Safety Issue

Following the runaway and derailment accident involving M02712, BHP rescinded operating instruction OI 18-72 and issued OI 18-75 to address findings from the internal BHP investigation and other learnings

The revised instruction OI 18-75 amended/reinforced the requirements of the rule book clauses applicable to an emergency ECP brake application when moving with the end of train monitor displaying ‘off’ or ‘?’. OI 18-75 additionally added yellow highlighting to several of the existing instructions a driver was to undertake. The instruction to secure an ECPB train had more highlighting added, with simplified text displayed in red font. The instruction now included a safety critical note, providing important information to drivers on the significance of compliance with that particular action (Figure 16).

Figure 16: Extract from BHP Operating Instruction OI 18-75 – procedure p6-4.0

Extract illustrating formats used to highlight key sections of instruction.

Source: BHP

Following the publication of OI 18-75, BHP published a further 5 revisions of the notice (Table 3). Amendments addressed by the revisions included the removal of duplicated clauses, and rewording of text to clarify the meaning and variations in the highlighting applied to sections of text.

Table 3: Operating Instruction – Brake Pipe Emergencies and Penalties

On 31 January 2022, BHP updated the above proactive action, advising:

To ensure the ‘why’ for a change is being communicated, in December 2018, BHP reviewed and updated the procedure - Issuing and Receiving Operating Instructions (0100312) to include the following:

- Section 3 page 4 "Context of the change must be included in the body of the Operating Instruction."

BHP is currently reviewing the Rail document management procedure (0155191) and subordinate documents to ensure consistency in updating and distributing safety critical information within the correct document type.

BHP has also undertaken to better inform front line staff by directly communicating any safety critical information with face to face engagement when an instruction is identified as critical. This is imbedded with the ‘Critical comms’ package and is managed through a register with Rail operations supervisors. When information is shared by this process the register is updated with all face to face interactions to assist Supervisors in tracking and delivering the necessary safety instructions.