Safe to Work examines the “unusual” circumstances, including multiple spider bites, that led to a multi-train collision at BHP’s Finucane Island site at Port Hedland, Western Australia.
The incident occurred on March 2 2024 shortly after 4:30am when two trains were waiting to be unloaded.
The Federal Government’s Australian Transport Safety Bureau (ATSB) investigated and found one of the train’s drivers had a microsleep while moving forward to unload.
While asleep, the driver collided with the back of another train, pushing it forward about 40m despite it having the brakes fully applied.
Fortunately, there were no injuries or damage.
“It was dark at the time of the collision, the driver had been experiencing a low workload while waiting to move their train in the yard, and it was their fourth consecutive night shift,” ATSB Chief Commissioner Angus Mitchell said.
“Poor quality sleep meant the driver was operating the train with a degraded level of alertness.”
The ATSB’s investigation revealed an “unusual” set of circumstances that led to the collision.
The driver at the centre of the incident was a fly-in, fly-out (FIFO) worker who reported being bitten by a white-tailed spider while sleeping in accommodation barracks at Port Hedland in the months leading up to the crash.
After having the bite assessed at a Port Hedland medical centre the driver returned home to Sydney, where he underwent surgery for the bite, and was subsequently cleared to resume duties about six weeks later.
A week after returning to work, in January 2024, the driver again awoke in the same barracks room and noticed similar signs of a white-tailed spider bite.
After returning to Sydney, the driver again underwent surgery, and another period of rehabilitation.
“Upon returning to Port Hedland after the second spider bite, the driver began to experience panic attacks and stress,” Mitchell said.
“Fearing another bite, the driver frequently sprayed insecticide in their locomotive cabs and, including waking from sleep to do so, their bedroom.”
While the driver had adequate opportunity for sleep, the stress and constantly waking up to spray insecticide disrupted his ability to obtain restorative sleep.
“While sleep duration is important, so too is sleep quality,” Mitchell said.
“Stress and interrupted sleep should prompt workers to assess and report an elevated risk of fatigue.”
As a result of the accident, BHP undertook a series of actions to manage fatigue and to address the limitations of its relevant locomotive’s vigilance systems.
This included reviewing the fatigue risk periods for its FIFO rail operations driver rosters and increasing the number of fatigue assessments during each rotation.
Fatigue assessments are now conducted on each of the first five 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.
The Big Australian has 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.
BHP also proposed several changes to the vigilance system installed on its relevant locomotives, including changing from fixed-time intervals to random intervals for the countdown, and limiting consecutive alerter resets to require different inputs and eliminate ‘muscle memory’.
Subscribe to Safe to Work for the safety news that matters most to the Australian mining industry.