations about reviewing the practice of commencing roll-over roster patterns with night shifts before day shifts. As a result, BHP initiated formal consultation with employees regarding this change, which was still ongoing as of June 2021.
In addition, BHP requested an additional consultancy organisation to conduct a review of its train driver rosters and alternatives. In January 2021, that consultancy organisation provided a report. The January 2021 review used the biomathematical model of fatigue ‘FAST’ to conduct modelling of BHP’s current FIFO rosters and some proposed alternatives. With regard to the type of swings being used at the time of the 18 November 2018 accident, the report noted that each swing, regardless of the initial sign-on time, would produce an overall average score (across the 14 shifts) that could be considered ‘extreme risk’ or ‘high risk’. Initial sign-on times associated with the worst average scores were from 2100–0300, with the highest scores being from 0000–0100.
The January 2021 review made 5 recommendations, which included ensuring a comprehensive fatigue risk management system (FRMS) was in place, considering a fundamental review of the shift and roster design, and conducting fatigue and performance monitoring of train drivers (by obtaining objective sleep and performance data). In June 2021, BHP advised it was continuing to assess the report and recommendations.
On 31 January 2022, BHP updated the above proactive action advising:
Although BHPs investigation into the 2018 rollaway event did not identify fatigue as a contributing factor, BHP did independently recognise the potential fatigue risks associated with the Rail Operations’ roster and proactively commissioned reviews from external fatigue subject matter experts [as described above] in order to:
- better understand this risk,
- evaluate the adequacy of controls in place; and
- make recommendations to further reduce fatigue risks to as low as is reasonably practicable.
BHP has considered the outcomes of those reviews and has sought to act on several of these recommendations. However, progress has been impacted by the COVID-19 pandemic, primarily as a result of reduced train driver availability and the redistribution of resources to safely manage the increasing health risks from COVID-19.
The following details the progress against some of these recommendations to date.
With reference to the subject matter reviews, BHP recognised the current roster design is not conducive to minimising fatigue and subsequently formed a working group to optimise rosters with a focus on reducing fatigue to as low as is reasonably practicable. This working group has been progressing this in line with the subject matter expert review recommendations.
BHP remains committed to progressing this work in identifying and implementing a fit-for-purpose roster that reduces fatigue risk for our train drivers to as low as is reasonably practicable.
BHP has engaged an external fatigue subject matter expert to deliver face to face, fit-for-purpose fatigue management training specific to Rail Operations. BHP has committed to complete this level of training with 100% of required personnel as soon as practicable with consideration of the current Covid 19 constraints on resource availability.
BHP Rail Operations is currently evaluating a sustainable approach to embedding face-to-face training and refresher training as part of the standard suite of training available to all Rail Operations personnel.
BHP has reviewed the current Fatigue Assessment Tool (FAT) and, as a result, has now developed an improved Mobile Fatigue Assessment Tool (MFAT) to close gaps identified in the BSS independent review, using scientific data from the Samn-Pirelli model. The MFAT allows for electronic completion and greater supervisory oversight of fatigue within the supervisor’s span of control via a live dashboard. Supervisors also receive push email notifications for MFAT forms completed by their team, which prompts appropriate action based on consideration of the determined fatigue risk scores.