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300677 Reasons Of Accident and Policy Changes to Prevent Future Accidents Assignment 1 Answer

300677 Safety and Risk Management Spring 2019

Assessment Details

1.1.1      Critical Review

Type   of Collaboration:Individual
Length:1,500   words
Curriculum   Mode:Report

Students of Safety and Risk Management need to understand and be able to apply safety management principles. A major part of the application of safety and risk management principles is the skill to analyse and evaluate safety incidents and to identify weaknesses and failures that led to safety breaches or major incidents. The analysis of Case Studies will develop students’s kills in risk management and practical application of theory.


There have been many train crashes in Australia and overseas as a result of safety breaches. Choose one train incident that has occurred as a result of safety breaches and, with supporting evidence, discuss how safety breaches contributed to the train crash. In some cases multiple breaches have led to the incident. Choose the safety breaches you feel contributed most heavily to the incident that you have chosen to discuss. Detail any changes to policy or practice that resulted from the incident and how this was implemented. Use evidence from existing literature to support the discussion. 


Your assignment will be assessed on the following:

  • Academic writing style
  • Depth of discussion of the safety breaches which lead to the incident
  • Depth of discussion of the changes to policy or practice that resulted from the incident.
  • Use of evidence to support the discussion using the APA referencing system.


Unit Name: Safety and Risk Management

Unit Code:  300677

Executive Summary:

The management of safety and risk assessment could be initiated with the efforts of the government and organisations to keep the public secure. The loss of BHP in its railway accident perceived a threat to its business in Western Australia. The country has been in the news many times for its rail accidents. The prevention of such accidents secures financial as well as human life loss in future. The case study will discuss the reasons that lead to the accident and the necessary policy changes that will prevent such accidents in future.  

1.0 Introduction

The safety and risk assessment ensures that the people involved in a particular incident or place are secured from the danger. It is the responsibility of the government to ensure that risk management and safety procedures are managed in all parts of society. It is also the government's responsibility to monitor and ensure that the organisations are maintaining safety and risk measurement. The purpose of this report is to critically review the safety and risk measurements of the rail accidents that are common in Australia. Fir, this report the BHP train crash that occurred in 2018 is selected and will be discussed. 

2.0 Case of BHP runaway train crash

The ATSB or Australian Transport Safety Bureau has reported several problems that led towards derailment of the BHP train within WA’s Pilbara involving the ways rail gang has initiated locked down the incorrect train. The completely laden runaway train was intentionally derailed prior on November 5th last year to 120 kilometres south of Port Hedland. The study by ATSB highlighted that rail gang sent to support drivers after the ore train stopped with disconnected cable, however they incorrectly went to another train on neighbouring track. The two of the locomotive has been destroyed within subsequent derailment, including 245 ore-cars and track of two-kilometre range (Weber, 2019). The default was initially noticed after the initial train went well of its path and started its 50-minute driverless voyage covering 91 km with reaching high speed nearly 162 kilometres per hours. The interior inquiry by BHP depicted that accident was the outcome of procedural non-compliance by the operator and incorporation problem with the electronically monitor pneumatic breaking arrangement (Martin, 2019). The BHP representative stated that in case track arrangement team had attended the accurately applied manual and train brakes, it might not have been effective to obstruct the rollaway occurrence. The president of the organisation has mentioned that if a driver has placed automatic brake knob to the crisis position prior leaving the cab as needed in the operating process, the train accident would have been avoided. The ore train was operating as the 2860-meter unit of train accounted to the weight of nearly 42500 ton. It was functioning between loading service at mining region placed on the spur path expansion from Yandi and unloaded services at nelson unit, port Hedland (, 2019). The operating unit of engine onboard automatic operation, distribution and braking power along with vigilance as well as track control panel has noted to be somewhat responsible and ignorant in leading such disruptive train crash. In order to avoid such consequences in future, the BHP preliminary inquiry suggested a sequence of the activities for establishing over the long and short term. The seven technical proposals have been made, including modification operation guideline for brake-pipe emergencies (Martin, 2019). The bureau of transport examination continued to undertake the design of the BHP train arrangement and process within the safety administration system.  

3.0 Assessment of Safety Risk Issues

3.1 Locomotive onboard automatic train protection system

The investigation over factors leading to the runaway train crash has highlighted that automated break has brought the train to a halt.  The fully loaded train with four locomotives and 268 cars on its way to Hedland Port from Newman has lost communication with combined end and lead locomotive train monitor around 3:39 am. It was noted to trigger the automated crisis brake and engine came to discontinue 210 kilometres from the Port Hedland (Weber, 2019). Hjort& Crosby (2018) added that the train operator descended in situational accountability produce catastrophic situation and confirmed as a crucial element in prior significant rain disasters. It is crucial to develop the procedure of locomotive driving by utilising decision support network (Tartakovskyi, Gorobchenko&Antonovych, 2016). The division of below-rail maintainers and the above-rail operator makes the establishment of technology to safeguard alongside train operator default complex without specialised automated procedure, independent of the human element.  

3.2 Braking and Distributed Power systems

The trail has been equipped with ECP or EP-60 New York Air Brake electrically monitored pneumatic braking arrangement.  The system included of engine equipment, communication or power distribution system, end-of-train monitor and ore-car braking monitor equipment (, 2019). The maintenance associate suggested that they had arrived to initiate applying brake pedal from the train end and apparently done so not acknowledging they worked on incorrect one. The ineffective distribution and braking power system have been responsible for train crash caused due to brake failure. Alturki & Reiff-Marganiec (2017) explained that possible invention in real-time processing of sensor data benefit the guiding function of moving vehicle. The embodiment of current invention associated with system, apparatus and methods for optimising real-time train function, safety or control within inter as well as intra-linked railway station helpful to detect trains.  

3.3 Vigilance control

The BHP train has also been equipped with vigilance administration system to track the driver action and obstruct train or locomotive. At the time of absence of a response from the driver to visual as well as aural, a warning is displayed through the FIRE system. In reference to the runaway train crash, the vigilance system has been a failure to set locomotive configuration at a defined slower speed and reverser within a centred position. The vigilance supervision device guide the attentiveness of the driving crew at the time of train movement (Punzet, Pignata& Rose, 2018). The safety action becomes crucial related to the examination of software or hardware solution whereby an onboard monitor arrangement, brake or FIRE computer automatically dumps the air from train breaking pipes under the varying situation. Fiumara (2015) added that vigilance facility for property goods or in concession arrangement effective to safeguard organisation assert as well as equipment of personnel onboard. In combination with BHP current signalling up-gradation work, the introduction of the latest automatic train safeguarding arrangement onboard all locomotives, Hi-rail and track management became effective within BHP fleet operation. 

4.0 Detail any changes to policy or practice that resulted from the incident and how this was implemented

Upgrading the automatic train protection system is being initiated in Australian for $11.8 million by the government. The exiting train operations technology is set to be upgraded with a modern equivalent that provides a more reliable and safe service (Automatic Train Protection System Upgrade, 2019). Train operations and control would be achieved effectively. The completion of the newer changes would be done by the end of 2019 and is said to include the commissioning of ATP encoders, installation and design. Many newer locations are included in the project and will replace and reconfigure the existing equipment. This will improve the rail network involving the back-end systems and its impact on the passengers (Filtness &Naweed, 2017). This will also help in the minimisation of the roads as well as rail users within Australia. Filtness &Naweed (2017) suggested novel methods for the supervision of the train integrity systems. The process included the acquisition of the data regarding the current position of the carriage, which has to be previously installed on the train. The positioning of the tracking unit will be coordinated in the routeing system (Route Access Standard General Information, 2019). This helps in the destination of a deviation between the length of the train and a position value to derive a tracking point. The deviation would be determined with the measurement of the deviation in railways carriages. This would be a part of the automatic train protection systems of the train to alert the driver as well as the network.The Australian government has operators that detect signalling and train detection interface. The system ensures safety at converging tracks and clearance point. Signalling Rolling Stock interfaceprovides the train barking, electromagnetic interfacing, positioning of signals, and tracking circuits throughout the ARTC network (Macii et al., 2015).Gerlici et al. (2018) provided resolution for the unstable brake operations in railways. The authors suggested that the increase in the temperature from the friction inhibit the contact during emergencies. The solution for the dissipation of the elements causing the brake management was done through a software module to signify the contact friction. The improvement in the modern rolling stock was made by improving the airflow supply into the brake system. The control of temperature would also be integrated to operate the breaking conditions. Cooling ribs and stabilisations pads might reduce the impact of the temperature and help in controlling the brake with increased friction. de la Fuente et al. (2014) opined that it is essential to generate smart electrical grids to operate railway power systems more efficiently. The successful integration of the information technology and the electrical control system would efficiency provide control in the railway network. Jin et al. (2016) opined this is more effective than the traditional power systems as the smart grids provide the response to the control centres from the operating system. Systemic reliability, energy efficiency, improved utilisation are some of the ways in which the implementation of the system can facilitate control. The government uses machines based on the complex programmable logic devices or CPLD instead of microprocessors and software, which is customised by the ARTC to increase the capability of the vigilance system. This system helps in the monitoring of the alertness of the driver and enhances the active driving systems.

5.0 Conclusion

There were a number of issues found in the BHP railway accident, including the disruption in the automatic train protection system and the locomotive control within the train. Suggestion regarding a newer and grid-based detection system would solve problems in future. The braking and distribution power system were also faulty within the particular train, and newer techniques to reduce the impact can be applied in its policy. The vigilance improvement policies can also be developed to reduce the number of train crashes in future. 

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