Task design – brake pipe emergencies and penalties
Date issue released
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.
Issue number
RO-2018-018-SI-02
Issue Status
Closed – Adequately addressed
Transport Function
Rail: Freight
Issue Owner
BHP Billiton Iron Ore - Train Operator
Mode of Transport
Rail
Issue Status Justification
The ATSB is satisfied that the action being taken by BHP has reduced the risk of this safety issue.
Proactive action
Action number
RO-2018-018-PSA-02
Action Status
Closed
Action description
Following the runaway and derailment accident involving M02712, BHP rescinded OI 18-72 and issued OI 18-75 to address findings from the internal BHP investigation and other learnings.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
