A report into the 2018 derailment of a runaway iron ore train has highlighted issues with BHP's risk assessments, unclear communication with train drivers and the company's FIFO work rosters.
The Australian Transport Safety Bureau (ATSB) has handed down its final report into the deliberate derailment of a fully-loaded train in WA's Pilbara region in November 2018, which cost the company hundreds of millions of dollars.
The report said the runaway train travelled more than 90 kilometres in about 40 minutes before BHP's Hedland control intentionally derailed the train, 120km from Port Hedland.
The derailment destroyed two remote locomotives, 245 ore cars and 2km of rail track.
The ATSB found BHP's ore trains were potentially vulnerable to a runaway event and BHP's risk assessments had limited focus on the potential causes of, and critical controls for, preventing a runaway event.
"A train runaway can cause injury or loss of life, and while there were no injuries as a result of this accident, it did carry a significant financial and economic cost," ATSB chief commissioner Angus Mitchell said.
"A certain set of specific circumstances meant not completing a single safety-critical action – placing the automatic brake handle in the pneumatic emergency position – had a significant consequence.
The ATSB said BHP did not clearly communicate with its drivers about the importance of this safety critical action.
It also found BHP's risk assessments did not focus enough on the causes and critical controls of a train runaway event.
"Although the operator had identified the need for the safety-critical action in its procedures in April 2017, this risk assessment did not include the procedure for responding to brake pipe emergencies and penalties as a critical control, and it did not test the effectiveness of this procedural control," Mr Mitchell said.
Fatigue management flagged in report
The ATSB also investigated how BHP manages train driver fatigue and found rosters for fly-in fly-out workers were conducive to fatigue that could influence performance.
It said BHP also had limited processes in place to ensure drivers got enough sleep.
However, the ATSB said based on the available evidence, it did not conclude that fatigue contributed to the train runaway event in 2018.
The report also detailed the cause of the event on November 5, 2018.
It said while travelling between Newman and Port Hedland an inter-car connector separated, severing trainline communications between the lead locomotive and the ore cars near the end of the train.
The ATSB report said the train stopped after an automated emergency brake application was initiated but an hour later, before the driver was able to secure enough of the ore cars' handbrakes, control devices shut down and the brakes were released on most of the ore cars on the train, and it began rolling away without the driver onboard.
Mining giant welcomes findings
BHP WA Iron Ore general manager of rail Warren Wellbeloved said BHP welcomed the findings.
"We welcome the release of the Australian Transport Safety Bureau report, as we continue to learn from and improve following the incident in 2018," Mr Wellbeloved said.
"We have significantly strengthened our systems and processes over the past few years, including through a new rail systems engineering framework that is aligned with industry best practice, better integration of our train braking systems, and stronger operating protocols.
"BHP has fully supported investigations by the ATSB and Office of the National Rail Safety Regulator and implemented improvements which address their findings."
The ATSB report said BHP has added extra controls related to potential train runaway events and has also commissioned external fatigue experts and formed a working group to optimise train driver rosters.
