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 acknowledges that BHP has recognised the risk associated with this safety issue, and the ATSB agrees that the action taken by BHP will reduce the risk. However, the ATSB notes that the current roster pattern is essentially the same as what it was at the time of accident. Further, while improvements have been made to assessing driver fatigue and/or alertness levels, the process still places substantial reliance on an employee assessing their own level of fitness for work. The ATSB believes there is opportunity to conduct further work to provide assurance that the fatigue assessment process is providing valid results. Nonetheless, in acknowledgement of the improvements, this safety issue has been closed partially addressed.
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:
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.
Roster design
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.
Training
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.
Fatigue Monitoring
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.
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.
Update 31 January 2025
On 2 March 2024, there was a low-speed train collision between 2 BHP trains at Finucane Island Balloon Loop. The ATSB commenced an investigation (RO-2024-002), and the final report was released on 17 December 2024. One of the findings stated:
The driver of train M05519B had been experiencing stress, sleeping with the light on, and waking often, resulting in poor quality sleep. As a result, on their fourth consecutive night shift, during darkness and while experiencing low workload, the driver set the train in motion while in a degraded level of alertness, possibly associated with a microsleep, and did not detect the impending collision.
No findings were made regarding fatigue management. The safety action section of the report included:
BHP reviewed the fatigue risk periods for its FIFO rail operations driver rosters and increased the number of fatigue assessments during each rotation. Fatigue assessments are now conducted on each of the first 5 night shifts and on the first and fourth day shifts of each rotation. These assessments are conducted face-to-face with the on-shift supervisor or coordinator at each depot location.
BHP is also implementing an additional check-in per shift, to be conducted with the rail crew team member either face-to-face or electronically via phone or radio. To support this activity, BHP employed additional resources to support existing operations supervisors and superintendents to identify and monitor fatigue concerns within the rostering environment.
Additionally, research was conducted into the viability of an interactive fatigue assessment tool (FAT), delivered through a mobile application, to improve the quality of fatigue assessments. A trial of the FAT was scheduled to commence at the end of November 2024.
As part of that investigation, the ATSB obtained information regarding BHP’s current fatigue management procedure (SPR-IHS-SAFOH-004). The ATSB notes that this procedure now contains substantial more detail, including explicit roles and responsibilities for personnel (including supervisors and employees).
The procedure also now includes minimum sleep requirements for workers, stating that ‘every effort shall be made by individual workers to … obtain sufficient sleep for their individual needs (at least 6 hours sleep per 24 hours)’ and that workers ‘not be awake for longer than 18 hours at the end of their shift’.
Based on other information received, the ATSB notes that the consultants involved in doing the January 2021 review of rosters had also been engaged in mid-2022 to provide support in the health and safety considerations of various roster patterns. In addition, a Roster Review Working Group was established in November 2022. The working group included various managers and employees. The working group has been reviewing a range of different roster options.
In December 2024, the ATSB requested further information from BHP. On 31 January 2025, BHP advised that the most common roster being used by its train drivers in 2024 was the 7N7D14X roster (that is, 7 12 hour night shifts, 7 12 hour day shifts and then 14 days off). That is the same roster pattern referred to in the safety issue. [A modified roster pattern involving only 7 days off between swings was used during the COVID period.]
BHP was asked if it had undertaken (or arranged for) any studies to determine how much sleep train drivers actually obtained on such a roster. BHP responded:
BHP uses industry standard inputs to modelling as guided by subject matter experts, including the biomathematical model Fatigue Audit InterDyne (FAID) which estimates sleep onset and time of wake up from available time. Rather than determining the specific numbers of hours of sleep drivers obtain, BHP has focussed its efforts on determining workers’ actual levels of alertness on the day by improving the fatigue assessment tool, increasing face-to-face or phone discussions with train drivers on fatigue and trialling new technology, such as a psychomotor vigilance testing tool that assesses workers’ level of impairment on the day.
BHP was also asked whether it had undertaken any studies to determine the accuracy of information its train drivers provided in the fatigue assessment tool or to determine the extent to which train drivers felt comfortable reporting when they were fatigued. BHP advised:
As part of a BHP biannual confidential survey (Engagement and Perception Survey – EPS) a range of responses are sought regarding safety matters, including a response to the statement, ‘I feel safe to speak up if work feels unsafe’. There is also an ability to provide de identified comments in this survey on any topic, including on fatigue management. The results of this survey are considered in formulating action plans for areas of concern or opportunities. A review of this aspect of the survey for the last four periods (the six month periods ending Mar 23, Sept 23, Mar 24 and Sept 24) was undertaken for our Rail Operations area with the majority of people employed in this area being train drivers, including all the FIFO train drivers. This showed results remaining reasonably consistent (between 79 and 84 out of 100 responding that they felt safe to speak up if work feels unsafe) for the two year period.
In addition our Crew Support Technicians capture confidential (de identified) suggestions or observations through discussions with train drivers and record these in a site based register. The register includes a number of comments relating to the accuracy of the fatigue assessment tool and fatigue discussions with supervisors. The information captured in the register will be used as one data source, in considering our approach to rostering, fatigue management and associated practices.
ATSB comment date: 14 February 2025
The ATSB notes the substantial work that BHP has done since the 2018 accident to improve its overall management of train driver fatigue. However, the ATSB also notes that the current roster pattern is essentially still the same as what it was when the November 2018 accident occurred. As stated in the safety issue, such roster patterns are conducive to result in cumulative sleep restriction and levels of fatigue likely to adversely influence performance on a significant proportion of occasions.
The ATSB recognises that various improvements have been made to the process of assessing’ driver’s fatigue and/or alertness levels using the fatigue assessment tool. However, the ATSB has concerns about the effectiveness of a fatigue assessment process that is primarily based on self-assessment by drivers. Although BHP advised that it has undertaken general assessments of employees’ willingness to report safety matters, no specific assurance processes have been conducted to verify the accuracy of the information reported by drivers on the assessment tool. Given the significant potential for fatigue associated with the roster, the ATSB believes there is opportunity to conduct further work to provide assurance that the fatigue assessment process is providing valid results.
